How is an enlarged prostate treated?
There are three main types of treatment for an enlarged prostate:
If tests show you have an enlarged prostate, your doctor or specialist nurse will look at your test results and medical history to see which treatments might be suitable. They will explain your treatment options and help you decide what’s right for you. It’s important to see how you feel about each treatment before making a decision.
Depending on the treatment you choose, you may have regular check-ups with your GP, or with a specialist at the hospital. They may repeat some tests to see how well your treatment is working. If your symptoms don’t improve or your treatment is causing side effects, you may be able to try a different treatment.
Lifestyle changes
If your enlarged prostate isn’t causing problems, you may decide to wait and see if your symptoms get worse before having treatment. An enlarged prostate usually develops slowly, and your symptoms may never get any worse.
There are simple changes you can make to your lifestyle that might help your symptoms.
Drink less alcohol, caffeine, artificial sweeteners and fizzy drinks - These can irritate the bladder and make urinary symptoms worse.
Drink less in the evening - Try to drink less in the late afternoon and evening, so you’re less likely to get up in the night. But make sure you drink enough during the day – 1.5 to 2 litres (3 to 4 pints) a day.
Empty your bladder before leaving the house - Remember to use the toilet before long journeys, and find out where there are public toilets before leaving home.
Double voiding - After you urinate, wait a few minutes and then try to go again. This can help to empty your bladder properly. But take care not to strain or push.
Check your medicines - Ask your doctor whether any medicines you take, such as anti-depressants or decongestants (medicines for a blocked nose), may be making your urinary symptoms worse.
Eat more fruit and fibre - This will help you avoid constipation (difficulty emptying your bowels), which can put pressure on the bladder and make urinary symptoms worse.
Keep a healthy weight - If you’re overweight, this can make your symptoms worse. Talk to your doctor if you’re worried about your weight. They can help you think about ways to lose weight healthily.
Exercise regularly - Regular exercise may help your symptoms. If you’re not usually very active, speak to your doctor before starting any kind of exercise plan. They can talk with you about exercising safely.
Bladder retraining - This technique can help you hold on for longer when you need to urinate. Ask your doctor or specialist nurse for more information.
Urethral massage - This technique helps to squeeze out any urine that's left in your urethra and prevent dribbling. You might hear it called urethral milking. After you urinate, press gently upwards behind the base of your scrotum (the skin around your testicles) with your fingertips. You should be able to feel your urethra. Keep pressing gently as you move your fingers forward from the base of your penis to the tip. Ask your doctor or specialist nurse for more information.
Absorbent pads or urinary sheaths - Absorbent pads and pants can be worn inside your underwear, or instead of underwear. They soak up any leaks. Urinary sheaths look like condoms with a tube attached to the end, which drains urine into a bag. The sheath fits tightly over your penis and you can strap the bag to your leg, under your clothes. Ask your doctor or specialist nurse for more information.
Medicines
If lifestyle changes don’t control your symptoms, medicines may be an option. Make sure you tell your doctor about any medicines or herbal remedies you already use, in case they interfere with medicines for an enlarged prostate.
The main types of medicine for an enlarged prostate are:
You might be given both types of medicine – this is known as a combination treatment.
You’ll have regular check-ups to talk about your symptoms and any side effects you might be getting. These check-ups may be with your GP or with a urologist or specialist nurse at the hospital.
These are tablets that relax the muscles in the prostate and around the opening of the bladder, making it easier to urinate. They don’t cure an enlarged prostate but they can help to relieve symptoms.
Alpha-blockers are usually the first type of medicine you will be offered, unless your prostate is very large. Symptoms may start to improve within a few hours or days, but you may need to take alpha-blockers for a few weeks before they work fully. Most men who take alpha-blockers find their symptoms improve within a few weeks of treatment. If your symptoms haven’t improved after about four to six weeks, your doctor may suggest trying a higher dose or a different treatment. For most men, alpha-blockers continue to work for several years.
