Enlarged Prostate (BPH)

A weak stream, getting up at night, trouble starting — what's behind it and the full range of treatments, from medication to same-day office procedures.

What is happening

Benign prostatic hyperplasia, or BPH, is non-cancerous growth of the prostate. The prostate sits directly around the urethra, so as it enlarges it squeezes the channel urine travels through. The bladder compensates by working harder, and over time the bladder muscle itself changes and becomes irritable.

BPH is extremely common and increases steadily with age. It is not prostate cancer, and having BPH does not raise your risk of prostate cancer. The two conditions are unrelated, though they can exist at the same time.

Symptoms

Symptoms fall into two groups. Obstructive symptoms include a weak or slow stream, trouble starting, straining, dribbling at the end, and a sense of not emptying completely. Irritative symptoms include urinating frequently, sudden urgency, and getting up at night — often the complaint that finally brings men in, because it wrecks sleep.

Symptom severity does not track neatly with prostate size. Some men with very large prostates have few complaints; some with modest enlargement are quite bothered.

How we evaluate it

We start with a symptom questionnaire, a urinalysis to rule out infection or blood, and a digital rectal exam. We usually check a PSA, both because prostate size affects PSA and because we want to be sure symptoms are not from something else. A bladder scan after you urinate tells us how much urine is left behind, and a uroflow study measures your stream. Cystoscopy or ultrasound is added in selected cases.

Treatment: medication

Alpha blockers relax the muscle of the prostate and bladder neck. They work within days. Side effects can include dizziness, and some men notice reduced or absent ejaculate volume.

5-alpha-reductase inhibitors shrink the prostate over months and are most useful for genuinely enlarged glands. They can affect libido and erections in a minority of men, and they lower PSA by about half — which we account for in interpreting your results.

Combination therapy is used when the prostate is large and symptoms are significant. Tadalafil is another option, particularly if erectile dysfunction is also a concern.

Treatment: procedures

Many men want off daily medication, or find it stops working. Modern options are far less invasive than the surgery most men have heard about from a father or uncle.

Water vapor therapy (Rezum) uses steam to shrink prostate tissue, done in the office with minimal anesthesia. Prostatic urethral lift (UroLift) places small implants that hold the lobes open, preserving ejaculation. Both have short recovery and a catheter for a few days.

TURP remains the long-standing benchmark, removing obstructing tissue through the urethra with excellent and durable results. Laser enucleation (HoLEP) and simple prostatectomy are used for very large glands.

Choosing among them depends on your prostate size and shape, your bladder function, whether preserving ejaculation matters to you, your other medical conditions, and blood thinners. This is a decision worth an unhurried conversation.