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Comprehensive guide

What is BPH?

BPH stands for benign prostatic hyperplasia. It’s an overgrowth of the cells in the prostate gland, which then becomes enlarged. Benign means that it’s not malignant, i.e. it’s not cancer, and it won’t spread to other parts of your body.

The prostate gland (or, simply, prostate) is a chestnut-shaped organ found just underneath the bladder in men. It’s normally about 4cm wide and 3cm thick (approximately 1.5” by 1”).13 It produces a milky fluid that, together with sperm and other secretions, makes up semen. Women don’t have a prostate.

The urethra is the tube that carries urine from the bladder out through the penis and runs through the middle of the prostate. As the prostate gets bigger, it starts to obstruct the urethra. This is what causes the symptoms of BPH.

How common is it?

BPH is very common. Young men aren’t often affected but, overall, one in four (25%) men over the age of 40 can expect to suffer from it as they get older.14

What are the symptoms of BPH and what causes them?

The symptoms of BPH are called lower urinary tract symptoms (LUTS) because they affect the lower urinary tract (the bladder and urethra).

Symptoms of BPH occur because the prostate presses on the urethra (the tube that carries urine), causing it to narrow. This means urine can’t pass down it as easily as before – it's obstructed. This is why some symptoms are called obstructive symptoms. The following are typical obstructive symptoms – try talking to your partner about whether he is affected:15

• He might find it difficult to start peeing (known as ‘hesitancy’)
• He might stop and start whilst peeing (‘intermittent stream’)
• He might have to push to get the pee out (‘straining’)
• He might have a weak, dribbly flow of pee (‘weak stream’)
• There may be some dribbling once he's finished a pee (‘terminal dribbling’)
• He may never feel that he's completely emptied his bladder (‘incomplete voiding’)

With obstructive symptoms, the bladder has to work to push the pee out. After a while, the muscle of the bladder wall starts to thicken because of the extra work it’s been doing. This means it becomes less stretchy, so the bladder can’t hold as much pee. That’s why your partner might have to go more often, including at night, and why he really can’t hold on when he needs to go. These are called irritative symptoms.

The following are typical irritative symptoms:

• Needing to pee often (‘frequency’)
• Needing to pee urgently (‘urgency’)
• Needing to pee at night, sometimes many times (‘nocturia’)
• Not being able to hold on when he needs a pee (‘urge incontinence’)

It’s often these symptoms that are most bothersome and cause the most disruption to both you and your partner.

What impact can BPH have?

Many men find that BPH really affects their enjoyment of life, not to mention yours. For example, you might feel tired all the time because he’s up so many times you can’t get a decent night’s sleep. You might feel anxious and embarrassed at social gatherings because he keeps having to disappear to the loo. Maybe he always has to think about what he's drinking and when – one more drink before the journey home might mean he can’t make it back without stopping for a pee.

Outings and car journeys can be frustrating if you have to stop at every public convenience just to make sure he won’t be caught short. It’s understandable that you might get annoyed with his toilet habits, and you’re not alone.

These behaviour adaptations are very common in men with BPH. Research among BPH sufferers has shown that 57% of men avoid drinking before bedtime, 40% of men plan their day around toilet stops and 30% of men avoid travelling long distances.16

Sex and BPH

It’s not inevitable, but some men with BPH also have problems with sex (called sexual dysfunction or erectile dysfunction). Because the prostate plays a role in sexual function, prostate problems and LUTS, may cause him to have difficulties. The worse his urinary symptoms are, the poorer his erection quality can be.17 This is a sensitive subject, but it’s worth trying to talk to your partner about sex because it affects you both.

Doctors don’t know why these problems occur. It may just be that the likelihood of having both sexual dysfunction and BPH increases with age. Or it could simply be because he’s so tired from having to get up several times at night to pee. All sorts of things can cause erectile problems, some of which (eg. heart disease and diabetes) increase with age. Other possible causes include:

• Alcohol, smoking and illegal drugs
• Some medicines, including anti-depressants and drugs for high blood pressure (such as ACE inhibitors and beta-blockers)
• Conditions affecting nerves or blood supply, including multiple sclerosis or a stroke
• Hormonal conditions, eg. too little testosterone in your body
• Conditions affecting the erectile tissue in the penis, such as prostate cancer
• Long-term conditions such as diabetes, kidney or liver failure

So it’s really important that you encourage your partner to seek advice from a healthcare professional if he experiences any serious or ongoing symptoms, such as having problems with his peeing habits. Your partner’s health and the health of your relationship may benefit from treatment, as well as any identifying any underlying cause.

How do I know if my partner has BPH?

Lower urinary tract symptoms are a sign of BPH. Get to know what these might be so that you can spot any of them in your partner. If you think he’s suffering, encourage him to assess and track how severe his symptoms are using the International prostate Symptoms Score (IPSS), or maybe you could even do this for him. He could assess how they affect his life by keeping a diary.

