Enlarged Prostate: Urinary Symptoms in Men and What Helps

Most men over 50 develop some degree of prostate enlargement, and many assume the resulting symptoms are simply age. They are treatable, and some of them point to problems other than the prostate, which is the main reason to get assessed rather than adapt.

What happens

The prostate sits below the bladder and surrounds the urethra. From around age 40 it slowly enlarges, a process called benign prostatic hyperplasia. Enlargement obstructs flow, and the bladder muscle thickens and becomes overactive in response.

Importantly, symptom severity correlates poorly with prostate size. A modestly enlarged prostate can cause severe symptoms, and a large one can cause few.

Benign enlargement is not prostate cancer and does not become it, though both can be present in the same man.

Symptoms

Obstructive, or voiding symptoms:

• Weak or interrupted stream
• Hesitancy, waiting for flow to start
• Straining to pass urine
• Prolonged voiding
• Terminal dribbling
• Sense of incomplete emptying

Irritative, or storage symptoms:

• Frequency
• Urgency
• Nocturia, waking at night to pass urine, usually the most disruptive symptom
• Urge incontinence

Doctors quantify these with the International Prostate Symptom Score, a seven-question tool plus a quality-of-life question, which guides treatment and tracks progress.

Red flags needing prompt attention

• Complete inability to pass urine, acute retention, which is a painful emergency requiring catheterisation
• Visible blood in the urine
• Fever with urinary symptoms
• Bone pain or unexplained weight loss
• Recurrent urinary infections
• Known kidney impairment
• Symptoms in a man under 40, which usually have another cause

Other causes of the same symptoms

Not everything is the prostate:

• Overactive bladder
• Urinary infection or prostatitis
• Bladder stones or tumour
• Urethral stricture, often after catheterisation or infection
• Diabetes, causing polyuria
• Neurological disease affecting bladder control
• Heart failure, which commonly causes nocturia as fluid redistributes at night
• Obstructive sleep apnoea, another frequent and overlooked cause of nocturia
• Medications: diuretics, decongestants, some antidepressants, antihistamines and anticholinergics
• Excess evening fluid, caffeine or alcohol

Assessment

Expect a symptom score, urinalysis, a digital rectal examination, kidney function tests, a post-void residual ultrasound measuring urine left after voiding, and often a flow rate study. A PSA test may be discussed; PSA rises with benign enlargement, infection, recent ejaculation and catheterisation as well as with cancer, so the result needs interpretation rather than alarm.

Treatment

Watchful waiting with lifestyle measures, for mild symptoms:

• Reduce fluids in the three hours before bed
• Cut caffeine and alcohol, both of which irritate the bladder and increase urine production
• Double voiding: pass urine, wait a few moments, and try again
• Bladder training to extend intervals
• Treat constipation
• Review medications with your doctor
• Stay physically active and manage weight
• Pelvic floor exercises for dribbling

Medications:

• Alpha blockers such as tamsulosin, alfuzosin and silodosin relax prostate smooth muscle and work within days. Side effects include dizziness on standing and retrograde ejaculation. Tell your eye surgeon before cataract surgery, since these drugs cause floppy iris syndrome
• 5-alpha reductase inhibitors such as finasteride and dutasteride shrink the prostate over three to six months, work best in larger glands, and reduce the risk of retention and surgery. They halve the PSA reading, which must be accounted for in interpretation, and can affect libido and erectile function
• Combination therapy for larger glands with significant symptoms
• Anticholinergics or beta-3 agonists added for storage symptoms, used carefully if emptying is poor
• Tadalafil, useful where erectile dysfunction coexists
• Desmopressin in selected cases of nocturnal polyuria, with careful sodium monitoring

Procedures, for failed medical therapy, retention, recurrent infection, bladder stones or kidney impairment:

• TURP, the long-standing standard, highly effective
• Laser enucleation or vaporisation, with less bleeding and shorter catheter time
• Minimally invasive options such as prostatic urethral lift and water vapour therapy, which better preserve ejaculatory function
• Open or robotic simple prostatectomy for very large glands

Retrograde ejaculation is common after most of these and should be discussed in advance; erectile function is usually preserved.

Herbal products

Saw palmetto has been tested in large trials and performed no better than placebo. Other herbal preparations have weak evidence. They are not a substitute for assessment, particularly because untreated obstruction can quietly damage the kidneys.

This is general information. Urinary symptoms in men deserve proper assessment, since treatment differs considerably by cause and some causes are serious.