Benign prostatic enlargement

BPE can result in a range of symptoms including:

• A delay in starting and/or finishing urinating
• Having to strain to urinate
• A weak stream of urine
• Stopping and starting while urinating
• Spraying urine while going to the toilet, or the urinary stream splitting
• The feeling that you cannot fully empty your bladder
• Needing to urinate more often than is normal and/or more urgently
• Waking up at night to urinate
• Finding it difficult to hold or control your bladder
• Accidentally leaking urine (urinary incontinence)

In some men, the symptoms are mild and do not need treatment. In others, they can be troublesome and can benefit from treatment.

Can you prevent BPE?

There are no known ways of preventing BPE, as its causes are unknown. BPE is more common in older men, so it is thought that advancing age is an important factor.

It is always a good idea to maintain a healthy lifestyle, which includes staying active and eating a balanced diet.

Click here to watch a video about benign prostatic enlargement

There are a number of different treatments for BPE. The treatment(s) you are offered will vary depending on your medical history, the type of symptoms you have, how severe they are, and how they affect your life.

Self-management of symptoms

You can actively manage, and potentially even improve, your own BPE symptoms by:

• Taking your time to completely empty your bladder each time you urinate. It may help to sit down.
• Double voiding. This involves waiting a few moments after you have finished urinating before trying to wee again. This can help to empty your bladder fully.
• Using an absorbent pad in your underwear to soak up any leaks.
• After urinating, pressing under your scrotum onto the urethra with your fingers, and then sliding your fingers from the base to the tip of the penis to squeeze out any last drops of urine. This can help to avoid wetting your underwear.
• Using breathing exercises to distract yourself when you feel an urgent need to urinate.
• Trying to hold on for longer when you feel the need to urinate. This will train the bladder to hold more urine before the urge to urinate comes.
• Eating plenty of fibre to avoid constipation.
• Bladder training to lengthen the time between urinating, by setting a target of, for example, 2 hours, and using relaxation techniques and muscle exercises to increase that length of time (your doctor can provide more information about this).
• Keeping a bladder diary so that you have a record of when you go to the toilet and your symptoms. After the event, it is often difficult to remember when symptoms worsened or became more bothersome. A diary can help your doctors to monitor your condition and lead to the best management of your BPE.

Watchful waiting

You may wish to consider ‘watchful waiting’ if your symptoms are mild to moderate and they aren’t bothersome enough to noticeably affect your quality of life.

A watchful waiting programme involves:

• Assessment of your symptoms during a consultation appointment with a doctor
• A physical examination
• Blood and urine tests
• Education and advice about your condition
• Ongoing support with managing your BPE

During watchful waiting, mild to moderate BPE symptoms can often be treated with lifestyle changes such as:

• Drinking at least 1 litre of fluid every day.
• Drinking less fluid before going to bed or before long trips to reduce the need to urinate during these times.
• Drinking less alcohol, caffeine, fizzy drinks and artificial sweeteners, which can irritate the bladder and make your symptoms worse.
• Taking regular exercise (at least 2-3 times a week). Lack of movement can make it more difficult to urinate.
• Having a balanced and varied diet.
• Keeping your lower abdomen warm and dry. Cold and damp increases the urge to urinate.
• If your urine sprays when you go to the toilet, it can be helpful to sit down to urinate instead of standing or if you prefer to stand, to urinate into a cup and pour that into the toilet.
• Discuss with your doctor, all medication you are taking for any condition as some medicines, such as ‘water tablets’ (called diuretics), may cause urinary symptoms to worsen.

You will be offered regular check-ups as part of watchful waiting, to make sure that your condition has not got any worse, or more troublesome to you. If it has, your doctor can discuss treatment options that are available to you.

Medicines

If lifestyle changes are not enough to manage your BPE symptoms, you may be offered medicines for your BPE. Many of these work by either relaxing the muscle of the prostate gland or bladder or shrinking the prostate gland, so that it doesn’t press on the urethra. Sometimes a combination of these medicines can be used.

If your symptoms are mainly related to the urgent need to urinate or having to urinate multiple times through the day and night, your doctor can recommend medications that affect the bladder alone, or which combine to act on the prostate as well, to improve your symptoms.

Many medicines cause mild to moderate side-effects and your doctor will discuss these with you before you make any decisions about medical treatments.