If you have any concerns or think your partner might have BPH, persuade him to speak to a healthcare professional.

Can the symptoms of BPH be caused by anything else?

If your partner is suffering from urinary symptoms he needs to talk to a healthcare professional, who will be able to determine if they are due to BPH and not another condition.

Other conditions or treatments can cause similar symptoms to BPH.18

• A urinary tract infection or some sexually transmitted infections STI) can make your partner need to pee more often or have pain when he pees. If he has an STI there may also be some discharge from the penis. Common STIs include gonorrhoea and chlamydia. It’s important that you get checked out too if an STI is a possibility, because there may be no symptoms in women. Other, non-sexually transmitted infections can also cause urinary symptoms. Infections can be treated with antibiotics.
• Certain medicines, including some antidepressants, antihistamines (eg. for hay fever) and decongestants can cause urine retention, where he can't pee. Encourage him to talk to a healthcare professional about the side-effects of any medicines he's taking. Also, read the leaflet that comes with the medicine and get him to do the same.
• The urethra can become narrowed even without obstruction by the prostate, leading to a weak urine flow and dribbling.
• Diabetes can make him need to pee more often, because the body needs to get rid of excess sugar.
• Advanced prostate cancer can often cause similar symptoms to BPH. Although early prostate cancer generally has no symptoms19 , early diagnosis will help to ensure he has a much better chance of successful treatment.
• Bladder or bowel cancer may cause lumps in the abdomen that may press on the urethra and lead to obstructive symptoms (weak flow, dribbling etc).
• Penis problems, such as phimosis, where the foreskin is tight and can’t be pulled back from the glans of the penis, can cause problems when your partner pees. There may be a poor stream of urine that sprays in different directions.
• Heart failure can make him need to pee at night.
• Problems with the nerve supply to the bladder can lead to incontinence, where he can’t get to the loo in time or he has problems emptying the bladder fully.

What will happen if he goes to the doctor about BPH?

There is no single test to diagnose BPH. The GP will want to rule out other conditions that can cause similar symptoms by listening to your partner talk about his symptoms and doing a physical examination.

The GP might go through the International prostate Symptom Score (IPSS) with your partner to find out how severe his symptoms are. Lower urinary tract symptoms (LUTS) can be graded as mild, moderate or severe. The IPSS also indicates how much his life is being disrupted by the symptoms and may help to decide on treatment. To work out how effective a treatment has been you can compare his IPSS scores before and after treatment has begun.

The GP will probably want to do some tests to exclude other conditions. These may include:

Urinalysis – i.e. analysis of the urine. The doctor will look for blood, which can be a sign of bladder cancer, and glucose, which might mean he has diabetes. If an infection is causing his symptoms, there may be white blood cells (leucocytes) and nitrites in the urine.

Blood test – He may also have a blood test to check his kidneys are working properly. This test measures the level of a substance called creatinine. Well-functioning kidneys keep the levels of creatinine below a certain point; raised creatinine in the blood can be a sign of kidney problems, which can cause urine retention (an enlarged, full bladder).

Digital Rectal Examination (DRE) – The GP will check the size, shape and consistency of the prostate by doing a digital rectal examination. This involves inserting a gloved finger into the rectum (back passage). Whilst this might be uncomfortable and your partner might well feel a bit embarrassed, it won’t hurt. If you’re with him, try to help him relax and remind him that the doctor has done this many times before.

PSA testing – The GP might want to measure the level of a hormone called PSA to check for prostate cancer. PSA stands for ‘prostate specific antigen’. It’s a type of protein produced by the prostate and is found in the cells of the prostate. If the prostate is damaged, more PSA leaks into the blood. So raised levels of PSA in the blood could mean prostate cancer.

But PSA also increases with age and other prostate conditions, including BPH, prostatitis and even after a fall or vigorous exercise. So it’s not possible to diagnose prostate cancer or BPH just by testing PSA. It is possible to have a normal PSA level and still have prostate cancer; it's also possible that he doesn't have cancer if his PSA is raised.20 The only way to find out is to have a biopsy. However, the PSA test can provide useful information, particularly if your partner has regular tests so his doctor can see if the PSA level is rising.

Other tests
If it turns out that he does have raised PSA and his doctor can feel a suspicious lump in the prostate, or if your partner is considering having prostate surgery, the GP might refer your partner to a specialist for further tests. These can include:

• Prostate biopsy - where a few samples (usually 6–12)22 of prostate tissue are taken for analysis in a laboratory. The biopsy is done via the back passage (rectum). There is some risk of bleeding or infection afterwards.
• Cystoscopy - where the doctor uses a small camera on the end of a flexible or rigid tube to see the inside of the urethra and bladder. The tube is passed up through the urethra (tube that carries urine out through the penis).
• Ultrasound scan - where a probe is inserted into the rectum, allowing the doctor to see images of the prostate on a screen.
• Urine flow testing - where the speed of the urine flow, the amount of urine left in the bladder after a pee and other detailed measurements are taken.

