Benign prostatic hyperplasia (BPH): symptoms, diagnosis and treatment

Benign prostatic hyperplasia (BPH) is the non-cancerous enlargement of the prostate that causes lower urinary tract symptoms (LUTS) and impairs quality of life. It is one of the most common male conditions of all: its prevalence rises with age, and it is among the leading reasons for a medical consultation in adult men in Italy, second only to arterial hypertension.

It is not a cancer, and it does not turn into one. BPH and prostate cancer are two distinct diseases. They may coexist in the same patient, but neither is the consequence of the other.

The symptoms: LUTS

Lower urinary tract symptoms fall into three groups.

Storage symptoms

• Increased daytime frequency: needing to pass urine too often during the day
• Nocturia: having to wake once or more each night to urinate
• Urgency: a sudden, compelling need to urinate that is difficult to defer
• Urinary incontinence: any involuntary loss of urine

Voiding symptoms

• Slow stream: the sense of a weaker flow than before
• Splitting or spraying of the urinary stream
• Intermittency: the flow stops and starts during voiding
• Hesitancy: difficulty and delay in initiating urination
• Straining: the muscular effort needed to start, maintain or improve the flow
• Terminal dribble: a prolonged final phase in which the flow slows to a dribble

Post-micturition symptoms

• Feeling of incomplete emptying
• Post-micturition dribble: involuntary loss of urine immediately after finishing, often once the man has left the bathroom

Why many men never see a doctor

Only a minority of men with symptoms consult a doctor. The reasons have been studied, and there are three:

• Regarding the symptoms as "normal" for advancing age (around 70% of cases)
• Scepticism about the effectiveness of available treatments (around 50%)
• Fear of surgery (around 25%)

All three beliefs can be set aside: BPH is a treatable disease, most patients never reach surgery, and urinary symptoms are not the inevitable price of ageing.

Diagnosis

The diagnostic pathway has several steps.

• Medical history: essential to rule out other conditions, urological and non-urological, that present with identical symptoms
• IPSS-QoL questionnaire (International Prostate Symptom Score): the most widely used LUTS assessment scale in the world, quantifying both the symptoms and their impact on quality of life
• Digital rectal examination: strongly recommended. It assesses anal sphincter tone (local neurological status), prostate size, and any change in the shape, consistency and tenderness of the gland
• Prostate ultrasound (suprapubic and transrectal) with measurement of the post-void residual: the most effective way of describing prostate morphology
• Uroflowmetry: measurement of urinary flow. Simple, non-invasive, repeatable and inexpensive; sensitive but not very specific

The PSA does not diagnose BPH

PSA (prostate-specific antigen) is a glycoprotein produced by the cells lining the prostatic ducts and acini, whose physiological role is to help liquefy seminal fluid. It is measured in blood as an organ marker, not a disease marker.

A raised PSA does not mean cancer. PSA has high sensitivity but poor specificity: it cannot distinguish between the different prostate conditions. A value above the age-adjusted range indicates only that the prostate may have a problem — inflammatory, congestive, or age-related enlargement. It is for the specialist, through proper assessment, to reach the correct diagnosis.

Treatment: it starts with watching and waiting

Watchful waiting

More than 90% of patients with mild LUTS managed by watchful waiting require no further intervention one year after the initial assessment. Starting with watchful waiting does not lead to worse symptom outcomes or a higher incidence of serious complications, even in patients with moderate symptoms.

Alpha-blockers

The bladder neck and the fibromuscular component of the prostate contain alpha receptors that govern the contraction and relaxation of these structures. Blocking them relaxes the muscle and improves voiding.

• Active ingredients: alfuzosin, doxazosin, tamsulosin, terazosin
• Effect: these are essentially symptomatic drugs, giving rapid relief by improving urinary flow and reducing outlet resistance. They significantly improve quality of life
• Caution: they may slightly lower blood pressure, so patients taking them should have their blood pressure checked periodically

5-alpha-reductase inhibitors

These lower intraprostatic levels of dihydrotestosterone (DHT), the 5-alpha-reduced metabolite of testosterone responsible for enlargement of the gland.