There are several alpha-blocker medicines available. They all work in the same way and are equally effective at managing symptoms of an enlarged prostate. The most common alpha-blockers are called:
- Tamsulosin ( Flomaxtra® Flomax Relief®)
- alfuzosin (Xatral®, Besavar®).
Like any medicine, alpha-blockers can cause side effects. These affect each man differently, and you may not get all of the possible side effects. Side effects usually stop if you stop taking the medicine. Possible side effects include:
- feeling dizzy or sick (nausea) or having a headache when you stand up – this usually stops after the first few doses
- tiredness or fatigue
- a blocked nose.
If you are taking tamsulosin you may have problems when you ejaculate, such as little or no semen when you orgasm.
Read the information leaflet that comes with your medicine for more information on side effects, or speak to your doctor, specialist nurse or pharmacist. If you are having any eye surgery, make sure you tell your eye surgeon that you are taking alpha-blockers. This is because some alpha-blockers can cause problems during eye surgery.
These medicines slowly shrink the prostate so that it stops pressing on the urethra, making it easier to urinate.
5-alpha-reductase inhibitors usually take at least six months to work fully, but they are effective at improving symptoms in the long term. Studies show that men’s symptoms may continue to improve up to four years after starting treatment. They also help to prevent acute acute urine retention and the need for surgery.
You’ll usually be offered 5-alpha-reductase inhibitors if your prostate is very large. This is because they work particularly well in men who have a larger prostate. You may also have to take them in combination with an alpha-blocker.
There are two 5-alpha-reductase inhibitor medicines available:
- finasteride (generic finasteride or Proscar®)
- dutasteride (Avodart®)11.
5-alpha-reductase inhibitors may cause side effects. These are most common during the first year of treatment. They usually stop if you stop taking the medicine. Possible side effects which are very uncommon include:
- problems getting or keeping an erection
- less desire for sex (low libido)
- breast swelling or tenderness
- changes in your ejaculation, such as dry orgasms or retrograde ejaculation (where semen doesn’t come out straightaway when you orgasm but leaves the body when you next urinate).
Read the information leaflet that comes with your medicine for more information on side effects, or speak to your doctor, specialist nurse or pharmacist.
If you’re taking 5-alpha-reductase inhibitors, you should use a condom during sex if there is a chance your partner is pregnant or could become pregnant. Pregnant women and children should avoid touching broken tablets or capsules. Ask your doctor or nurse for more information.
5-alpha-reductase inhibitors and your PSA level
5-alpha-reductase inhibitors reduce the amount of PSA in your blood. This means your doctor or nurse will need to change the way they look at any PSA tests you have, as your PSA levels will be lower than normal. If you have a PSA test, always tell your doctor or nurse if you are taking 5-alpha-reductase inhibitors. If your PSA level rises, your doctor should offer you further tests to find out why.
Your doctor may suggest other medicines to help control your symptoms, including the following.
- Antimuscarinics(anticholinergics), such as solifenacin, tolterodine and darifenacin. These can help improve symptoms such as a sudden urge to urinate, needing to urinate more often than usual, and leaking before you reach the toilet.
- Phosphodiesterase type 5 (PDE5) inhibitor. You might be offered a PDE5 tablet called tadalafil (Cialis®). Tadalafil relaxes the muscles in the prostate and around the opening of the bladder, making it easier to urinate. Symptoms may start to improve within the first week. Tadalafil is more commonly used to treat erection problems and is usually only given to men with an enlarged prostate as part of a clinical trial.
- Mirabegron (Betmiga®). If anticholinergics aren’t working, or you can’t take anticholinergics, your doctor may recommend trying mirabegron tablets. Mirabegron is a type of drug called a beta-3-adrenoceptor agonist. It can help if you need to urinate more often than usual or get sudden urges to urinate.
- Desmopressin. If you urinate a lot during the night, your doctor may recommend taking a desmopressin tablet before you go to bed. This causes the kidneys to produce less urine for six to eight hours. You will have regular blood tests to monitor your kidney function. Desmopressin isn’t usually an option if you’re over 65 or have heart failure.