Types of Medicines

Medicines to treat BPE symptoms work by relaxing the muscles in the prostate or bladder to reduce the number of times you feel you need to urinate, or by preventing the prostate from growing, thereby stopping symptoms from worsening. They fall into several categories, depending on the way they work.

• Alpha-blockers are a group of drugs which help the symptoms and the flow of urine by relaxing the smooth muscles of the prostate. This is the most commonly recommended group of drugs for men with BPE.
• Beta-3 agonists are a type of medicine that can help to relax the bladder. These drugs are usually prescribed for the treatment of overactive bladder (OAB) symptoms, but they can also help men with specific symptoms caused by BPE.
• 5-alpha-reductase inhibitors (5ARIs) are a group of drugs which prevent the prostate from growing and may even shrink it. These drugs work better in prostates larger than 40 mL and are only prescribed when prostate enlargement symptoms cause significant problems.
• Muscarinic receptor antagonists (MRAs) are a group of drugs which reduce abnormal contractions, or squeezing, of the muscles in the bladder. These drugs are usually prescribed for the treatment of overactive bladder (OAB) symptoms, but they can also help men with specific symptoms caused by BPE, such as an urgent need to pee. These medicines are generally not prescribed if the bladder does not empty completely after urination.
• Phosphodiesterase 5 inhibitors (PDE5Is) are a group of drugs used for the treatment of erectile dysfunction. These drugs can also improve some symptoms caused by BPE.
• Phytotherapy, which is also known as plant extracts or herbal drugs. Hexane-extracted Serenoa repens, in particular, is also now recommended by the EAU as phytotherapy can provide moderate benefits for men to help ease their BPE symptoms. Phytotherapy also has very few side-effects.

Combinations of medicines

The combination of alpha-blockers with 5ARIs is recommended if:

• your prostate is larger than 40 mL;
• your prostate-specific antigen level is 1.5 ng/mL or higher;
• your symptoms are severe, and you have slow flow of urine.

This combination of drugs is only advised for long-term treatment.

The combination of alpha-blockers and MRAs or beta-3 agonists is recommended if you have symptoms such as an increased or sudden need to urinate and your symptoms have not improved when taking one type of drug.

Common surgical treatment of BPE

Most men with urinary symptoms arising from BPE do not need to have surgery, but it may be an option if other treatments have not worked, or if your symptoms have worsened and you feel they are noticeably affecting your quality of life. Your doctor will discuss whether surgery is appropriate for you, and the potential options so that you can make an informed decision.

Things you may wish to consider when discussing surgery with your doctor include:

• How your symptoms are affecting your quality of life.
• How well you are tolerating any medication you are currently taking.
• Whether your enlarged prostate is causing problems with your kidneys or repeated urine infections, kidney stones, or if you are unable to completely empty your bladder.
• If your medical history makes you a suitable candidate for surgery.
• The surgical treatments that are available at your hospital.
• Your personal preferences.

There are many different types of surgical procedures for BPE, but all of them aim to relieve your symptoms and improve the flow of urine. Although surgery works well for most men, it can cause side-effects. It is important to discuss these with your doctor before deciding whether to proceed with surgery for your BPE.

Transurethral resection of the prostate (TURP)

This is the most common surgery for BPE and is usually done under a general anaesthetic or spinal anaesthetic so you will not feel any pain during the procedure.

During the procedure, a thin device called a resectoscope is inserted through the urethra. The resectoscope has a wire loop at the end of it which uses a high-frequency electrical current to cut the prostate tissue. It also has a camera which allows the surgeon to see a high-quality image of the prostate on a video monitor. The surgery involves removing the section of prostate tissue that is blocking the flow of urine.

At the end of the operation, a catheter is placed in your bladder to help drain urine while you recover from the surgery.

The catheter tube is inserted via the urinary opening in the penis. It is passed down the length of the penis, up the urethra and into the bladder. The catheter is inserted at the end of your surgery, so you will not feel any discomfort as you will still be asleep or numb (depending on the type of anaesthetic you have) when the catheter is placed.

You will not need to use the toilet to urinate while a catheter is in place as it drains urine out of the bladder, down the catheter tube and into a urine bag that your medical team will empty for you, as needed.