• Active ingredients: finasteride, dutasteride
• Effect: they reduce prostate volume by 15–25% at 12 months, particularly in larger glands, and prevent further progressive enlargement
• Difference from alpha-blockers: they act on the disease rather than only on the symptom, but the improvement in symptoms and peak flow is slower and smaller than with alpha-blockers

The two classes may be used as monotherapy or in combination, depending on prostate volume and the risk of progression.

Phytotherapy: what the studies actually show

Plant-derived preparations are widely used in Europe, but they deserve an honest assessment. The composition of plant extracts is highly complex, containing a wide range of chemical compounds, and it is unclear which is the active principle. The mechanism of action is generally unknown. A further problem: preparations of identical declared composition vary widely in the actual quantity of active compounds they contain.

• Serenoa repens (saw palmetto): the studies are largely underpowered, with insufficient follow-up and sometimes without placebo control. What emerges is moderate efficacy on symptom score, peak urinary flow and nocturia
• Pygeum africanum: symptomatic improvement reported by 65% of patients on active treatment versus 30% on placebo; nocturia reduced by 19%, post-void residual by 24%, and peak flow increased by 23%
• Other plant derivatives (Secale cereale, Urtica dioica, pumpkin seed, Hypoxis rooperi and others): although commercially available, they have no proven efficacy in the treatment of LUTS/BPH

Surgical treatment

For decades surgery was the only effective approach to bladder outlet obstruction caused by BPH. It remains the reference treatment in the cases that require it.

When surgery is indicated

• Moderate or severe LUTS resistant to medical therapy, with an impact on quality of life
• Chronic urinary retention refractory to medical therapy
• Recurrent urinary retention
• Chronic renal failure
• Bladder stones
• Recurrent haematuria refractory to medical therapy
• Bladder diverticula with septic complications
• Recurrent urinary tract infections

The reference techniques

• TURP (transurethral resection of the prostate): the reference technique against which all others are measured. It is performed with a diathermic loop, traditionally using monopolar current; bipolar current has been introduced in recent years
• TUIP (transurethral incision of the prostate): one or two incisions of the bladder neck and prostatic tissue. For prostates between 20 and 30 ml it gives results comparable to TURP in terms of LUTS improvement, with a lower incidence of complications, bleeding, transfusion and retrograde ejaculation, and shorter operating and hospital times. The drawbacks: more reoperations (9.3% versus 5.5% for TURP) and no tissue available for histological examination
• Open prostatic adenomectomy: performed transvesically or retropubically. European and American guidelines agree in recommending it for prostates larger than 80–100 ml

Late complications of prostate surgery

• Urinary incontinence: the most feared complication. Incidence is lower after TUIP (0.06–1.1%); after open adenomectomy it can reach up to 10% of cases
• Urethral stricture: on average 3.8% after TURP, 1.7% after TUIP, around 2% after open surgery
• Bladder neck sclerosis: around 4% after TURP, 0.4% after TUIP, 2.5% after open surgery. These rates are slightly higher in older patients
• Sexual dysfunction: common after prostate surgery, in particular retrograde ejaculation

Laser and endoscopic techniques

• Holmium laser enucleation (HoLEP): the Holmium laser (2,140 nm) is used in urology for a range of endourological applications. Comparative studies with traditional techniques indicate that it is an option for motivated patients, and particularly for those with significant coagulation disorders
• Prostate vaporisation: removal of prostatic tissue by vaporisation, using a dedicated electrode or a laser source

Alternative minimally invasive treatments

Minimally invasive techniques exist for specific patient profiles: typically men who prefer to avoid surgery and who do not respond to or cannot tolerate medical therapy, or high-surgical-risk patients with an indwelling catheter. This group includes transurethral microwave thermotherapy (TUMT), transurethral needle ablation (TUNA), water-induced thermotherapy (WIT) and prostatic stents. High-intensity focused ultrasound (HIFU) is not recommended for LUTS/BPH in clinical practice, and intraprostatic alcohol injection remains an experimental technique without reliable clinical data.

