What is benign prostatic hyperplasia?

BPH is a non-cancerous enlargement of the prostate, driven by proliferation of the transition zone that surrounds the urethra. Because the prostate encircles the urethra, growth can obstruct urine flow, producing lower urinary tract symptoms — a weak or intermittent stream, hesitancy in starting, straining, dribbling at the end, a sense of incomplete emptying, and the storage symptoms of frequency, urgency and getting up at night. It is a normal consequence of male ageing: microscopic BPH is present in about half of men in their sixties and more than eighty per cent by the age of eighty. Importantly, BPH is not prostate cancer, does not become prostate cancer, and does not increase the risk of it.

Do urinary symptoms in men always mean prostate trouble?

No, and assuming so is the single most consequential mistake in this area. Overactive bladder — a problem of the bladder muscle rather than the prostate — is extremely common and produces urgency and frequency that alpha-blockers will not fix. Nocturnal polyuria, where most of the day's urine is produced overnight, is the commonest cause of isolated night-time waking and is a fluid-distribution problem: it can result from heart failure, leg swelling, sleep apnoea, diabetes, or simply evening fluid and alcohol. Diabetes, urethral stricture, bladder stones, neurological conditions and medication side effects all produce identical symptoms. A three-day bladder diary recording the time and volume of every void is the cheapest and most informative test available, and frequently changes the diagnosis entirely.

What medicines are used and how quickly do they work?

There are two main classes with quite different timescales. Alpha-blockers (tamsulosin, alfuzosin, silodosin, doxazosin) relax the smooth muscle of the prostate and bladder neck, and work quickly — most men notice improvement within days to two weeks. They relieve symptoms but do not shrink the prostate or change the course of the disease. 5-alpha reductase inhibitors (finasteride, dutasteride) block the hormone driving prostate growth and genuinely shrink the gland by around a fifth, reducing the risk of urinary retention and the need for surgery — but they take six to twelve months for full effect and are only worthwhile if the prostate is genuinely enlarged. For men with larger prostates and higher risk of progression, taking both together is more effective than either alone. Antimuscarinics or mirabegron can be added when storage symptoms dominate.

Why must I tell my eye surgeon I take tamsulosin?

Because alpha-blockers, tamsulosin especially, cause intraoperative floppy iris syndrome. The drug relaxes the smooth muscle of the iris dilator, so during cataract surgery the iris becomes floppy, billows with the fluid currents, constricts progressively and can prolapse towards the incision. This substantially increases the risk of complications including posterior capsule rupture. Crucially, the effect persists long after the drug is stopped — sometimes for years — so stopping tamsulosin shortly before surgery does not solve the problem. What does solve it is forewarning: an ophthalmologist who knows in advance can use pupil expansion devices, intracameral phenylephrine and modified technique, and outcomes are then very good. Every man on an alpha-blocker should mention it at his eye assessment, and every clinician starting one should ask about planned cataract surgery.

When is surgery needed?

Surgery is indicated when symptoms remain bothersome despite adequate medical therapy, or when complications develop: recurrent urinary retention, recurrent urinary infections, bladder stones, recurrent haematuria from the prostate, or kidney impairment caused by chronic obstruction. Transurethral resection of the prostate (TURP) remains the reference operation, with excellent and durable results. For very large prostates, laser or bipolar enucleation (HoLEP) achieves the same outcomes with less bleeding, which also makes it useful for men who cannot stop anticoagulants. The essential consent point is ejaculation: most men will have retrograde ejaculation afterwards, meaning semen passes into the bladder rather than outwards. If preserving ejaculation matters, ejaculation-preserving options such as prostatic urethral lift, water vapour therapy or prostatic artery embolisation should be discussed.

How does GMJ News cover BPH?

GMJ News covers the weak correlation between prostate size and symptoms, IPSS and bother-driven treatment, the crucial distinction between male LUTS and BPH including nocturnal polyuria and overactive bladder, bladder diaries, alpha-blocker and 5-ARI pharmacology and timescales, the PSA halving rule and floppy iris syndrome, combination therapy evidence from CombAT and MTOPS, antimuscarinics and mirabegron in men, acute and chronic retention including post-obstructive diuresis, urodynamics for distinguishing obstruction from detrusor underactivity, the full range of surgical options and retrograde ejaculation counselling, and the negative evidence on saw palmetto. Relevant to PHIG's men's health and ageing programmes.

Home › Topics › Benign Prostatic Hyperplasia

Benign Prostatic Hyperplasia

GMJ News knowledge hub · last reviewed August 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Benign prostatic hyperplasia (BPH) — non-malignant proliferation of the prostatic transition zone — is an almost universal consequence of male ageing, present histologically in around 50% of men in their sixties and over 80% by age eighty, and is the dominant cause of male lower urinary tract symptoms (LUTS): weak stream, hesitancy, straining, incomplete emptying, frequency, urgency and nocturia (WHO). Two points dominate good practice: prostate SIZE correlates poorly with symptom severity, so treatment is driven by the International Prostate Symptom Score (IPSS) and bother rather than by gland volume; and the most consequential clinical error is assuming that male LUTS equals BPH — overactive bladder, nocturnal polyuria, poorly controlled diabetes, heart failure, obstructive sleep apnoea, medication effects and prostate cancer all produce identical symptoms, and a simple bladder diary frequently reveals that the problem is fluid distribution overnight rather than the prostate at all.