- Loop diuretic. This makes you urinate a lot before you go to bed, making it less likely that you’ll need to get up during the night. You take it as a capsule in the late afternoon.
Some men find that taking more than one type of medicine works better than taking a single medicine on its own. This is known as combination treatment. You might be given separate tablets, or you might be given a single tablet containing both medicines to take each day.
Alpha-blocker plus 5-alpha-reductase inhibitor
You may be offered an alpha-blocker together with a 5-alpha-reductase inhibitor if:
- your symptoms affect your day-to-day life, and
- you have a very large prostate or a PSA level of more than 1.4 ng/ml.
Alpha-blockers and 5-alpha-reductase inhibitors can both cause side effects, so you might get side effects from both medicines. Some side effects, such as less desire for sex, changes in your ejaculation and erection problems, are more common in men taking both medicines than in men who take either medicine on its own.
Alpha-blockers can start to work within a few hours or days, while 5-alpha-reductase inhibitors usually take at least six months to work fully. This means that men on combination treatment may be able to stop taking the alpha-blocker after around six months, without making their treatment less effective.
Alpha-blocker plus anticholinergic
You may be offered an alpha-blocker together with an anticholinergic, if treatment with either medicine alone isn’t working. Alpha-blockers and anticholinergics can both cause side effects, and these may be worse if you’re taking both medicines at the same time. The most common side effects in men taking both medicines include a dry mouth, constipation and indigestion.
Some men like to use herbal remedies, such as saw palmetto or red stinkwood (African plum). But studies suggest they’re unlikely to improve symptoms of an enlarged prostate. We need more research before herbal remedies can be recommended as a treatment.
Not all herbal remedies in the UK are licensed, and the quality varies a lot. Be very careful when buying herbal remedies over the internet. Many are made outside the UK and may not be high-quality. Many companies make claims that aren’t based on proper research. There may be no real evidence that their products work, and some may even be harmful. Remember that even if a product is ‘natural’, this doesn’t mean it is safe.
At the moment, there’s no evidence that acupuncture or homeopathy can help manage symptoms of an enlarged prostate.
It’s important to tell your doctor about any complementary therapies you are using. Some may interfere with your enlarged prostate treatment or with other medicines you may be taking. Some herbal remedies may also affect your PSA level, making the PSA test unreliable. For more information about using herbal remedies safely, visit the MHRA website.
Surgery
Surgery may be an option if your symptoms don’t improve with lifestyle changes or medicines, or if your symptoms are severe.
Several different types of surgery can be used to treat an enlarged prostate. The main types used in the UK include:
- transurethral resection of the prostate (TURP)
- holmium laser enucleation of the prostate (HoLEP)
- transurethral water vapour therapy (Rezūm®)
- GreenLight™ laser surgery
- prostatic urethral lift (UroLift®)
Your hospital might not offer all of these types of surgery. The options available to you may depend on the size of your prostate and any other health problems you may have. Your doctor or nurse will discuss the advantages and disadvantages of each type of surgery they offer, to help you decide what is right for you.
You can read a summary of some of the most common types of surgery for an enlarged prostate below. Your doctor or nurse can also give you more information, or you can speak to our Specialist Nurses.
This is an operation to remove the parts of the prostate that have grown too large and are pressing on the urethra. It is the most common type of surgery for an enlarged prostate.
During the operation, the surgeon passes a thin tube up your penis into your urethra. They then pass an electrically-heated wire loop through the tube and use it to remove small pieces of prostate tissue.
This is similar to TURP but uses a high-powered laser to remove the parts of the prostate that are blocking the urethra. Studies suggest that HoLEP is as effective as TURP at improving symptoms of an enlarged prostate, with similar side effects in the short term. HoLEP may be particularly useful in men with a very large prostate. You may also be less likely to need further surgery after HoLEP than after a TURP.
HoLEP uses specialist equipment and the surgeon needs to have had special training. This is why HoLEP is usually only available at specialist centres.