Frequently asked questions about benign prostatic hyperplasia

Is benign prostatic hyperplasia a cancer?

No. BPH is a benign enlargement of the prostate and does not turn into cancer. They are two distinct diseases, which may coexist in the same patient but do not cause one another.

Does a high PSA mean I have prostate cancer?

No. PSA is an organ marker, not a disease marker: high sensitivity, poor specificity. A raised value indicates only that the prostate may have a problem — inflammatory, congestive, or age-related enlargement — and must be interpreted by a specialist within the overall clinical picture.

Will I definitely need surgery?

No. More than 90% of patients with mild symptoms on watchful waiting need no intervention at one year. Surgery comes into play when symptoms are moderate or severe and resistant to medical therapy, or when complications appear: urinary retention, bladder stones, renal failure or recurrent infections.

Is getting up at night to urinate normal with age?

It is common, but not "normal" in the sense of inevitable or untreatable. Nocturia is one of the cardinal symptoms of BPH and one of the most common reasons quality of life deteriorates. Treating it as the price of ageing is precisely why around 70% of men with symptoms never consult a doctor.

Does prostate surgery affect sexual life?

Sexual dysfunction after prostate surgery is common, and the most frequent form is retrograde ejaculation: semen flows back into the bladder instead of being expelled. It should be discussed with the surgeon before the operation, along with the risk of incontinence and stricture.

Does saw palmetto (Serenoa repens) work?

The available studies show moderate efficacy on symptom score, peak flow and nocturia, but they are largely underpowered, with insufficient follow-up and sometimes no placebo control. It should also be borne in mind that preparations of identical declared composition may contain widely varying amounts of active compounds.

Do you have urinary symptoms or an abnormal PSA? Ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment. All medicines mentioned are prescription-only.

Benign prostatic hyperplasia (BPH): symptoms, diagnosis and treatment

Benign prostatic hyperplasia (BPH) is the non-cancerous enlargement of the prostate that causes lower urinary tract symptoms (LUTS) and impairs quality of life. It is one of the most common male conditions of all: its prevalence rises with age, and it is among the leading reasons for a medical consultation in adult men in Italy, second only to arterial hypertension.

It is not a cancer, and it does not turn into one. BPH and prostate cancer are two distinct diseases. They may coexist in the same patient, but neither is the consequence of the other.

The symptoms: LUTS

Lower urinary tract symptoms fall into three groups.

Storage symptoms

• Increased daytime frequency: needing to pass urine too often during the day
• Nocturia: having to wake once or more each night to urinate
• Urgency: a sudden, compelling need to urinate that is difficult to defer
• Urinary incontinence: any involuntary loss of urine

Voiding symptoms

• Slow stream: the sense of a weaker flow than before
• Splitting or spraying of the urinary stream
• Intermittency: the flow stops and starts during voiding
• Hesitancy: difficulty and delay in initiating urination
• Straining: the muscular effort needed to start, maintain or improve the flow
• Terminal dribble: a prolonged final phase in which the flow slows to a dribble

Post-micturition symptoms

• Feeling of incomplete emptying
• Post-micturition dribble: involuntary loss of urine immediately after finishing, often once the man has left the bathroom

Why many men never see a doctor

Only a minority of men with symptoms consult a doctor. The reasons have been studied, and there are three:

• Regarding the symptoms as "normal" for advancing age (around 70% of cases)
• Scepticism about the effectiveness of available treatments (around 50%)
• Fear of surgery (around 25%)

All three beliefs can be set aside: BPH is a treatable disease, most patients never reach surgery, and urinary symptoms are not the inevitable price of ageing.

Diagnosis

The diagnostic pathway has several steps.

