Benign prostatic hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS) are common conditions affecting aging men. BPH is the non-cancerous enlargement of the prostate gland, driven by hormonal changes, particularly the accumulation of the androgen dihydrotestosterone (DHT). As the prostate increases in size, it physically compresses the urethra, the tube that carries urine from the bladder. This compression, combined with increased smooth muscle tone, creates resistance to urine outflow, known as bladder outlet obstruction (BOO).
Understanding BPH and LUTS
BPH describes the physical growth of prostate tissue, but LUTS are the symptoms men typically experience and report. LUTS are classified into two main categories: storage and voiding. Storage symptoms relate to how the bladder holds urine and include increased urinary frequency, urgency (a sudden, strong urge), and nocturia (waking up multiple times at night to urinate).
Storage issues occur because the bladder, working against the obstruction, may become thickened and overly sensitive. Voiding symptoms, resulting from obstructed outflow, include a weak or slow urinary stream, difficulty starting urination (hesitancy), an intermittent stream, and the sensation of incomplete emptying. Although symptom severity does not always correlate with prostate size, LUTS are the primary reason men seek treatment for BPH.
The Diagnostic Process
The initial evaluation confirms BPH as the likely cause of LUTS and rules out other conditions like prostate cancer, urinary tract infection (UTI), or bladder stones. The process starts with a detailed medical history and a standardized symptom questionnaire, such as the American Urological Association (AUA) Symptom Index. This seven-question tool objectively quantifies symptom severity, which is important for tracking the condition and assessing treatment effectiveness.
A physical examination includes a Digital Rectal Exam (DRE), where the doctor manually assesses the prostate’s size, shape, and consistency. Laboratory tests involve a urinalysis to check for infection, blood, or glucose, which may indicate a UTI or diabetes. A Prostate-Specific Antigen (PSA) blood test may also be performed; while BPH can elevate PSA levels, this test is primarily used to screen for prostate cancer. Optional tests include measuring the maximum urinary flow rate (uroflowmetry) and checking the post-void residual (PVR) volume to assess bladder emptying efficiency.
Lifestyle Changes and Medication
For men with mild to moderate symptoms, management begins with behavioral and lifestyle modifications, which are considered a low-risk, first-line approach. These interventions focus on minimizing bladder irritation and managing fluid intake to reduce symptom frequency. Fluid management involves limiting intake before bedtime to reduce nocturia, and reducing consumption of bladder irritants like caffeine and alcohol, which act as diuretics and increase urgency.
Behavioral techniques include “double voiding,” where the patient attempts to urinate again shortly after the first void to ensure more complete bladder emptying. Pelvic floor muscle training, such as Kegel exercises, may help improve control, especially with urgency symptoms. Maintaining a healthy body weight and managing constipation are also recommended, as both can place pressure on the bladder and worsen LUTS.
When symptoms are more bothersome, medical therapy uses two distinct classes of drugs. Alpha-blockers relax the smooth muscles in the prostate and bladder neck, immediately reducing resistance to urine flow. These medications provide quick symptomatic relief, often within days or weeks, regardless of prostate size.
The second class is 5-alpha reductase inhibitors (5-ARIs), which shrink the prostate gland by addressing the root cause of enlargement. These drugs inhibit the enzyme 5-alpha reductase, lowering DHT levels and causing prostate tissue to involute. This effect takes significantly longer, often requiring three to six months for symptom improvement and up to a year for maximum shrinkage. For men with larger prostates (greater than 30-40 mL), a combination of an alpha-blocker and a 5-ARI is often prescribed to maximize both rapid relief and long-term size reduction.
When Surgery is Necessary
Surgery is generally reserved for men with severe symptoms unresponsive to medication or those who develop complications. Absolute indications include recurrent urinary tract infections, persistent blood in the urine, bladder stones, kidney damage from obstruction, or acute urinary retention requiring catheterization. These complications signal that bladder outlet obstruction poses a serious health risk.
The traditional standard approach is Transurethral Resection of the Prostate (TURP). This involves inserting a scope through the urethra and using an electrical loop to scrape away obstructing prostate tissue. TURP provides durable symptom relief but typically requires a hospital stay and several weeks of recovery. Newer, minimally invasive procedures offer alternatives with potentially shorter recovery times and fewer side effects.
Holmium Laser Enucleation of the Prostate (HoLEP)
HoLEP uses a laser to precisely remove the entire obstructing inner portion of the prostate, which is then morcellated and removed from the bladder. This method is preferred for very large prostates, offering excellent long-term results with less bleeding and a shorter hospital stay compared to TURP.
Minimally Invasive Surgical Treatments (MISTs)
Other MISTs include the UroLift system, which uses small implants to hold the enlarged prostate lobes apart, and the Rezūm system, which uses water vapor to destroy excess prostate tissue. These are typically outpatient procedures best suited for men with smaller to moderate-sized prostates who wish to avoid the potential sexual side effects associated with more extensive surgery.