“Why do I have to pee so much?” Urologists and primary care physicians field this question all the time. More often than not, for men the culprit is an enlarged prostate, also known as benign prostatic hyperplasia (BPH). By age 60, about half of all men will have BPH…by age 85, that number jumps to 90%.
Bottom Line Personal asked renowned medical oncology and urologic cancer expert Marc B. Garnick, MD, of Harvard Medical School, to explain what BPH is and how it is treated today…
The prostate is a walnut-shaped gland responsible for the production of semen. It sits just below the bladder and wraps around the urethra (the tube that carries urine and semen through the penis and out of the body). The prostate gets bigger with age, progressing from the size of a walnut in a man’s 20s and growing over the decades, reaching a substantially larger size. As the prostate grows, it squeezes the urethra…and blocks the easy passage of urine through this tubular structure. This can cause problems with the flow of urine. The bladder must work harder to push urine through the urethra, and like other muscles, this causes the bladder wall to bulk up…and a thicker bladder wall means less space to store urine. Over time, the bladder can become fatigued and less efficient in its ability to contract and extrude the urine, leading to the backing up of urine.
BPH doesn’t always cause bothersome symptoms, but about 40% to 50% of men with BPH will experience urinary side effects ranging from mild to severe. The pinching of the urethra and the ensuing bladder changes are responsible for many of the hallmark symptoms of BPH, which doctors divide into two categories—storage and voiding, collectively called lower urinary tract symptoms (LUTS).
Storage symptoms include…
Frequent urination. Less storage space in the bladder means it takes a smaller-than-usual volume of urine to activate the “Time to go!” signal sent by the bladder to the brain.
Urinary urgency. Many men with BPH feel as though they must urinate as soon as the urge hits.
Nighttime urination. Needing to pee more often at night, known as nocturia, can rob you of sleep.
Voiding symptoms include…
Difficulty starting to urinate or feeling like you need to push to start your urinary flow.
Weak or start-and-stop urine stream, along with dribbling at the end of urination and/or feeling as if your bladder hasn’t fully emptied.
Why Do Men Develop BPH?
Aging and male hormones are the two most common BPH risk factors. Dihydrotestosterone (DHT), the main byproduct of the hormone testosterone, triggers prostate growth. (DHT also promotes the development and growth of male genitalia in utero and during male puberty.) Some men have very high levels of a particular enzyme, 5-alpha-reductase 2, that converts testosterone to DHT, and because DHT has a much stronger impact on prostate size than testosterone, these men are more prone to developing BPH.
Obesity—especially when most of the excess weight is in the midsection (called central obesity)—is another risk factor. Metabolic syndromes such as obesity spark the gene that produces 5-alpha-reductase 2, increasing DHT levels and raising BPH risk. Central obesity also fuels system-wide inflammation, which correlates with prostate enlargement…and excess abdominal weight puts pressure on the bladder, potentially exacerbating existing BPH symptoms.
When It’s Time to See a Doctor
If LUTS interfere with your daily activities or quality of life, see your primary care doctor or a urologist. The workup for BPH may include any or all of the following…
Physical exam, including a digital rectal examination to assess the prostate’s size and symmetry.
Questions about your symptoms, including details about your urinary flow…history of genitourinary procedures…and medications you’re taking that might be mimicking BPH symptoms (some antihistamine drugs, for instance, can weaken the bladder).
Urine testing to help the doctor rule out other potential LUTS causes, including bacterial infections and diabetes. While many men with BPH have LUTS, not all men with LUTS have BPH.
Post-void residual urine test to measure the amount of urine remaining in your bladder immediately after urinating.
Questionnaire to assess the impact of your symptoms, such as the International Prostate Symptom Score (IPSS) or American Urological Association (AUA) Symptom Index.
Blood testing for prostate-specific antigen (PSA). While this test is often associated with prostate cancer, elevated PSA levels can also indicate BPH.
Important: BPH is not cancerous, a fact reflected by the inclusion of the word “benign” in benign prostatic hyperplasia. But BPH and prostate cancer share several symptoms, and they can coexist in the same prostate. A PSA test may help your doctor pinpoint the correct diagnosis.
Also good to know: Men with BPH typically experience both storage and voiding symptoms that develop slowly over time. An enlarged prostate gland can also increase the likelihood of a prostate infection called prostatitis.
Treatment for BPH
Not everyone with BPH requires treatment. Your health-care provider might recommend a watch-and-wait approach if your symptoms are not terribly disruptive or burdensome. But if dealing with urinary frequency, urgency, straining and other symptoms makes it difficult to work, travel or otherwise enjoy life, there are treatments.
To determine if you need treatment: Ask yourself, What’s my “bother score”? The final question on the IPSS is, “How would you feel if you had to live with your urinary condition the way it is now—no better, no worse—for the rest of your life?” Rated on a scale of 0 (delighted) to 5 (unhappy), a patient’s answer to this question often dictates whether he needs treatment for BPH.
BPH treatments fall into three categories—medical, lifestyle and surgical…
Medical BPH treatments
There are several FDA-approved benign prostatic hyperplasia medications. Some target BPH’s “going” (urinary) difficulties, while others tackle the “growing” (prostate enlargement) issue.