• Medical history: essential to rule out other conditions, urological and non-urological, that present with identical symptoms
• IPSS-QoL questionnaire (International Prostate Symptom Score): the most widely used LUTS assessment scale in the world, quantifying both the symptoms and their impact on quality of life
• Digital rectal examination: strongly recommended. It assesses anal sphincter tone (local neurological status), prostate size, and any change in the shape, consistency and tenderness of the gland
• Prostate ultrasound (suprapubic and transrectal) with measurement of the post-void residual: the most effective way of describing prostate morphology
• Uroflowmetry: measurement of urinary flow. Simple, non-invasive, repeatable and inexpensive; sensitive but not very specific

The PSA does not diagnose BPH

PSA (prostate-specific antigen) is a glycoprotein produced by the cells lining the prostatic ducts and acini, whose physiological role is to help liquefy seminal fluid. It is measured in blood as an organ marker, not a disease marker.

A raised PSA does not mean cancer. PSA has high sensitivity but poor specificity: it cannot distinguish between the different prostate conditions. A value above the age-adjusted range indicates only that the prostate may have a problem — inflammatory, congestive, or age-related enlargement. It is for the specialist, through proper assessment, to reach the correct diagnosis.

Treatment: it starts with watching and waiting

Watchful waiting

More than 90% of patients with mild LUTS managed by watchful waiting require no further intervention one year after the initial assessment. Starting with watchful waiting does not lead to worse symptom outcomes or a higher incidence of serious complications, even in patients with moderate symptoms.

Alpha-blockers

The bladder neck and the fibromuscular component of the prostate contain alpha receptors that govern the contraction and relaxation of these structures. Blocking them relaxes the muscle and improves voiding.

• Active ingredients: alfuzosin, doxazosin, tamsulosin, terazosin
• Effect: these are essentially symptomatic drugs, giving rapid relief by improving urinary flow and reducing outlet resistance. They significantly improve quality of life
• Caution: they may slightly lower blood pressure, so patients taking them should have their blood pressure checked periodically

5-alpha-reductase inhibitors

These lower intraprostatic levels of dihydrotestosterone (DHT), the 5-alpha-reduced metabolite of testosterone responsible for enlargement of the gland.

• Active ingredients: finasteride, dutasteride
• Effect: they reduce prostate volume by 15–25% at 12 months, particularly in larger glands, and prevent further progressive enlargement
• Difference from alpha-blockers: they act on the disease rather than only on the symptom, but the improvement in symptoms and peak flow is slower and smaller than with alpha-blockers

The two classes may be used as monotherapy or in combination, depending on prostate volume and the risk of progression.

Phytotherapy: what the studies actually show

Plant-derived preparations are widely used in Europe, but they deserve an honest assessment. The composition of plant extracts is highly complex, containing a wide range of chemical compounds, and it is unclear which is the active principle. The mechanism of action is generally unknown. A further problem: preparations of identical declared composition vary widely in the actual quantity of active compounds they contain.

• Serenoa repens (saw palmetto): the studies are largely underpowered, with insufficient follow-up and sometimes without placebo control. What emerges is moderate efficacy on symptom score, peak urinary flow and nocturia
• Pygeum africanum: symptomatic improvement reported by 65% of patients on active treatment versus 30% on placebo; nocturia reduced by 19%, post-void residual by 24%, and peak flow increased by 23%
• Other plant derivatives (Secale cereale, Urtica dioica, pumpkin seed, Hypoxis rooperi and others): although commercially available, they have no proven efficacy in the treatment of LUTS/BPH

Surgical treatment

For decades surgery was the only effective approach to bladder outlet obstruction caused by BPH. It remains the reference treatment in the cases that require it.