Key messages

Prostate size correlates poorly with symptoms — treat the bother, not the gland

BPH is present histologically in around 50% of men in their sixties and over 80% by eighty, but the relationship between gland volume and symptom severity is weak. A 30g prostate with a predominantly intravesical median lobe can obstruct severely, while a 100g gland may cause minimal symptoms. Treatment decisions are therefore driven by the International Prostate Symptom Score (IPSS), the bother question, and objective findings (flow rate, post-void residual) — not by prostate size on examination or ultrasound alone.

Male LUTS is not the same as BPH — the most consequential clinical error

Assuming that lower urinary tract symptoms in a man must be prostatic causes years of ineffective treatment. Alternative or coexisting causes: overactive bladder (detrusor overactivity, frequently the dominant problem); nocturnal polyuria (a fluid-distribution problem, not a bladder problem — the commonest cause of isolated nocturia); poorly controlled diabetes with osmotic diuresis; heart failure and peripheral oedema mobilising at night; obstructive sleep apnoea (which raises natriuretic peptide and causes nocturnal polyuria); medications (diuretics, calcium channel blockers, anticholinergics); urethral stricture; bladder stones; neurological bladder dysfunction; and prostate or bladder cancer. A 3-day frequency-volume bladder diary is the single most informative and most underused investigation.

Alpha-blockers act in days; 5-alpha reductase inhibitors take months

Alpha-1 blockers (tamsulosin, alfuzosin, silodosin, doxazosin) relax prostatic smooth muscle, improving symptoms within days to two weeks. They do not shrink the prostate or alter disease progression. 5-alpha reductase inhibitors (finasteride, dutasteride) block conversion of testosterone to dihydrotestosterone, reducing prostate volume by around 20-25% — but require 6-12 months for full effect and are only worthwhile in genuinely enlarged glands (typically above 30-40g or PSA above 1.5). Combination therapy (CombAT, MTOPS trials) is superior to either alone for men with larger glands and higher progression risk, reducing acute retention and need for surgery.

Two prescribing points that matter: floppy iris and PSA halving

Intraoperative floppy iris syndrome: alpha-blockers, tamsulosin in particular, cause iris dilator smooth muscle atony that persists long after the drug is stopped and substantially complicates cataract surgery. Any man being considered for an alpha-blocker should be asked about planned cataract surgery, and any man on one must tell his ophthalmologist — this is a mandatory disclosure. PSA halving: 5-alpha reductase inhibitors reduce serum PSA by approximately 50% after 6-12 months, so PSA values must be DOUBLED for cancer-screening interpretation. Failure to do this masks prostate cancer; a rising PSA on a 5-ARI is a red flag regardless of absolute value.

Acute urinary retention — catheterise, then trial without catheter on an alpha-blocker

Acute urinary retention presents with painful inability to void and a palpable, tender bladder. Management: immediate urethral catheterisation with documentation of residual volume; monitor for post-obstructive diuresis (which can be substantial and cause hypovolaemia and electrolyte disturbance after high-volume retention); start an alpha-blocker, which significantly increases the success of a trial without catheter (TWOC) at 2-3 days. CHRONIC retention differs importantly: it is typically painless with a large residual, may present with overflow incontinence and hydronephrosis with renal impairment, and requires careful monitoring for post-obstructive diuresis and haematuria ex vacuo.

Surgery has moved well beyond TURP alone

Transurethral resection of the prostate (TURP) remains the reference standard against which others are measured, with excellent durable outcomes but a recognised complication profile: retrograde ejaculation in the great majority (an essential consent point for younger men), bleeding, TUR syndrome with monopolar resection (now largely avoided by bipolar technique using saline irrigation), stricture and, uncommonly, incontinence. Alternatives now well established: holmium laser enucleation (HoLEP) and thulium enucleation, suitable for very large glands and with low bleeding risk, making them attractive for anticoagulated patients; photoselective vaporisation (GreenLight); and minimally invasive ejaculation-preserving options — prostatic urethral lift (UroLift), water vapour thermal therapy (Rezum), and prostatic artery embolisation.

Key statistics

~50% / >80%

histological BPH prevalence in men in their sixties / over eighty

EAU/AUA

IPSS

symptom score and bother — not prostate size — drive treatment decisions

EAU/NICE

~50%

PSA reduction on 5-alpha reductase inhibitors — DOUBLE the value for cancer interpretation

EAU/FDA

20-25%

prostate volume reduction with 5-ARIs — but requires 6-12 months for full effect

CombAT/MTOPS

Floppy iris

tamsulosin causes intraoperative floppy iris syndrome — must be disclosed before cataract surgery

EAU/AAO

Bladder diary

a 3-day frequency-volume chart is the single most informative and most underused investigation

EAU/ICS

BPH treatments — approximate IPSS symptom improvement

Source: EAU/AUA. Surgery gives the largest improvement; combination medical therapy exceeds either drug alone.

