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ENLARGED PROSTATE
(Benign Prostatic Hyperplasia – BPH)

What is the prostate?

The prostate is a small gland that only men have. It sits just below the bladder and surrounds the first part of the water pipe (urethra) that carries urine out through the penis.

Its main job is to produce a fluid that mixes with sperm to form semen. This fluid helps to nourish and protect sperm.

All men are born with a prostate. During puberty it grows under the influence of male hormones. Later in life, usually from the age of 40–50 onwards, it often starts to grow again. This age-related growth is called benign prostatic hyperplasia (BPH), which means “non-cancerous enlargement of the prostate”.

An enlarged prostate is only considered a medical problem when it starts to block the flow of urine or causes troublesome urinary symptoms.

How common is prostate enlargement?

Enlarged prostate is very common:

• Many men over 50 have some degree of enlargement

• The likelihood increases with age

However:

• Not all men with a large prostate have symptoms

• Some men with only mild enlargement can still have marked urinary problems

The size of the prostate is only one factor. Where the tissue grows and how it affects the urine channel are just as important.

What symptoms can prostate enlargement cause?

As the prostate enlarges, it can squeeze the urethra and make it harder for urine to flow freely. This can cause “lower urinary tract symptoms”. These fall into two main groups.

Storage symptoms (when the bladder is filling):

• Going to the toilet more often than before

• Getting up at night to pass urine (nocturia)

• Sudden, strong urges to pass urine

• Leakage of urine if you cannot reach the toilet in time

Voiding symptoms (while passing urine):

• Difficulty getting the flow started

• Weak or thin flow

• Stopping and starting several times (intermittent stream)

• Splitting or spraying of the stream

• Feeling that the bladder has not emptied completely

• Dribbling after finishing

In more advanced cases you may also experience:

• Blood in the urine

• Repeated urine infections

• A build-up of urine in the bladder (residual urine)

• Sudden inability to pass urine at all, needing an emergency catheter

• Over time, possible strain on the kidneys if the blockage is severe and long-standing

Symptoms can vary a lot from person to person. Some men are very bothered by relatively mild changes; others cope for years with more significant problems.

Is enlarged prostate the same as prostate cancer?

No. These are two different conditions.

Benign Prostatic Hyperplasia (BPH):

• “Benign” means non-cancerous

• It is age-related overgrowth of prostate tissue, usually in the central part that surrounds the urethra

• It can squeeze the urine channel and cause urinary symptoms

• It does not spread to other organs

Prostate cancer:

• “Malignant” means cancerous

• It usually starts in the outer part of the prostate

• It can, in some cases, spread beyond the prostate if not detected and treated appropriately

• The treatment (surgery, radiotherapy, active surveillance, etc.) and course are very different from BPH

Having BPH does not mean you will get prostate cancer. A small prostate does not rule cancer out either. This is why regular checks are important from a certain age or if you have risk factors.

What happens at a prostate check? What is PSA?

From around the age of 50, many men are offered a prostate health check. Men with a strong family history of prostate cancer or men of higher-risk ethnic backgrounds may start earlier, for example from 45.

A typical assessment includes:

History

• Questions about urinary symptoms (daytime and night-time)

• How much these bother you and affect your daily life and sleep

• Any blood in the urine, infections, pain or weight loss

Examination

• A digital rectal examination (DRE), in which a doctor gently feels the prostate through the back passage to assess its size, shape and texture

PSA blood test

• PSA stands for Prostate Specific Antigen

• It is a protein made by the prostate and measured in a sample of blood

• PSA can be raised in prostate cancer, but also in benign enlargement, inflammation (prostatitis), urine infection, after ejaculation or after catheter insertion and prostate examinations

A raised PSA does not automatically mean cancer. It does mean:

• The result needs to be interpreted in context (age, prostate size, family history, examination findings)

• Sometimes the test is repeated

• In selected cases, further tests such as MRI scan and, if needed, prostate biopsy may be advised

Your urologist will discuss the meaning of your PSA result and whether any further investigation is appropriate.

How is prostate enlargement diagnosed?

The aim is to confirm that the prostate is the main cause of your symptoms and to exclude other problems such as stones, tumours or bladder nerve disorders.

Common assessments include:

Symptom assessment

• Discussion about your urinary symptoms

• Often a questionnaire such as the International Prostate Symptom Score (IPSS) to rate severity and impact on quality of life

Physical examination

• General examination

• Abdominal examination to feel for a full bladder

• Digital rectal examination of the prostate

Urine tests

• Standard urine dipstick or laboratory test to look for infection, blood, sugar and protein

Blood tests

• Kidney function tests (urea and creatinine)

• PSA where appropriate

Ultrasound scan

• To check the kidneys, bladder and prostate

• To see whether you are leaving a significant amount of urine behind in the bladder after passing water (post-void residual)

Additional tests in selected cases:

• Uroflowmetry – a test that measures how fast your urine flow is

• Urodynamics – more specialised tests to study bladder function and pressures, used in complex cases

Not every man needs every test. The exact work-up is tailored to your symptoms, risk factors and general health.

