Enlarged Prostate (BPH)

Medically reviewed by David Shusterman, MD · Updated September 16, 2026

Benign prostatic hyperplasia is the ordinary enlargement of the prostate that begins in most men in their forties and continues for the rest of their lives. It is not cancer, it does not become cancer, and having it says almost nothing about your cancer risk. What it does do is sit around the urethra and gradually make the bladder work harder.

That last part is the part worth understanding, because it explains why two men with identically sized prostates can have completely different problems. The prostate is the obstruction; the bladder is the organ that suffers. A bladder that has been pushing against resistance for fifteen years thickens, loses elasticity, and becomes irritable — which is why so many men with an enlarged prostate complain not of a weak stream but of urgency, frequency and waking at night. Treating the prostate late, after the bladder has remodelled, gives a worse result than treating it earlier, and this is the single most important thing to know about timing.

What the symptoms actually tell us

Symptoms divide into two groups that behave differently. Voiding symptoms — a weak or hesitant stream, straining, dribbling at the end, a sense of incomplete emptying — point fairly directly at obstruction. Storage symptoms — urgency, frequency, waking at night — point at the bladder, and may be caused by the obstruction, by an independently overactive bladder, by something else entirely, or by all three at once.

This matters because the storage symptoms are the ones that bother men most, and they are the ones least reliably fixed by relieving the obstruction. A man who is told that a prostate procedure will stop him waking at night is being promised something the procedure may not deliver. We would rather say that plainly beforehand than explain it afterwards.

The evaluation

A proper BPH workup is short and almost entirely non-invasive. We take a symptom history and score it, because a score is what lets us tell later whether a treatment actually worked. We examine the prostate, check a urinalysis to exclude infection and blood, and check kidney function if there is any suggestion the bladder is not emptying. A bladder ultrasound immediately after you urinate tells us how much is left behind, which is a more useful number than prostate size alone. A uroflow measures the stream objectively. Where the picture is unclear — particularly when storage symptoms dominate — cystoscopy and urodynamics distinguish an obstructed bladder from an overactive one before anyone commits to a procedure.

PSA is checked, and it needs a caveat: an enlarged prostate raises PSA on its own, so an elevated result in a man with a large gland is not automatically a cancer signal. It is a reason to interpret the number in context rather than to panic. Our approach to that is set out under prostate cancer screening.

Watchful waiting is a real option

If your symptoms are mild and nothing on the evaluation suggests the bladder or kidneys are suffering, doing nothing is a legitimate choice, not a failure to act. BPH progresses slowly and unpredictably; a meaningful minority of men stay stable or improve. What watchful waiting should involve is a scheduled review rather than disappearance — fluid timing, a look at the medications that quietly make urination harder (antihistamines, decongestants, some antidepressants), and a symptom score repeated at intervals so that change is measured rather than remembered.

Medication

Alpha blockers — tamsulosin, alfuzosin, silodosin — relax the muscle in the prostate and bladder neck. They work within days, help the stream, and do not shrink anything. Their common costs are dizziness on standing and retrograde ejaculation, where semen goes backwards into the bladder. That last effect is reversible on stopping the drug but is frequently not mentioned beforehand, and men find it alarming when it is not explained.

5-alpha reductase inhibitors — finasteride, dutasteride — genuinely shrink the gland over six to twelve months and reduce the long-term risk of retention and surgery. They also lower PSA by roughly half, which must be accounted for in any later interpretation. A minority of men report reduced libido or erectile difficulty, and a smaller number report that it persists after stopping. The evidence on persistence is contested; our position is that a man deserves to hear that the debate exists before he starts, rather than to discover it on the internet afterwards.

Tadalafil daily helps both urinary symptoms and erections and suits men who have both problems. Combination therapy works better than either drug alone for larger glands, at the cost of stacking the side effects.

Procedures, and how they really compare

The honest summary is that every option trades three things against each other: how much it improves the stream, what it does to sexual function, and how much recovery and anesthesia it requires. There is no option that wins on all three, and any clinic that presents one as strictly superior is selling rather than advising.

Embolization deserves a word because it is the service the group built its interventional radiology suite around. It is performed by an interventional radiologist through a catheter, with nothing passed through the penis and no general anesthetic. It suits men on blood thinners, men with glands too large for most other options, and men for whom preserving ejaculation matters more than achieving the maximum possible flow rate. It is not the right answer for everyone, and it is slower to work than resection. The full explanation is on our embolization page and at greater length on 1prostate.com.

What we would want you to ask

Ask what your post-void residual is, and whether your bladder is emptying. Ask whether your dominant symptoms are storage or voiding, and what proportion of them a prostate procedure is expected to fix. Ask specifically what each option does to ejaculation, and get the answer before the consent form rather than after. Those three questions separate a considered recommendation from a default one.