Glossary of key terms

International Prostate Symptom Score (IPSS)
UrologySeven questions scored 0-5 each (incomplete emptying, frequency, intermittency, urgency, weak stream, straining, nocturia), giving a total of 0-35: mild 0-7, moderate 8-19, severe 20-35. An eighth question — the bother or quality-of-life question, scored 0-6 — is arguably the most important single item, since it determines whether the patient actually wants treatment. IPSS is used to establish baseline severity, to select and monitor therapy, and to demonstrate response. Its limitations matter: it does not distinguish storage from voiding symptoms adequately, is not specific to prostatic obstruction (women score similarly), and cannot identify nocturnal polyuria — which is why it should always be paired with a bladder diary.

Nocturnal polyuria
Urology/PhysiologyDefined as more than 33% of the 24-hour urine output produced overnight in older adults (more than 20% in young adults). It is the commonest cause of isolated nocturia and is frequently misattributed to the prostate, leading to years of futile alpha-blocker therapy. Causes: age-related loss of the nocturnal rise in antidiuretic hormone; excess evening fluid, alcohol or caffeine; peripheral oedema from heart failure, venous insufficiency or calcium channel blockers, mobilising when supine; obstructive sleep apnoea, which raises atrial natriuretic peptide; diabetes mellitus and diabetes insipidus; and diuretic timing. Diagnosis requires a frequency-volume chart. Management targets the cause: evening fluid restriction, afternoon diuretic timing, compression stockings and leg elevation, treatment of sleep apnoea and heart failure — with desmopressin reserved for refractory cases and used cautiously because of hyponatraemia risk, particularly in the elderly, where sodium must be monitored.

Urodynamics and pressure-flow studies
UrologyUroflowmetry with post-void residual measurement is the basic non-invasive assessment: a maximum flow rate below 10 mL/s with adequate voided volume suggests obstruction, though it cannot distinguish obstruction from detrusor underactivity. Invasive pressure-flow urodynamics simultaneously measures detrusor pressure and flow, and is the only test that definitively separates bladder outlet OBSTRUCTION (high pressure, low flow) from detrusor UNDERACTIVITY (low pressure, low flow) — a distinction that matters enormously, because a man with an underactive detrusor will not improve after prostate surgery and may end up in retention. Indicated before surgery in men with equivocal findings, younger men, those with neurological disease or diabetes, prior pelvic surgery, or predominantly storage symptoms.

Anticholinergics and beta-3 agonists in male LUTS
PharmacologyHistorical teaching held that antimuscarinics were contraindicated in men with BPH because of retention risk. Evidence has substantially revised this: in men with predominantly storage symptoms and a post-void residual below approximately 150 mL, antimuscarinics (solifenacin, tolterodine) or the beta-3 agonist mirabegron can be added safely to an alpha-blocker with low retention risk, and often produce the symptom relief that the alpha-blocker alone did not. Mirabegron is generally preferred in older men because it avoids the cognitive burden of anticholinergics — cumulative anticholinergic load is associated with dementia risk in observational studies, a consideration that applies to the whole prescribing picture in this age group. Post-void residual should be monitored after initiation.

Retrograde ejaculation and the consent conversation
Surgery/CounsellingRetrograde ejaculation — semen passing backwards into the bladder because the bladder neck no longer closes — occurs in the great majority of men after TURP and after enucleation procedures, and in a smaller proportion on alpha-blockers, particularly silodosin and tamsulosin. It is not harmful and does not affect erection or orgasmic sensation, but it does impair fertility and many men find it distressing if it is not discussed beforehand. This is one of the commonest sources of postoperative dissatisfaction and complaint, and it is entirely avoidable through explicit preoperative counselling. Where ejaculatory function is a priority, ejaculation-preserving options — prostatic urethral lift, water vapour therapy, prostatic artery embolisation, or ejaculation-preserving TURP techniques — should be offered and discussed.

Herbal therapy — saw palmetto
EvidenceSerenoa repens (saw palmetto) is among the most widely used supplements for BPH worldwide. The evidence is clear and negative: the Cochrane review of 32 randomised trials, and the well-conducted CAMUS and STEP trials — the latter using escalating doses up to three times the standard dose — found saw palmetto no better than placebo for urinary symptoms, flow rate or prostate size. It is generally well tolerated and unlikely to cause harm directly, but the harm lies in delay: men remain on ineffective treatment while symptoms progress, and some develop retention or renal impairment that timely effective treatment would have prevented. Patients should be told the evidence plainly rather than left to infer efficacy from availability.

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