Some men experience the following:

• Needing to urinate often, especially at night

• Having trouble starting to urinate (this means that he might have to wait or strain before urine will come out)

• Having a weak urine stream

• Leaking or dribbling urine

• Feeling as though his bladder is not empty even after he urinates

These are the symptoms that suggest benign prostatic hyperplasia (BPH). BPH is very common in men 50 years and above. In fact, it is estimated that about 50% of men above 50 years experience the symptoms mentioned above, which are collectively known as the lower urinary tract symptoms (LUTS). Many men who have BPH, however, do not have issues with peeing. Scientists have yet to find out the exact reasons behind this observation.  

What is BPH?

BPH is the medical term for an enlarged prostate. It only affects men. The prostate is a gland that surrounds the urethra (the tube that carries urine from the bladder out through the penis). 

Image credit: © 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

This drawing shows male internal organs and a close-up of the prostate gland. 

This gland often gets bigger as a person gets older. Approximately 8% of men aged 31 to 40 have BPH. In men over age 80, the number of people who have BPH increases to 80%.

Image credit: https://www.cancer.gov/types/prostate/understanding-prostate-changes#:~:text=BPH%20is%20not%20linked%20to,prostate%20cancer%20can%20be%20similar.&text=Urine%20flow%20in%20a%20normal,and%20enlarged%20(right)%20prostate.

Urine flow in a normal (left) and enlarged (right) prostate. In the diagram on the left, urine flows freely. On the right, urine flow is affected because the enlarged prostate is pressing on the bladder and urethra.

What causes BPH?

As mentioned, it is unclear why some men develop symptoms of BPH and others do not. The prostate normally enlarges to some degree in all men with advancing age, although not all men require treatment. Several hormones are required for BPH to develop, but these hormones alone do not cause the condition. 

Nonetheless, scientific studies have shown that the following can increase a man’s risks of developing BPH and worsen the peeing problems :

• Have family members who are diagnosed with BPH, which suggests genes play a role in BPH

• Have family members who are diagnosed with bladder cancer (but this connection is not observed with prostate cancer)

• Obesity

• Glucose intolerance, which is an umbrella term that describes a person’s inability to metabolise sugar properly. An unhealthy, Western diet is known to increase glucose intolerance and paves the gateway to Type 2 diabetes.

• Metabolic syndromes such as type 2 diabetes 

• High blood cholesterol

• Heart conditions such as heart failure and high blood pressure 

• Lack of physical activity and exercise

• Higher consumption of coffee or caffeinated beverages

• Neurologic conditions such as Parkinson’s disease

Is BPH the same as urinary incontinence?

Some men with BPH eventually start to experience urinary incontinence, i.e. uncontrollable peeing. There are many reasons for urinary incontinence, and one of them is an overactive bladder, which can be caused by BPH. 

Normally, the brain says "time to pee" when your bladder is only partially full. That gives you a fair warning to find a place to relieve yourself. When you decide to let go, a valve called the urinary sphincter opens to allow the bladder to drain. Muscles in the bladder wall squeeze inward to empty the storage tank.

But with overactive bladder, the bladder muscles contract on their own, with little warning. This results in a powerful urge to urinate. If a man is unable to hold his urine until he reaches a bathroom, the result can be anything from a small leak to soaked garments. 

Urinary incontinence can significantly affect a person’s quality of life. It may mean difficulty to sit through a long meeting or a movie. It may also mean that you must always find yourself an aisle seat so that there is a quick escape to the toilet. In worse cases, It may become necessary to wear absorbent pads to contain accidental urine leaking.

Is it a prostate cancer?

Benign prostatic hyperplasia (BPH) has nothing to do with prostate cancer. In fact, the word "benign" means "not cancer." BPH is not linked to cancer and does not increase your risk of getting prostate cancer—yet the symptoms for BPH and prostate cancer can be similar. It is possible to have both BPH and prostate cancer at the same time. Your doctor may conduct a blood PSA test for you to screen for your risks of developing BPH and/or prostate cancer.