Does every enlarged prostate need treatment?

No. Treatment decisions are based on:

• How severe your symptoms are

• How much they affect your quality of life

• Whether your bladder and kidneys are at risk

Treatment may not be needed if:

• Symptoms are mild and do not bother you very much

• Kidney function is normal

• You are emptying the bladder reasonably well

• There are no repeated infections, stones or bleeding

In these cases, a “watchful waiting” approach may be used, with:

• Lifestyle advice

• Regular monitoring

• Starting treatment only if and when things worsen

Treatment is more often recommended if:

• Symptoms are moderate or severe and affect daily life

• Tablets are not helping enough

• You have had urine retention (inability to pass urine)

• You have repeated infections, bladder stones or bleeding

• There is a significant amount of urine left in the bladder

• Kidney function is starting to suffer

Medical treatment for BPH

For many men, the first active step is medication. The aim is to relieve symptoms and improve urine flow.

Main groups of medicines:

Alpha-blockers

• Relax the smooth muscle in and around the prostate and bladder neck

• Help the urine channel open more easily

• Often start to work within days or weeks

Possible side-effects:

• Tiredness, dizziness or low blood pressure

• Occasionally, semen going backwards into the bladder during orgasm (retrograde ejaculation). Sexual pleasure is usually unchanged, but the amount of visible semen is reduced.

5-alpha reductase inhibitors

• Work by blocking the conversion of testosterone to a more active form inside the prostate

• Over months, this can shrink the prostate and slow further growth

• Best suited to men with a clearly enlarged prostate

Possible side-effects:

• Reduced sex drive

• Difficulties with erection

• Reduced semen volume

Combination therapy

• In some men with larger prostates and more marked symptoms, an alpha-blocker and a 5-alpha reductase inhibitor are used together, at least for a period of time.

Other medicines

• Bladder-relaxing tablets (anticholinergics or beta-3 agonists) can help if urgency and frequency are the main issues

• In some cases, tablets originally developed for erectile dysfunction can also help urinary symptoms

The choice of medicine depends on your symptom pattern, prostate size, blood pressure, other medical conditions and any other drugs you are taking.

When is surgery or a procedure needed?

Surgery or other procedures are considered when:

• Symptoms remain troublesome despite tablets

• Problems return quickly if you stop medication

• There are complications such as urine retention, repeated infections, stones, bleeding or kidney strain

The aim is to remove or destroy the part of the prostate that is blocking the urethra so that the bladder can empty more easily.

Below are three key options described in more detail:
TURP (the classic operation), Rezūm (water vapour therapy) and Aquablation (robotic waterjet surgery). Other methods are summarised briefly afterwards.

TURP / Plasmakinetic TURP
(Endoscopic prostate surgery)

What is TURP?

TURP (Transurethral Resection of the Prostate) has been the standard operation for BPH for many years.

• A telescope is passed through the tip of the penis into the urethra

• There is no cut on the skin

• The inner part of the prostate that is pressing on the urethra is shaved away in small chips and removed through the scope

Plasmakinetic (bipolar) TURP is the same basic procedure using a newer energy system with some safety advantages in certain situations.

Who is it suitable for?

• Men with moderate to large prostates

• Men whose symptoms have not improved enough with tablets

• Men who are fit enough for spinal or general anaesthetic

How is it done?

• Done in the operating theatre under spinal (from the waist down) or general anaesthetic

• The surgeon shaves out the obstructing tissue from inside the prostate

• The removed tissue is sent to the laboratory for microscopic examination

After the operation:

• A catheter is left in the bladder for 1–3 days

• It is normal to see some blood in the urine at first

• Most men stay in hospital for 1–3 days

• For a few weeks you may notice frequency, urgency or burning when passing urine; these symptoms usually settle gradually

Possible risks:

• Bleeding (rarely requiring a transfusion)

• Infection

• Temporary leakage or urgency

• Retrograde ejaculation (semen going backwards into the bladder instead of out through the penis during orgasm)

• Rarely, longer-term scarring or persistent incontinence

For many men with moderate to large prostates, TURP / plasmakinetic TURP remains the reference standard treatment.

Rezūm water vapour therapy
(Minimally invasive BPH treatment)

What is Rezūm?

Rezūm is a minimally invasive treatment that uses water vapour (steam) to shrink excess prostate tissue from the inside.