This uses steam to destroy the prostate tissue that is blocking the urethra. It is used to treat men with moderate to severe urinary symptoms, who have a moderately enlarged prostate. Rezum has a low risk of causing sexual problems, and has been shown to improve people's quality of life.
This uses a high-energy laser to heat up and destroy the prostate tissue that is blocking the urethra. You might also hear it called photo-selective vaporisation of the prostate (PVP), GreenLight XPS™, or laser prostatectomy.
GreenLight™ laser surgery may be as effective as TURP, at least in the first two years after surgery. But we don’t know how long it works for or about any long-term side effects.
It involves putting small implants into the prostate. The implants pull the excess prostate tissue away from the urethra so that urine can flow more easily. This can help to improve symptoms without actually removing any tissue from the prostate.
It isn’t available in all hospitals because the surgeon needs to have had special training. Urolift has shown to be effective in improving symptoms up to 5 years. But we don’t yet know about the possible side effects in the long term (longer than five years).
There are some other less common types of surgery, such as:
- Bladder neck incision
- simple prostatectomy
- prostate artery embolisation
- transurethral water jet therapy (Aquablation® .
These are rarely used to treat symptoms of an enlarged prostate in the UK. Your surgeon or nurse may be able to give you more information about them.
As with most treatments, there is a risk of side effects after surgery to treat an enlarged prostate. Possible side effects include:
- needing to urinate more often or urgently
- leaking urine when you cough, sneeze, laugh or exercise
- blood in your urine
- urine infection
- a weak flow when you urinate
- retrograde ejaculation
- problems getting or keeping an erection.
Your chances of getting each of these side effects will depend on many things, including the type of surgery you choose. Speak to your doctor or nurse for more information.
What if I can't have surgery?
Surgery isn’t always an option – you may not be fit or well enough for an operation, or you may not like the idea of it. If surgery isn’t suitable for you and lifestyle changes and medicines haven’t worked, your doctor or nurse may suggest using a catheter. This is a thin, flexible tube used to drain urine from your bladder. The catheter may be permanent or temporary.
A permanent catheter is passed up into the bladder through your penis, or through a small cut in your abdomen (stomach area). The catheter is usually attached to a drainage bag, which you strap on to your body under your clothing. Your doctor or nurse will usually change your catheter every 12 weeks.
A temporary catheter (self-catheterisation) is where you put a catheter in yourself when you need to urinate, rather than leaving one in all the time. Your doctor or nurse will show you how to put the catheter in and tell you how often to use it. Some men can urinate quite well without a catheter and only use it once a day to make sure they empty their bladder regularly. Other men need to use a temporary catheter several times a day.
Urine infections are common in men who use a catheter. Your urine should usually be a pale yellow colour. If it becomes dark or cloudy with a strong smell, this could be a sign of a urine infection. Other signs of a possible infection include a fever (high temperature), a burning feeling when you urinate, and feeling unwell. Tell your doctor or nurse if you have any of these symptoms. They’ll usually give you antibiotics to treat the infection.
You can lower your chances of getting a urine infection by keeping your catheter and the area around it clean. You may find the following tips helpful.
- Always wash your hands with warm, soapy water before and after touching your catheter or drainage bag.
- Wash the catheter and the area around it at least twice a day with warm water and unscented soap. Use one wash cloth for this and a different one for the rest of your body. Wipe downwards along the catheter, away from your body, and dry it carefully afterwards.
- Drink plenty of fluids (1.5 to 2 litres, or 3 to 4 pints a day).
- Eat plenty of foods containing fibre to avoid constipation, such as fruit, vegetables and wholemeal bread. Constipation can stop your catheter from draining properly.
Let your nurse know if your catheter isn’t draining properly. If urine hasn’t drained from your bladder for 2 to 3 hours, contact your GP or district nurse straight away.
