What is the prostate and what does it do?

What Is Prostate Enlargement (Benign Prostatic Hyperplasia)?

The prostate is a gland in the male reproductive system, located just below the bladder and surrounding the initial section of the urinary passage (urethra). It produces part of the fluid in semen. Benign prostate enlargement can become more common with age. Because the prostate surrounds the urethra, its enlargement may affect urine flow and bladder emptying in some people.

Benign prostatic hyperplasia (BPH) is not prostate cancer. BPH does not turn into cancer; however, benign enlargement and prostate cancer can occur in the same person. Symptoms and any necessary tests should therefore be assessed by a doctor.

Why Does the Prostate Enlarge?

Ageing and the effects of hormones on prostate tissue play a role in the development of BPH. There is no single cause or mechanism that works in the same way in every patient. Prostate size and symptom severity do not always correlate: in some people, significant enlargement causes few symptoms, while a smaller degree of enlargement may affect urine flow.

What Are the Symptoms of Prostate Enlargement?

Symptoms generally involve difficulty passing urine or problems related to bladder filling.

Symptoms that may occur when passing urine:

1. A delay or difficulty in starting urination
2. A weak or interrupted urine stream
3. Prolonged urination or a need to strain
4. Dribbling after urination
5. A feeling that the bladder has not emptied completely

Symptoms related to bladder filling:

1. Frequent urination
2. A sudden urge to urinate that is difficult to defer
3. Waking at night to urinate
4. Urine leakage before reaching the toilet

These symptoms are not specific to prostate enlargement; bladder problems, infections, certain medications and other conditions can cause similar symptoms. Blood in the urine, burning or pain when passing urine requires assessment; these symptoms should not be attributed solely to BPH.

How Is It Diagnosed?

Assessment begins by establishing when the symptoms started, how much they affect daily life, which medications are being taken and any other health conditions. The doctor may request the following investigations when needed:

1. Symptom assessment questionnaire: Helps measure the frequency of symptoms and their impact on quality of life.
2. Physical examination and digital rectal examination of the prostate: The characteristics of the prostate and examination findings are assessed. The examination does not precisely measure prostate volume.
3. Urinalysis: Checks for infection and other findings, such as blood or glucose.
4. PSA blood test: May contribute to the assessment of prostate volume and prostate cancer risk. PSA alone does not diagnose cancer; elevated results can also occur for other reasons, such as BPH or infection.
5. Urine flow rate and post-void residual urine measurement: Performed when needed to assess urine flow and bladder emptying.
6. Ultrasonography: Not required for every patient; it may be used when the prostate, bladder or kidneys need to be examined.

The PSA test should not be interpreted on its own as a diagnostic test for cancer. The result is assessed alongside age, family history, examination findings and other findings; for newly elevated results, the doctor may arrange a repeat test or further investigations. 

What Are the Treatment Options?

Not every case of prostate enlargement requires medication or surgery. If symptoms are mild and the person is not experiencing significant problems in daily life, monitoring planned with a doctor may be appropriate. Adjustments to daily habits and monitoring symptoms are also part of this approach. 

If symptoms affect quality of life, the doctor may recommend medication based on findings related to the prostate and bladder. Medications differ in their effects and possible side effects; the choice is tailored to the individual.

Surgery or other interventional procedures may be considered when medication is insufficient or problems caused by urinary tract obstruction develop. Treatment decisions take into account symptom severity, examination and test results, the person's overall health and their preferences.

When Should a PSA Test Be Considered?

PSA testing for the early detection of prostate cancer is not a screening procedure that everyone should undergo at the same age and at the same intervals. The decision should be made after discussing the potential benefits and risks, such as unnecessary further investigations or treatment, with a doctor.

The EAU recommends risk-based early assessment for informed men with a life expectancy of at least 15 years: PSA testing may be discussed from age 50 for those at average risk, from age 45 for those at increased risk, such as a family history of prostate cancer at an early age or African ancestry, and from age 40 for carriers of a BRCA2 mutation. As guidelines and screening approaches may differ, these ages should not be interpreted as an automatic requirement for testing. 

When Should You Seek Urgent Medical Help?

Being unable to pass any urine, particularly if it occurs suddenly, requires urgent assessment. You should also seek medical attention without delay if urinary symptoms occur with fever and chills, or if there is visible blood in the urine or severe pain.