As well as draining urine away, the catheter also allows your doctor to flush your bladder and urethra with a sterile solution to help prevent blood clots.

The catheter will be removed shortly after surgery, once you can urinate on your own. Removing the catheter is usually done by a nurse and is very straightforward, with little discomfort.

You will usually be advised to avoid sexual activity for 2-3 weeks and it is not uncommon when you do to experience what is called “retrograde ejaculation”. Sometimes called a dry orgasm, retrograde ejaculation is a condition where semen goes into the bladder, rather than through your urethra and out of your penis during an orgasm. It isn’t harmful and the semen will pass through the bladder when you pee, but it can cause fertility issues.

If you have undergone TURP surgery and are producing little to no semen when you climax, have cloudy urine after sex, or your female partner is struggling to get pregnant, then you may wish to talk to your doctor about a test for retrograde ejaculation.

A resectoscope is inserted through the urethra

The resectoscope removes part of the prostate

Transurethral incision of the prostate (TUIP)

A TUIP procedure is only suitable for men with very small prostates. During a TUIP procedure, rather than removing the section of prostate tissue that is blocking the flow of urine (called a TURP procedure), the surgeon uses a resectoscope to make a small incision in the neck of the bladder next to the urethra to widen it. The procedure involves having the resectoscope inserted through the urethra, but it is done under a general anaesthetic or spinal anaesthetic so you will not feel anything.

At the end of the operation, a catheter is placed in your bladder to help drain urine while you recover from the surgery.

The catheter tube is inserted via the urinary opening in the penis. It is passed down the length of the penis, up the urethra and into the bladder. The catheter is inserted at the end of your surgery, so you will not feel any discomfort as you will still be asleep or numb (depending on the type of anaesthetic you have) when the catheter is placed.

You will not need to use the toilet to urinate while a catheter is in place as it drains urine out of the bladder, down the catheter tube and into a urine bag that your medical team will empty for you, as needed.

The catheter will be removed shortly after surgery, once you can urinate on your own. Removing the catheter is usually done by a nurse and is very straightforward, with little discomfort.

Open prostatectomy

An open prostatectomy is only carried out in certain situations. This is because, while the surgery is known to be effective, it is major surgery and may take longer to heal. It is generally only suitable for men who have an enlarged prostate over a certain size (usually 80 mL, which is approximately 4 times the size of a healthy prostate).

During an open prostatectomy the prostate gland is removed through a cut in your lower abdomen under a general anaesthetic or spinal anaesthetic so you will either be asleep during the procedure or awake but will be numb from the waist down.

At the end of the operation, a catheter is placed in your bladder to help drain urine while you recover from the surgery.

The catheter tube is inserted via the urinary opening in the penis. It is passed down the length of the penis, up the urethra and into the bladder. The catheter is inserted at the end of your surgery, so you will not feel any discomfort as you will still be asleep or numb (depending on the type of anaesthetic you have) when the catheter is placed.

You will not need to use the toilet to urinate while a catheter is in place as it drains urine out of the bladder, down the catheter tube and into a urine bag that your medical team will empty for you, as needed.

As well as draining urine away, the catheter also allows your doctor to flush your bladder and urethra with a sterile solution to help prevent blood clots.

You may need to keep the catheter in place for a week or more until you can urinate on your own. Removing the catheter is usually done by a nurse and is very straightforward, with little discomfort.

Removing the prostate means you will no longer ejaculate when you orgasm. You will still feel the sensation of an orgasm, but no semen is produced. So, while it may feel a little different at first, you can still experience sexual pleasure.

Removal of the prostate through the lower abdomen

Laser vaporisation of the prostate

A thin device called a resectoscope is inserted through the urethra. The resectoscope has a laser at the end of it which uses heat to destroy part of the prostate tissue, and a camera that allows the surgeon to see a high-quality image on a video monitor. The procedure is done under a general anaesthetic or spinal anaesthetic so you will not feel anything.

At the end of the operation, a catheter is placed in your bladder to help drain urine while you recover from the surgery.

The catheter tube is inserted via the urinary opening in the penis. It is passed down the length of the penis, up the urethra and into the bladder. The catheter is inserted at the end of your surgery, so you will not feel any discomfort as you will still be asleep or numb (depending on the type of anaesthetic you have) when the catheter is placed.