For help with “going”: Alpha blockers. Short for alpha adrenergic–receptor antagonist, alpha blockers smooth muscles in the prostate, causing it to relax its grip on the urethra and allowing urine to flow more freely. Alpha blockers tend to be the first choice for men with BPH. When they work, they usually do so within one to two weeks. Examples: Tamsulosin (Flomax), alfuzosin (Uroxatral), doxazosin (Cardura), prazosin (Minipress), silodosin (Rapaflo), terazosin (Tezruly)
Potential side effects: Dizziness…headache…fatigue…nasal congestion…dry mouth…ankle swelling…reduced ejaculate volume and retrograde ejaculation (when semen flows back into the bladder, not out through the urethra.)
Cautions…
Tell your doctor if you’re already on blood pressure medication—some older alpha blockers (specifically, doxazosin and terazosin, which are considered nonselective alpha blockers) can further lower blood pressure, potentially causing dangerous side effects. Selective alpha blockers (tamsulosin, alfuzosin, prazosin, silodosin) don’t lower blood pressure and may be a better fit.
All alpha blockers can cause orthostatic hypotension, a temporary blood pressure drop that occurs when moving from a seated position to standing, resulting in lightheadedness and dizziness. These drugs should be taken at night and only when there will be no need to drive.
Alpha blockers can cause complications during cataract surgery, so let your ophthalmologist know if you’re taking one before undergoing any cataract procedures.
For “growing” help: 5-alpha-reductase inhibitors. 5-alpha-reductase inhibitors help shrink enlarged prostates by lowering DHT levels within the prostate. 5-alpha-reductase inhibitors are more variable in their onset and work more slowly than alpha blockers—three to nine months or longer. They are better suited for men with particularly large prostates (over 40 to 50 grams). Examples: Dutasteride (Avodart) and finasteride (Proscar)
Potential side effects: Patients tend to tolerate finasteride and dutasteride better than alpha blockers. Still, elderly patients with a history of mood issues may experience depression and suicidal thinking while taking finasteride. Tell your doctor about your mental health history before starting this drug.
About 10% of men on 5-alpha-reductase inhibitors will experience erectile dysfunction and lowered libido. Adding the drug tadalafil (Cialis) can improve the erectile side effects. (Tadalafil is also FDA-approved as a stand-alone treatment for BPH-related urinary symptoms.)
Other possible side effects include fatigue and sleep troubles.
Before starting a 5-alpha-reductase inhibitor, your doctor should obtain a baseline PSA value, then retest after six to eight months. Reason: Dutasteride and finasteride tend to lower PSA levels by about 50% in men without prostate cancer, so if your PSA level doesn’t decrease by that amount…or if it rises…you may want to discuss with your physician a possible referral to a urologist to help determine the reason.
If you are screened for prostate cancer while taking a 5-alpha-reductase inhibitor and didn’t get a baseline PSA value, you should double your PSA results to compensate for the drug’s PSA-lowering effects. Otherwise, your PSA value will be misleadingly low.
For help with “going” and “growing.” Some men, especially those with very large prostates, may need an alpha blocker plus a 5-alpha-reductase inhibitor to control their LUTS. This is called combination therapy. The drug Jalyn combines the alpha blocker tamsulosin with the 5-alpha-reductase inhibitor dutasteride, but other combinations are possible.
Lifestyle BPH treatments
There are non-medication steps you can take to improve BPH symptoms…
- Avoid drinking fluids in the evening, especially caffeinated and alcoholic beverages. (Both are diuretics and contribute to nighttime awakenings and bathroom trips.)
- Take your time when urinating and try to empty your bladder. Try double-voiding—waiting 30 seconds to a minute or so after urinating, then trying to urinate again. This increases the odds of emptying your bladder as completely as possible.
- Try “timed trips.” Try to pee every two to three hours, even if you don’t feel the need to go. Like double-voiding, this can minimize urinary retention and help “train” the bladder to empty more efficiently.
- When flying, urinate before takeoff…avoid diuretics like alcohol and coffee…choose an aisle seat to make restroom trips easier…and proactively urinate every 60 to 90 minutes.
- Don’t avoid drinking water in an effort to minimize bathroom trips. Dehydration can lead to kidney stones and worsen kidney function overall.
Surgical BPH treatments
If medication and lifestyle tweaks haven’t sufficiently moved the needle for your symptoms, it may be time to consider surgical therapy, especially if your BPH is causing urinary tract infections (UTIs)…prostatitis…blood in urine… and/or bladder stones. There is an entire spectrum of surgical treatments for BPH. Discuss with your urologist the different choices and the best one for you.
Warning: Urinary retention that causes a complete inability to urinate is a medical emergency that requires immediate treatment—usually draining the bladder with a catheter—to avoid kidney damage.
Office-based procedures performed under local anesthesia include Rezūm, which uses steam to shrink the prostate…or prostate artery embolization, which limits the prostate’s blood supply. More invasive procedures performed in a hospital setting under spinal or general anesthesia include transurethral resection of the prostate (TURP)…laser prostatectomy, which removes pieces of prostate gland surrounding the urethra…prostatic urethral lift (UroLift) …and more. A urologist who specializes in BPH can walk you through the options.