Is there a test for BPH?

Some of the common tests and examination your doctor may carry out when suspecting BPH are:

• Rectal exam. That means that he or she will put a finger into your anus to check how big your prostate is and what it feels like.

Image credit: © 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

During a rectal exam, the doctor or nurse puts a finger inside your rectum and feels your prostate gland. That way he or she can see how big it is and whether it has bumps or dents or anything unusual.

• Urine test: This is to rule out possible bladder infection, as the symptoms of bladder infection are also similar to BPH.

• Blood tests to check the level of prostate-specific antigen (PSA) in your blood. PSA is a protein produced by prostate cells; the PSA level may be increased in men with BPH. Men who have prostate cancer often have a highly disproportionately elevated PSA level, although prostate cancer is also found in men who do not have an elevated PSA.

How is BPH treated?

There are various treatment options available for men with BPH. The choices depend on the severity of the symptoms.

If you have BPH but do not have any symptoms, your doctor may recommend a “wait and watch approach”. This means that you will watch your symptoms over time. In some cases, BPH symptoms improve without treatment.

However, if your symptoms worsen over time, the following can be adopted:

• Modifying your lifestyle and behaviors to accommodate the peeing problems. These may include avoiding fluids prior to bedtime or before going out as well as reducing consumption of caffeine and alcohol (these beverages make you pee more often). You can also work with health professionals on pelvic floor training and use of biofeedback to improve your urgency issue.

• Take medications that improve BPH symptoms. Unfortunately there has yet to be a cure for BPH, but your doctor may prescribe you medications that improve your peeing issues. Examples of the medications are:

  • Alpha blockers, e.g. terazosin and tamsulosin. They relax the muscle at the prostate and bladder necks, which make it easier for you to void your bladder.

  • Alpha-reductase inhibitors, e.g. finasteride and dutasteride (Avodart^®). They stop the prostate from growing larger or even cause it to shrink. 

  • Combination of both, e.g. Tamsulosin + dutasteride (Duodart^®)

• Surgery

Can I take saw palmetto supplements for my BPH instead?

Dietary saw palmetto supplement is a common product sold in many pharmacies in Malaysia. It is widely used for treatment of BPH, but there are few scientific studies to support its efficacy. 

A 1998 systematic review including 18 mostly European randomized controlled trials concluded there was promising evidence for efficacy of saw palmetto compared with placebo for decreasing nocturia (frequent urination at night), residual urine volume, and urinary tract symptom score. However, a subsequent 2012 systematic review including 32 randomized trials showed that saw palmetto did not improve BPH symptoms. 

Nevertheless, if you are inclined to try saw palmetto to relieve your BPH symptoms, talk to your doctor or pharmacist. Do not give up your BPH treatment completely without consulting your doctor first.

Image credit: https://www.alpropharmacy.com/oneclick/product/bio-life-saw-palmetto-pumpkin-30s/

Meanwhile, what can I do to relieve the discomforts?

1. Reducing the amount of fluid you drink, especially just before bed

2. Limiting the amount of alcohol and caffeine you drink. These drinks can make you urinate more often.

3. Avoiding cold and allergy medicines that contain antihistamines or decongestants. These medicines can make the symptoms of BPH worse.

4. Doing something doctors call "double voiding." That means that after you empty your bladder, you wait a moment, relax, and try to urinate again.

5. Practising a healthy lifestyle, which involves healthy diet and adequate physical exercise. This is even more important if you are obese or have other long-term medical conditions such as high blood pressure and diabetes.

References:

1. NIDDK- Prostate Enlargement (Benign Prostatic Hyperplasia). 

2. UpToDate - Patient education: Benign prostatic hyperplasia (enlarged prostate) 

3. Malaysian Urological Association - Benign Prostatic Hyperplasia (BPH)

Written By

Ms Joyce Toh

Reviewed By

Doc2us Medical Board