You will not need to use the toilet to urinate while a catheter is in place as it drains urine out of the bladder, down the catheter tube and into a urine bag that your medical team will empty for you, as needed.

The catheter will be removed once you can urinate on your own. Removing the catheter is usually done by a nurse and is very straightforward, with little discomfort.

You will usually be advised to avoid sexual activity for 2-3 weeks and it is not uncommon when you do to experience retrograde ejaculation. Sometimes called a dry orgasm, retrograde ejaculation is a condition where semen goes into the bladder, rather than through your urethra and out of your penis during an orgasm. It isn’t harmful and the semen will pass through the bladder when you pee, but it can cause fertility issues.

If you have had laser vaporisation and are producing little to no semen when you climax, have cloudy urine after sex, or your female partner is struggling to get pregnant, then you may wish to talk to your doctor about a test for retrograde ejaculation.

 A resectoscope is inserted through the urethra

The resectoscope destroys part of the prostate

Laser enucleation of the prostate (also called Holmium laser enucleation of the prostate or HoLEP)

Laser enucleation is generally suitable for men who have an enlarged prostate over a certain size (usually 80 mL, approximately 4 times the size of a healthy prostate). The procedure involves a surgeon passing a thin device called a resectoscope through the urethra. The resectoscope has a high pulse laser at the end of it which removes the prostate gland and a camera that allows the surgeon to see a high-quality image on a video monitor. The prostate is cut into very small pieces and removed using a surgical tool passed through the urethra.

The procedure is done under a general anaesthetic or spinal anaesthetic so you will not feel anything.

At the end of the operation, a catheter is placed in your bladder to help drain urine while you recover from the surgery.

The catheter tube is inserted via the urinary opening in the penis. It is passed down the length of the penis, up the urethra and into the bladder. The catheter is inserted at the end of your surgery, so you will not feel any discomfort as you will still be asleep or numb (depending on the type of anaesthetic you have) when the catheter is placed.

You will not need to use the toilet to urinate while a catheter is in place as it drains urine out of the bladder, down the catheter tube and into a urine bag that your medical team will empty for you, as needed.

As well as draining urine from the bladder, the catheter also allows your doctor to flush your bladder and urethra with a sterile solution to help prevent blood clots.

The catheter will be removed once you can urinate on your own. Removing the catheter is usually done by a nurse and is very straightforward, with little discomfort.

You will usually be advised to avoid sexual activity for 2-3 weeks and it is not uncommon when you do to experience retrograde ejaculation. Sometimes called a dry orgasm, retrograde ejaculation is a condition where semen goes into the bladder, rather than through your urethra and out of your penis during an orgasm. It isn’t harmful and the semen will pass through the bladder when you pee, but it can cause fertility issues.

If you have undergone laser enucleation surgery and are producing little to no semen when you climax, have cloudy urine after sex, or your female partner is struggling to get pregnant, then you may wish to talk to your doctor about a test for retrograde ejaculation.

 A resectoscope is inserted through the urethra

The resectoscope removes the enlarged prostatic tissue

Prostatic urethral lift

During this procedure, a surgeon uses a thin device to insert implants into both sides of the prostate to force it away from the urethra, so it is no longer blocked. This helps to relieve symptoms such as pain or difficulty when urinating. It is usually done under sedation .

The following surgical procedures have been more recently developed. The EAU currently considers these techniques to require further assessment and to show strong scientific evidence of benefit before they can be approved, so they are currently under evaluation.

Fewer doctors are trained in these techniques, so they may not be available in your local hospital.

Aquablation

This is a new treatment for BPE. Water is injected into the prostate using a probe passed into the urethra. The pressure of the water is used to destroy some of the prostate tissue, making it smaller.

Water ablation is less likely to cause side effects, however not all surgeons are trained to do this procedure.

Prostatic artery embolisation

A vascular catheter is inserted into an artery in your groin. Using X-ray guidance, it is passed into the blood vessels that supply the prostate gland. Tiny plastic particles are injected into these vessels to reduce the prostate gland’s blood supply, which shrinks it. This procedure can be done under a local anaesthetic as an outpatient.