References
Updated: May 2022 | Due for Review: May 2025
- National Institute for Health and Care Excellence. Lower urinary tract symptoms in men: management [Internet]. 2010. Available from: https://www.nice.org.uk/guidance/cg97
- Lokeshwar SD, Harper BT, Webb E, Jordan A, Dykes TA, Neal DE, et al. Epidemiology and treatment modalities for the management of benign prostatic hyperplasia. Transl Androl Urol. 2019 Oct;8(5):529–39.
- Braeckman J, Denis L. Management of BPH then 2000 and now 2016 – From BPH to BPO. Asian J Urol. 2017 Jul;4(3):138–47.
- Gravas S, Cornu JN, Gacci M, Gratzke C, Herrmann TRW, Mamoulakis C, et al. Management of Non-neurogenic Male LUTS. European Association of Urology; 2021.
- Madersbacher S, Sampson N, Culig Z. Pathophysiology of Benign Prostatic Hyperplasia and Benign Prostatic Enlargement: A Mini-Review. Gerontology. 2019;65(5):458–64.
- Lim KB. Epidemiology of clinical benign prostatic hyperplasia. Asian J Urol. 2017 Jul;4(3):148–51.
- Raheem OA, Parsons JK. Associations of obesity, physical activity and diet with benign prostatic hyperplasia and lower urinary tract symptoms: Curr Opin Urol. 2014;24(1):10–4.
- Abdelmoteleb H, Jefferies ER, Drake MJ. Assessment and management of male lower urinary tract symptoms (LUTS). Int J Surg. 2016 Jan;25:164–71.
- Yu ZJ, Yan HL, Xu FH, Chao HC, Deng LH, Xu XD, et al. Efficacy and Side Effects of Drugs Commonly Used for the Treatment of Lower Urinary Tract Symptoms Associated With Benign Prostatic Hyperplasia. Front Pharmacol. 2020 May 8;11:658.
- National Institute for Health and Care Excellence. Alpha-blockers | Prescribing information | LUTS in men | CKS | NICE [Internet]. LUTS in men: Alpha- blockers. [cited 2021 Nov 30]. Available from: https://cks.nice.org.uk/topics/luts-in-men/prescribing-information/alpha-blockers/
- 5-alpha reductase inhibitors | Prescribing information | LUTS in men | CKS | NICE [Internet]. [cited 2021 Nov 30]. Available from: https://cks.nice.org.uk/topics/luts-in-men/prescribing-information/5-alpha-reductase-inhibitors/
- Avodart 0.5mg soft capsules - Summary of Product Characteristics (SmPC) - (emc) [Internet]. [cited 2021 Dec 1]. Available from: https://www.medicines.org.uk/emc/product/6758/smpc#gref
- National Institute for Health and Care Excellence. 5-alpha reductase inhibitors | Prescribing information | LUTS in men | CKS | NICE [Internet]. [cited 2021 Dec 1]. Available from: https://cks.nice.org.uk/topics/luts-in-men/prescribing-information/5-alpha-reductase-inhibitors/
- National Institute for Health and Care excellence. Lower urinary tract symptoms in men overview - NICE Pathways [Internet]. [cited 2021 Dec 14]. Available from: https://pathways.nice.org.uk/pathways/lower-urinary-tract-symptoms-in-men
- Zhou Z, Cui Y, Wu J, Ding R, Cai T, Gao Z. Meta-analysis of the efficacy and safety of combination of tamsulosin plus dutasteride compared with tamsulosin monotherapy in treating benign prostatic hyperplasia. BMC Urol. 2019 Dec;19(1):17.
- Qiangzhao L, Xiaofeng Z, Fenghai Z, Qiong L, Fa Z, Bohong G, et al. Efficacy and tolerability of combination therapy with alpha-blockers and phosphodiesterase-5 inhibitors compared with monotherapy for lower urinary tract symptoms. Medicine (Baltimore). 2020 Oct 23;99(43):e22834.