Can BPH be treated?

Yes it can. There are various options:

Watchful waiting

Maybe your partner’s symptoms are just an inconvenience and don’t trouble either of you too much. In this case, he may feel that he is happy enough living with the symptoms once he’s had BPH diagnosed. And that's fine. However, you should make sure that he still keeps an eye on things and he needs to have regular check-ups. This is often referred to as “watchful waiting”.

Medicines

If, like many men, the symptoms of BPH are spoiling his enjoyment of life, and yours too, there’s no need to put up with them. There are several drugs available to help.

Alpha-blockers
Symptoms can usually be relieved with a type of medicine called ‘alpha-blockers’. They work by relaxing the muscle in the bladder and around the prostate so that pee can flow more freely in the urethra. These are often the first choice of treatment if the symptoms are bothersome, especially as they work quickly.

Somewhere between six and nine out of 10 men find that alpha-blockers help them.23 They can improve the IPSS symptom score by 30-40% and urine flow rate by 16-25%. There should be an improvement in symptoms within about two weeks, although it can take four to six weeks for the full effect of the drug to develop.24

There are different types of alpha-blockers available and they are all similar, although they may have slightly different side-effects. If one doesn’t work for your partner, it’s unlikely that a different one will work any better.25 But if one kind gives him side-effects, such as low blood pressure, dizziness, drowsiness or headaches, he might do better with another.

5-alpha reductase inhibitors
Another option is a type of medicine called ‘5-alpha reductase inhibitors’, which can slow the growth or even shrink the prostate over time. These work by stopping an enzyme (called 5-alpha reductase) from converting the male hormone testosterone into the more potent dihydrotestosterone. High levels of dihydrotestosterone are linked to growth of the prostate.

These drugs can shrink the prostate by 20–30%, thereby improving flow rate and reducing obstructive symptoms. The IPSS symptom score can improve by up to 15%.26

Since 5–alpha reductase inhibitors work by reducing a potent form of testosterone, side-effects can include reduced sex drive, erectile problems and slight breast enlargement or tenderness.27

Your partner can take 5-alpha reductase inhibitors together with an alpha-blocker if either drug is not helping on its own. Or he can take a 5-alpha reductase inhibitor on its own if he can’t put up with the side-effects of an alpha-blocker.

Surgery

Surgery is an option if medicines are not suitable for your partner, if the prostate has enlarged so much that medicines won’t help, or if he has developed complications (see What happens if I don't treat it? ).

Bear in mind that it’s often really worth talking to your partner about getting treatment before he reaches this stage.

The most common operation for BPH is called transurethral resection of the prostate, or TURP. This involves removing the excess prostate tissue from within the urethra, a bit like coring an apple. The operation is carried out under a general anaesthetic, and usually takes about an hour. Having a TURP used to mean a hospital stay of 2–5 days, but now your partner might only need to stay in for one day.28

TURP is usually very successful at treating the symptoms of BPH; improving IPSS Symptom Scores markedly, and increasing the urine flow rate significantly. However, in about 1–2% of men the operation doesn’t work and needs to be repeated.

Other surgical procedures

There are new alternatives to TURP on offer in some hospitals, which might be suitable for your partner. He should talk to his doctor if he’s interested in finding out more. They are minimally-invasive procedures, which usually mean a shorter hospital visit, sometimes just a day, and fewer after-effects such as blood in the urine.

What happens if he doesn't treat it?

It is essential that your partner speaks to a healthcare professional if he has urinary symptoms or thinks he might be suffering from BPH. Although some men find that nothing happens if their BPH is not treated, many find that their symptoms get worse and affect their quality of life more and more.29

BPH can also lead to urinary tract infections, such as cystitis (bladder infection), or pyelonephritis (kidney infection), which need treatment with antibiotics.30

Without treatment or advice from a healthcare professional, it’s possible he could eventually suffer from a serious condition known as ‘acute urinary retention’. This happens when he can’t pee at all and the bladder fills up. It can be painful and needs urgent medical treatment. He’ll need to have a catheter (a fine tube) put in to empty the bladder.31 Sometimes acute urinary retention is triggered by an unrelated operation under general anaesthetic, a new medicine or a urinary tract infection.

In some men where BPH has been a long-standing untreated condition, chronic (long-term) urinary retention develops32 . This means the bladder is always full, becomes extremely distended and causes pressure to build up towards the kidneys. This can cause the kidneys not to function properly.