Convective water vapour energy (WAVE) ablation, or the Rezum system

The surgeon passes a tool into the urethra and forces sterile water vapour or steam through it, into targeted parts of the prostate tissue. When the steam turns back into water, it causes the treated prostate cells to die. Over time, the body’s natural healing response removes the dead cells, thereby shrinking the prostate and enabling the urethra to open.

iTind

iTind is a folded medical device which is inserted into the urethra, where it makes contact with the prostate. iTind stays in place for up to a week, during which time it unfolds, expands, and re-widens the urethra. The device is then removed, but the urethra stays re-shaped even after iTind has been taken out. This means that normal urine flow is restored and remains.
iTind is usually inserted under sedation and local anaesthetic.

It is important to discuss the side-effects of any treatment recommended to treat your BPE. It is likely that you will have a number of treatment options and your doctor will be happy to discuss what each involves, the benefits and the risks and side-effects of each. It is important to be fully informed so that you and your medical team make decisions that you are comfortable with.

This section covers some of the common side-effects of BPE treatments so that you can read and consider these before speaking to your medical team for advice relating to your own personal circumstances.

Medicines

Medicines to treat BPE generally do not have many side effects, but for those few medicines that do, the side effects are usually mild and disappear shortly after the medicine is stopped.

Side-effects of BPE medicines include:

• Dizziness
• Blood pressure changes
• Headache
• Indigestion
• Dry eyes
• Dry mouth
• Constipation

Additionally, some medicines can cause side-effects related to sexual dysfunction, such as decreased sexual drive, erectile dysfunction, or problems with ejaculation. Although it may feel uncomfortable, it is important to discuss these side-effects with your doctor if you experience them.

It is important to note that just because a side-effect is listed for a medicine, it does not mean that you will necessarily experience it. Some people do not notice any side-effects at all when taking medicines for BPE.

The advantage of medication is that if it doesn’t suit you, you can stop taking it and try something else.

Surgery

The most common temporary side-effects of surgery for BPE include:

• Infections
• Risk of bleeding
• Being unable to pass urine
• Scarring that narrows the urethra
• Temporary pain when urinating

If you experience any of the above side-effects, they should resolve a short time after surgery but please speak to your doctor if you are concerned, or if the effects seem to be lasting for longer than a few days post-surgery.

Permanent retrograde ejaculation (where semen enters the bladder instead of emerging through the penis) is a possible long-term to permanent side-effect of surgery and this should be discussed with your doctor.

Effects on your social life

The symptoms of BPE, such as needing to urinate urgently or very often, can be difficult to deal with. You may be worried about carrying out your usual social activities due to fear that there may not be a toilet nearby. It is important that you do not avoid social activities that you enjoy. Instead, go to your doctor, who will be able to give you advice and discuss possible treatment options that can help you manage your symptoms.

Effects on your personal relationships and sex life

BPE symptoms can have a negative effect on your personal relationships and sex life. It can be difficult to feel confident when you do not always feel in control of your body. Episodes of leaking or needing to find a toilet quickly can be embarrassing and lower your self-esteem. Side-effects of drug treatments, such as lack of sexual drive or erectile dysfunction, can add to these feelings.

These changes can be difficult to deal with and some men can suffer from depression as a result. That is why the effect of BPE on a person’s quality of life should not be underestimated. Living with BPE can be challenging for yourself and your partner, so it’s very important that you talk together and discuss the best way to cope with this condition. Together with your partner and your doctor, you can identify what is important in both your everyday life and your sex life and choose the best treatment option, to make it easier for you to live with BPE.

Seeking help

It may feel difficult to talk to your doctor about problems with urinating or about your sexual activity. Or perhaps you are afraid that you have an incurable disease or will receive the wrong diagnosis. These concerns are understandable, but your doctor will have helped many patients like you.

Do not let a prostate condition rule your life, arrange an appointment with your doctor today.

What happens if BPE comes back?

BPE cannot be completely cured and all medical and surgical treatments that are available focus on reducing the symptoms as far as possible. BPE symptoms and how bothersome they are can change over time. You may or may not decide to have further or more invasive treatment depending on your circumstances or how much the symptoms affect your daily life.

Your doctor will help you to make informed decisions about how you decide to treat your BPE and advise you of any new treatment options available so that your BPE is as well-managed as it can be, and you are able to enjoy your relationships and participate in all aspects of your life.