Benign Prostatic Hyperplasia: Symptoms and Treatment Step by Step

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland, a practically unavoidable part of aging in the male genitourinary system. The enlarged prostate surrounds the urethra and increasingly compresses it over time, leading to the characteristic lower urinary tract symptoms — more frequent urination (including at night), a weaker or interrupted stream, a feeling of incomplete bladder emptying, and a sudden, hard-to-control urge to urinate.

The primary tool for assessing symptom severity is the International Prostate Symptom Score (IPSS) — a self-administered questionnaire evaluating seven symptoms (including urinary frequency, nocturia, stream strength, and the feeling of incomplete emptying), each scored 0-5, giving a total score from 0 to 35 points.

The IPSS score helps not only determine the initial approach but also track treatment effectiveness over time — repeating the same questionnaire at follow-up visits allows an objective assessment of whether a given intervention is actually improving the patient's quality of life, not just the flow parameters on a urodynamic study.

With an IPSS score in the mild range (0-7), or moderate but not very bothersome to the patient, a reasonable strategy is lifestyle modification combined with periodic monitoring, without introducing drug therapy right away. Simple, practical changes include limiting fluids, especially in the evening, and caffeine and alcohol (which have a diuretic and bladder-irritating effect), regularly and fully emptying the bladder, avoiding medications that can worsen symptoms (e.g., some first-generation antihistamines and vasoconstricting decongestants), and the double-voiding technique (urinating, pausing briefly, then trying again) when there's a feeling of incomplete emptying.

Alpha-blockers (e.g., tamsulosin, alfuzosin, silodosin) work by relaxing the smooth muscle in the bladder neck and the prostate itself, easing urine flow almost immediately after starting therapy, without affecting the size of the gland itself. The most common side effects include dizziness, drops in blood pressure on standing (especially in older patients), and ejaculation disorders.

5-alpha-reductase inhibitors (finasteride, dutasteride) block the enzyme that converts testosterone into dihydrotestosterone (DHT) — the hormone responsible for prostate glandular tissue growth. Unlike alpha-blockers, their effect only emerges after several months of therapy (an assessment after 3-6 months is usually recommended), but in that time they can genuinely reduce prostate volume by as much as 15-25%, which makes them especially useful for large glands (usually over 30 cm³) or elevated PSA. In men with a smaller prostate, the effect tends to be less pronounced, so drug selection depends heavily on gland size as assessed by imaging.

In men with moderate or severe symptoms and an enlarged prostate, guidelines allow combining an alpha-blocker with a 5-alpha-reductase inhibitor — this combination produces a better effect in some studies than either drug alone, at the cost of combining the side effects of both classes. Phosphodiesterase type 5 inhibitors (e.g., low-dose daily tadalafil), originally used for erectile dysfunction, have also found a place in LUTS/BPH treatment, which can be especially practical for men dealing with both problems at once.

Transurethral resection of the prostate (TURP) remains one of the best-studied and most commonly performed procedures for BPH, providing lasting, marked symptom improvement in the vast majority of patients. It does, however, have a significant, well-documented side effect — retrograde ejaculation, occurring in as many as most operated men, while the ability to achieve an erection is preserved in most of them. Newer surgical techniques that spare the structures responsible for normal ejaculation show a lower rate of this complication in studies, with comparable effectiveness in relieving urinary symptoms.

Alongside TURP, minimally invasive methods are now available (including laser enucleation or vaporization of the prostate, prostatic artery embolization, and procedures using implants that lift the lateral lobes of the gland), which in selected cases offer shorter recovery times and — in some techniques — a lower risk of ejaculation disorders, at the cost of somewhat less long-term comparative data than classic TURP. The choice of method depends on prostate size, coexisting conditions, patient priorities (e.g., preserving ejaculation), and the availability of a given technique at the treating center.

Benign prostatic hyperplasia is often dismissed as an unavoidable, embarrassing part of aging rather than a medical problem worth treating — an approach that needlessly worsens the quality of life of many men, given the wide, well-studied range of treatment options now available. Readers specifically interested in saw palmetto as an alternative or complement to therapy can find a detailed discussion of the evidence in our article on saw palmetto and prostate enlargement — here we've focused on the full picture of medical treatment, from watchful waiting to surgery.