- Kim HJ, Sun HY, Choi H, Park JY, Bae JH, Doo SW, et al. Efficacy and Safety of Initial Combination Treatment of an Alpha Blocker with an Anticholinergic Medication in Benign Prostatic Hyperplasia Patients with Lower Urinary Tract Symptoms: Updated Meta-Analysis. Bid HK, editor. PLOS ONE. 2017 Jan 10;12(1):e0169248.
- van der Worp H, Jellema P, Hordijk I, Lisman-van Leeuwen Y, Korteschiel L, Steffens MG, et al. Discontinuation of alpha-blocker therapy in men with lower urinary tract symptoms: a systematic review and meta-analysis. BMJ Open. 2019 Nov;9(11):e030405.
- Leisegang K, Jimenez M, Durairajanayagam D, Finelli R, Majzoub A, Henkel R, et al. A systematic review of herbal medicine in the clinical treatment of benign prostatic hyperplasia. Phytomedicine Plus. 2022 Feb;2(1):100153.
- Huang SW, Tsai CY, Tseng CS, Shih MC, Yeh YC, Chien KL, et al. Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: systematic review and network meta-analysis. BMJ. 2019 Nov 14;l5919.
- Rees J, Bultitude M, Challacombe B. The management of lower urinary tract symptoms in men. BMJ. 2014 Jun 24;348(1):g3861–g3861.
- Teo JS, Lee YM, Ho HSS. An update on transurethral surgery for benign prostatic obstruction. Asian J Urol. 2017 Jul;4(3):195–8.
- Welliver C, Helo S, McVary KT. Technique considerations and complication management in transurethral resection of the prostate and photoselective vaporization of the prostate. Transl Androl Urol. 2017 Aug;6(4):695–703.
- Cornu JN, Ahyai S, Bachmann A, de la Rosette J, Gilling P, Gratzke C, et al. A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update. Eur Urol. 2015 Jun;67(6):1066–96.
- Zhong J, Feng Z, Peng Y, Liang H. A Systematic Review and Meta-analysis of Efficacy and Safety Following Holmium Laser Enucleation of Prostate and Transurethral Resection of Prostate for Benign Prostatic Hyperplasia. Urology. 2019 Sep;131:14–20.
- Elkoushy MA, Elshal AM, Elhilali MM. Reoperation After Holmium Laser Enucleation of the Prostate for Management of Benign Prostatic Hyperplasia: Assessment of Risk Factors with Time to Event Analysis. J Endourol. 2015 Jul;29(7):797–804.
- Kampantais S, Dimopoulos P, Tasleem A, Acher P, Gordon K, Young A. Assessing the Learning Curve of Holmium Laser Enucleation of Prostate (HoLEP). A Systematic Review. Urology. 2018 Oct;120:9–22.
- National Institute for Health and Care Excellence. Rezum for treating lower urinary tract symptoms secondary to benign prostatic hyperplasia [Internet]. 2020. Available from: www.nice.org.uk/guidance/mtg49
- Schwartz RN, Couture F, Sadri I, Arezki A, Nguyen DD, Zakaria AS, et al. Reasons to believe in vaporization: a review of the benefits of photo-selective and transurethral vaporization. World J Urol. 2021 Jul;39(7):2263–8.
- Tran PU, Chung ASJ. Beyond medications: office-based procedures for benign prostatic obstruction. World J Urol. 2019 Jun;37(6):1023–7.
- National Institute for Health and Care Excellence. UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia [Internet]. 2021. Available from: www.nice.org.uk/guidance/mtg58
- Vahr S, Cobussen-Boekhorst H, Eikenboom J, Geng V, Holroyd S, Lester M, et al. Catheterisation Urethral Intermittent in adults [Internet]. European Association of Urology Nurses; 2013 [cited 2021 Dec 14]. Available from: https://nurses.uroweb.org/guideline/catheterisation-urethral-intermittent-in-adults/
- Geng V, Cobussen-Boekhorst H, farrell J, Gea-Sánchez M, Pearce I, schwennesen T, et al. Catheterisation- Indwelling catheters in adults. European Association of Urology Nurses; 2012.