When surgery is indicated

• Moderate or severe LUTS resistant to medical therapy, with an impact on quality of life
• Chronic urinary retention refractory to medical therapy
• Recurrent urinary retention
• Chronic renal failure
• Bladder stones
• Recurrent haematuria refractory to medical therapy
• Bladder diverticula with septic complications
• Recurrent urinary tract infections

The reference techniques

• TURP (transurethral resection of the prostate): the reference technique against which all others are measured. It is performed with a diathermic loop, traditionally using monopolar current; bipolar current has been introduced in recent years
• TUIP (transurethral incision of the prostate): one or two incisions of the bladder neck and prostatic tissue. For prostates between 20 and 30 ml it gives results comparable to TURP in terms of LUTS improvement, with a lower incidence of complications, bleeding, transfusion and retrograde ejaculation, and shorter operating and hospital times. The drawbacks: more reoperations (9.3% versus 5.5% for TURP) and no tissue available for histological examination
• Open prostatic adenomectomy: performed transvesically or retropubically. European and American guidelines agree in recommending it for prostates larger than 80–100 ml

Late complications of prostate surgery

• Urinary incontinence: the most feared complication. Incidence is lower after TUIP (0.06–1.1%); after open adenomectomy it can reach up to 10% of cases
• Urethral stricture: on average 3.8% after TURP, 1.7% after TUIP, around 2% after open surgery
• Bladder neck sclerosis: around 4% after TURP, 0.4% after TUIP, 2.5% after open surgery. These rates are slightly higher in older patients
• Sexual dysfunction: common after prostate surgery, in particular retrograde ejaculation

Laser and endoscopic techniques

• Holmium laser enucleation (HoLEP): the Holmium laser (2,140 nm) is used in urology for a range of endourological applications. Comparative studies with traditional techniques indicate that it is an option for motivated patients, and particularly for those with significant coagulation disorders
• Prostate vaporisation: removal of prostatic tissue by vaporisation, using a dedicated electrode or a laser source

Alternative minimally invasive treatments

Minimally invasive techniques exist for specific patient profiles: typically men who prefer to avoid surgery and who do not respond to or cannot tolerate medical therapy, or high-surgical-risk patients with an indwelling catheter. This group includes transurethral microwave thermotherapy (TUMT), transurethral needle ablation (TUNA), water-induced thermotherapy (WIT) and prostatic stents. High-intensity focused ultrasound (HIFU) is not recommended for LUTS/BPH in clinical practice, and intraprostatic alcohol injection remains an experimental technique without reliable clinical data.

Frequently asked questions about benign prostatic hyperplasia

Is benign prostatic hyperplasia a cancer?

No. BPH is a benign enlargement of the prostate and does not turn into cancer. They are two distinct diseases, which may coexist in the same patient but do not cause one another.

Does a high PSA mean I have prostate cancer?

No. PSA is an organ marker, not a disease marker: high sensitivity, poor specificity. A raised value indicates only that the prostate may have a problem — inflammatory, congestive, or age-related enlargement — and must be interpreted by a specialist within the overall clinical picture.

Will I definitely need surgery?

No. More than 90% of patients with mild symptoms on watchful waiting need no intervention at one year. Surgery comes into play when symptoms are moderate or severe and resistant to medical therapy, or when complications appear: urinary retention, bladder stones, renal failure or recurrent infections.

Is getting up at night to urinate normal with age?

It is common, but not "normal" in the sense of inevitable or untreatable. Nocturia is one of the cardinal symptoms of BPH and one of the most common reasons quality of life deteriorates. Treating it as the price of ageing is precisely why around 70% of men with symptoms never consult a doctor.

Does prostate surgery affect sexual life?

Sexual dysfunction after prostate surgery is common, and the most frequent form is retrograde ejaculation: semen flows back into the bladder instead of being expelled. It should be discussed with the surgeon before the operation, along with the risk of incontinence and stricture.

Does saw palmetto (Serenoa repens) work?

The available studies show moderate efficacy on symptom score, peak flow and nocturia, but they are largely underpowered, with insufficient follow-up and sometimes no placebo control. It should also be borne in mind that preparations of identical declared composition may contain widely varying amounts of active compounds.

Do you have urinary symptoms or an abnormal PSA? Ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment. All medicines mentioned are prescription-only.