Prostate Enlargement (BPH): Symptoms, Causes & Which Doctor to See

What is prostate enlargement and why does it happen?

The prostate is a walnut-sized gland below the bladder that surrounds the urethra, the tube carrying urine out of the body. It grows gradually with age under the influence of hormones, and by the 50s and 60s many men have some enlargement. When the gland squeezes the urethra or irritates the bladder, urinary symptoms develop.

Enlargement is benign and does not turn into cancer, although both conditions can exist together and cause similar symptoms. The size of the prostate does not always match how bothersome symptoms are; some men with large glands have few symptoms and vice versa.

• Increasing age, especially over 50
• Family history
• Obesity and lack of physical activity
• Diabetes and heart disease
• Hormonal changes with ageing

What are the symptoms of an enlarged prostate?

Symptoms fall into two groups. Voiding symptoms relate to emptying: a weak or interrupted stream, hesitancy, straining, a feeling that the bladder is not empty and dribbling afterwards. Storage symptoms relate to filling: needing to go often, urgency, and waking at night to pass urine (nocturia).

These symptoms can also come from an overactive bladder, urinary infection, diabetes, some medicines, drinking a lot in the evening or, less commonly, prostate cancer or a narrowing of the urethra. Assessment sorts out which applies.

Waking at night to urinate is not always due to the prostate. Producing large volumes of urine at night can result from drinking late, swelling in the legs, heart or kidney problems, sleep apnoea or diabetes, and a bladder diary helps identify this.

• Weak or slow urine stream
• Difficulty starting to urinate
• Stream that stops and starts
• Needing to go often or urgently
• Waking at night to pass urine
• Feeling the bladder is not empty
• Dribbling after finishing

When are prostate symptoms an emergency?

Acute urinary retention, a sudden inability to pass urine with a painful, swollen lower abdomen, is a medical emergency and needs a catheter to drain the bladder. It can be triggered by cold and flu medicines containing decongestants or antihistamines, alcohol, constipation or holding urine for too long. If any of the following apply, go to the nearest emergency department or call 112 or 108.

Visible blood in the urine is not always an emergency but should be checked by a urologist promptly, because it can signal bladder or kidney problems.

• Unable to pass urine with lower abdominal pain
• Fever, chills and pain on passing urine
• Large amounts of blood or clots in the urine
• Swelling of legs, drowsiness, vomiting and very little urine (possible kidney strain)
• Severe pain in the back or side with urinary symptoms

Which doctor should I see for prostate problems?

A urologist is the specialist for prostate enlargement and other urinary problems in men. At Lotus, the urology team assesses urinary symptoms, examines the prostate, interprets PSA results and discusses medicines and procedures.

Book an appointment if urinary symptoms are bothering you, if you wake more than once or twice a night to urinate, if your stream has become weak, if you have had an episode of retention or a urinary infection, or if you have a raised PSA result or a family history of prostate cancer.

• Bothersome urinary symptoms
• Night-time urination disturbing sleep
• Weak stream or straining
• Past urinary retention or infection
• Raised PSA or abnormal prostate examination
• Blood in the urine

What happens at a urology consultation for prostate symptoms?

The urologist asks about your symptoms, fluid intake, caffeine and alcohol, medicines, diabetes, previous surgery and family history. You may be asked to complete the International Prostate Symptom Score questionnaire and keep a three-day bladder diary recording what you drink and when and how much you pass.

Examination includes the abdomen and a digital rectal examination, in which a gloved finger gently feels the prostate for size, texture and lumps. It takes less than a minute. The urologist discusses PSA testing with you beforehand, including what a raised result might mean.

• Complete a bladder diary for three days if asked
• List all medicines, including cold remedies
• Note how often you wake at night to urinate
• Bring previous PSA and scan reports
• Ask what your symptom score means

Which tests are done for an enlarged prostate?

A urine test checks for infection, blood and sugar. A blood test checks kidney function and, after discussion, PSA (prostate-specific antigen), which can be raised by enlargement, infection, recent ejaculation or cancer. A raised PSA needs interpretation rather than alarm.

Uroflowmetry measures how fast you pass urine, and an ultrasound measures prostate size and how much urine is left in the bladder after voiding. Cystoscopy or urodynamic studies are used in selected cases, often before surgery.

Early prostate cancer usually causes no symptoms, so urinary symptoms are more often due to benign enlargement. Even so, the urologist looks for features that need further tests, such as a hard or irregular prostate on examination or a PSA raised for your age, which may lead to an MRI scan of the prostate and possibly a biopsy.

• Urine routine examination
• Serum creatinine
• PSA after counselling
• Uroflowmetry
• Ultrasound with post-void residual urine
• Cystoscopy or urodynamics in selected cases

How is an enlarged prostate treated?

Mild symptoms often improve with lifestyle measures and watchful waiting. Medicines include alpha-blockers such as tamsulosin, which relax the prostate and work within days, and 5-alpha reductase inhibitors such as finasteride or dutasteride, which shrink larger prostates over six months or more and lower PSA, which your doctor will account for. Combinations and medicines for bladder urgency are also used.

When medicines are not enough, or there is retention, recurrent infection, bladder stones, bleeding or kidney effects, procedures are considered. Transurethral resection of the prostate (TURP) is a long-established option. Laser procedures such as holmium laser enucleation (HoLEP), vaporisation and newer minimally invasive treatments suit different prostate sizes and priorities, such as preserving ejaculation. Your urologist will explain the trade-offs.

Each option has possible side effects, including dry ejaculation (semen passing back into the bladder), bleeding, infection, urinary leakage or, less commonly, erection problems. Herbal and over-the-counter prostate supplements have limited evidence of benefit; tell your urologist if you take any.

• Lifestyle changes and watchful waiting
• Alpha-blockers
• 5-alpha reductase inhibitors
• Combination or bladder-calming medicines
• TURP
• Laser enucleation or vaporisation
• Other minimally invasive procedures in selected men
• Catheter for retention

How can I manage prostate symptoms day to day?

Drink enough through the day, but reduce fluids in the two hours before bed, and limit tea, coffee and alcohol in the evening. In Bengaluru’s warm months, avoid cutting daytime fluids too much, which can lead to urinary infection and stones. Empty your bladder before bed and before long drives through traffic, and try double voiding: wait a moment after finishing and try again.

Avoid constipation, which presses on the bladder, keep active, manage weight and diabetes, and check with a doctor or pharmacist before taking cold, allergy or sleep medicines, which can worsen symptoms or trigger retention.

• Reduce fluids two hours before bed
• Limit evening tea, coffee and alcohol
• Double void and avoid holding urine too long
• Prevent constipation
• Stay active and manage weight
• Check medicines that can affect urination

When should I follow up for prostate enlargement?

After starting a medicine, a review within a few weeks to three months checks benefit and side effects such as dizziness or changes in ejaculation. Long-term, an annual review of symptoms, urine flow, residual urine and kidney function is common.

Return sooner if symptoms worsen, you have difficulty passing urine, develop an infection, or notice blood in the urine.

• Review after starting treatment
• Annual check of symptoms and kidney function
• PSA monitoring as discussed with your urologist
• Urgent review for retention or bleeding
• Remind any doctor checking PSA if you take finasteride or dutasteride, which lower the reading