BPH: what it is, why it causes symptoms, and how we treat it.

What BPH actually is

The prostate is a walnut-sized gland that sits below the bladder and surrounds the urethra — the tube that carries urine out of the body. Starting in the 40s and continuing for the rest of life, the prostate slowly grows. For some men, this growth is uneventful. For others, the growing prostate squeezes the urethra and obstructs the normal flow of urine.

About 50% of men in their 50s and 90% of men in their 80s have BPH. But not every man with BPH has symptoms, and not every man with symptoms needs treatment. The key question is always: how much are symptoms actually affecting your quality of life?

Common symptoms

Doctors group BPH symptoms into two categories:

Obstructive symptoms (related to the blocked flow)

• Weak urinary stream
• Straining or pushing to start urination
• Stopping and starting mid-stream
• Dribbling at the end
• Feeling like the bladder didn't empty completely

Irritative symptoms (related to the overworked bladder)

• Urgency (a sudden urge you can't ignore)
• Frequency (urinating many times per day)
• Nocturia (waking up at night to urinate, often multiple times)
• Urge incontinence (leaking before reaching the bathroom)

How BPH is diagnosed

Evaluation starts simple and adds tests only as needed:

• Symptom assessment (typically the AUA Symptom Index) — a questionnaire that scores how bothered you are.
• Physical exam, including a digital rectal exam to estimate prostate size and check for abnormal firmness.
• PSA blood test — mostly to screen for prostate cancer, but also an indirect measure of prostate size.
• Urinalysis to rule out infection or blood in the urine.
• Post-void residual ultrasound (bladder scan) — quick ultrasound after you urinate to see what's left behind.
• UroCuff test — evaluates flow and pressure to confirm obstruction. Read more about UroCuff.

Treatment options — from simplest to most involved

1. Watchful waiting

If symptoms are mild and not bothering you much, the right answer may be to do nothing for now — just monitor. BPH doesn't always get worse; some men's symptoms stabilize or even improve with time.

2. Lifestyle changes

• Limit fluids in the 2 hours before bed (reduces nocturia).
• Cut back on caffeine and alcohol, which irritate the bladder.
• Avoid medications that can worsen urinary retention (certain cold medicines, some antihistamines).
• Double-voiding — urinate, wait a minute, urinate again.

3. Medications

Two main drug classes, often used together:

• Alpha blockers (tamsulosin / Flomax, silodosin / Rapaflo, alfuzosin / Uroxatral) relax the muscle in the prostate and bladder neck, making it easier to urinate. Work within days. Most common side effect is retrograde ejaculation and sometimes dizziness.
• 5-alpha reductase inhibitors (finasteride / Proscar, dutasteride / Avodart) actually shrink the prostate by blocking a hormone. Take 3–6 months for full effect. Can reduce libido in some men.

Medications work well for many men — but they also have to be taken forever, and the effect can diminish over time. Many men eventually want an alternative.

4. Office-based procedures

• Rezūm (water vapor therapy) — steam is used to ablate excess prostate tissue. Office procedure, moderate recovery. Best for small-to-medium prostates.
• UroLift — small implants hold prostate tissue away from the urethra. Minimal downtime, preserves ejaculation. Best for small prostates with specific anatomy.
• Optilume — a drug-coated balloon that dilates the prostatic urethra. Newer, promising for certain patients.

5. Surgery

For larger prostates, severe symptoms, complications from BPH (retention, stones, kidney damage), or when minimally invasive options don't work:

• HoLEP (holmium laser enucleation of the prostate) — the modern gold standard. Removes the entire obstructing prostate tissue through the urethra. Works for any prostate size. Durable result — most men never need another BPH procedure. Read the complete HoLEP guide.
• TURP (transurethral resection of the prostate) — the traditional surgery. Works well for medium prostates but less durable than HoLEP for larger glands.
• Aquablation, Simple Prostatectomy — alternative approaches used in specific scenarios.

When surgery becomes the right answer

We usually consider a procedure when:

• Symptoms are significantly affecting your quality of life despite medication.
• You don't want to take daily medication forever.
• Medications aren't working or cause side effects you can't tolerate.
• You've had a complication from BPH — urinary retention, recurrent UTIs, bladder stones, kidney problems.
• You've had to go to the ER because you couldn't urinate.

One important thing

BPH is not prostate cancer. They are two separate conditions. However, both become more common with age, and many men have both. That's why we screen for cancer (with PSA) as part of a BPH workup, and why we continue periodic cancer screening even after BPH is treated.