• A small device is passed through the urethra into the prostate

• Short, carefully controlled bursts of steam are injected into targeted areas of the prostate

• The steam damages the excess tissue in those areas

• Over weeks, the body naturally absorbs this treated tissue and the prostate shrinks, opening up the urethra

Who is it suitable for?

Typically:

• Men with a moderately enlarged prostate

• Men whose symptoms are not well controlled with tablets

• Men who would like a day-case or short-stay procedure rather than a full operation

• Men for whom preservation of ejaculation is an important priority

How is it done?

• Usually performed as a day case under light sedation and local anaesthetic, or a short general/spinal anaesthetic

• A scope is passed through the penis into the prostate

• Several injections of steam are placed at different points within the prostate

• The actual treatment time is usually around 10–15 minutes

• At the end, a catheter is normally left in place for a few days while the initial swelling settles

When does it start to work?

• In the first days or weeks, symptoms can temporarily worsen due to swelling and irritation

• Most men start to notice improvement after about 4–6 weeks

• Maximum benefit is usually reached by around 3 months

Advantages:

• Minimally invasive, usually with very short hospital stay

• No cutting or removal of large pieces of tissue

• Ejaculation and sexual function are often better preserved than with some traditional operations

• Can be suitable for men who are not ideal candidates for more extensive surgery

Limitations:

• Not ideal for very large prostates

• The effect builds gradually; it is not an instant fix

• A small number of men may need further treatment later in life

Aquablation
(Robotic waterjet prostate surgery)

What is Aquablation?

Aquablation is a modern, robotic, endoscopic operation for BPH that uses a high-pressure waterjet to remove the obstructing tissue.

• As with TURP, instruments are introduced through the urethra, without any external cut

• An ultrasound probe is used to create a three-dimensional image of the prostate during the operation

• The surgeon plans on a computer screen exactly which tissue should be removed

• A computer-controlled waterjet then sculpts away this tissue accurately and rapidly

• Little or no heat is used in the cutting phase, which may help protect nearby structures

Who is it suitable for?

• Men with small, medium or relatively large prostates (often up to around 100–150 ml, depending on centre)

• Men with moderate to severe symptoms

• Men who would like a precise, image-guided treatment and, in some cases, a higher chance of preserving ejaculation compared with some traditional techniques

How is it done?

• Done under general or spinal anaesthetic in the operating theatre

• The prostate is mapped using ultrasound

• The surgeon uses the computer system to define the area to be removed

• The robotic system delivers the waterjet to remove that tissue in a short treatment phase

• Bleeding points are then sealed with light cautery if needed

• The removed tissue is collected and sent to the laboratory

After the operation:

• A catheter is usually kept for 1–2 days

• Most men stay in hospital for one night

• Some blood in the urine, frequency and urgency can occur for a few weeks and then improve

Advantages:

• Precise, image-guided removal of the blocking tissue

• Suitable for a wide range of prostate sizes

• In some studies, preservation of ejaculation appears better than with some traditional operations

• Short active removal time, which can be helpful in larger prostates

Limitations:

• A newer technology; very long-term data are still accumulating

• As with any operation, there is a risk of bleeding, infection and temporary irritation symptoms

• Only available in centres with the specific equipment and experience

Other treatment options (briefly)

Laser enucleation and vapourisation (for example HoLEP, GreenLight)

• Laser energy is used to peel out (enucleate) or vapourise the inner, obstructing part of the prostate

• Particularly useful in very large prostates in experienced centres

Open or robotic simple prostatectomy

• Used mainly for very large glands (often over 120–150 grams) or when another abdominal procedure is also needed (for example, removal of large bladder stones)

• Involves an incision in the lower abdomen

Other minimally invasive options

• Urethral lift implants, temporary prostatic stents and prostatic artery embolisation are available in some centres for selected men, depending on anatomy, symptom pattern and local expertise

General risks of prostate surgery and procedures

All procedures carry some degree of risk. These vary by technique but may include:

• Bleeding

• Infection

• Temporary burning, urgency and frequency

• Temporary difficulty controlling urine

• Rarely, longer-term leakage or difficulty passing urine

• Changes in ejaculation (for some procedures, semen goes backwards into the bladder)

The specific risks and benefits of the recommended approach should always be discussed in detail with your urologist before you decide.

Which is the “best” treatment?

There is no single operation or procedure that is best for every man.

The most suitable option for you depends on:

• The size and shape of your prostate

• The type and severity of your symptoms

• Your age and general health

• Whether you are taking blood-thinning medication

• How important preserving ejaculation and other aspects of sexual function are to you

• The experience of your surgeon and what is available in your hospital

For some men, simple monitoring or tablets are enough. For others, procedures such as Rezūm, Aquablation or TURP and related operations can greatly improve urinary symptoms and quality of life.

The right plan is one that you and your urologist agree together after a thorough face-to-face discussion of your symptoms, test results, expectations and priorities.