Case study
David King, a 70-year-old retired engineer, attended urgent care with voiding difficulties. He reported that his bladder was ‘full to bursting’ but he couldn’t pass even a drop of urine. An intermittent catheter was passed and drained 725 ml of urine. Mr King was given a differential diagnosis of benign prostatic hyperplasia but this was to be confirmed by further tests and response to treatment. He was prescribed tamsulosin 400 micrograms once daily and advised to visit his GP for further investigations. 

Mr King was seen by a nurse practitioner at his GP surgery. He reported that he had been experiencing bothersome lower urinary tract symptoms for over a year but avoided seeking investigations and treatment. He reported that his brother had prostate surgery and now had continence problems, and he didn’t want that to happen to him. Mr King was assured that there is a continuum of treatment and that surgery is reserved for those who do not respond to other treatments. 

Mr King was asked to complete a symptom score and a frequency volume chart. He had bloods checked including his prostate-specific antigen (PSA) level and physical examination. His blood pressure was low (90/60 mmHg), and he was taking amlodipine 10 mg daily for hypertension, but was otherwise in good health. The tamsulosin was effectively treating the symptoms of benign prostatic hyperplasia but, in combination with his antihypertensive, was dropping his blood pressure. He was advised to reduce amlodipine to 5 mg daily, to check his blood pressure twice a day and to return for a review in 6 days. A week later Mr King’s blood pressure was 100/60 mmHg and his amlodipine was reduced to 2.5 mg daily. His blood pressure normalised at this stage. 

What is benign prostatic hyperplasia?
Benign prostatic hyperplasia (BPH) refers to the non-malignant growth or hyperplasia of prostate tissue and is a common cause of lower urinary tract symptoms in older men (Ng et al, 2024).

BPH develops because of an imbalance between cell growth (prostatic cellular proliferation) and cell death (apoptosis). Cell growth outpaces cell death and there are increased numbers of prostatic periurethral epithelial and stromal cells (Roehrborn, 2008). 

A man with BPH may develop mild, moderate or severe lower urinary tract symptoms (National Institute for Health and Care Excellence, 2024; 2025). 
Understanding the structure and function of the prostate 
The prostate gland lies in the pelvic cavity in front of the rectum. It consists of several lobes made up of columnar epithelial cells. The lobes are enclosed by a capsule, an outer layer of tissue. The prostate surrounds the first part of the urethra – the prostatic urethra. The prostate gland’s main function is to secrete an alkaline fluid that mixes with semen. Prostatic secretions nourish and protect sperm in the acid vagina (Deters, 2024). Prostatic fluid is bacteriostatic and reduces the risk of urinary tract infections in healthy men (Fair and Parrish, 1981). 

The prostate doubles in size at puberty and continues to enlarge throughout a man’s life. At the age of 25 years it is the size of a walnut and on rectal examination feels like a water chestnut. Testosterone and dihydrotestosterone (DHT) contribute to prostatic enlargement. Testosterone is converted to DHT by the enzyme 5α-reductase, and DHT is thought to be responsible for prostatic enlargement (Ng et al, 2024). Table 1 illustrates how prostate size increases with age (Andrade and Knight, 2017). 
 
Table 1. How the prostate enlarges with age
Age Size
20–25 years Walnut
30–35 years Golf ball
50–60 years Lemon
70–80 years Cricket ball
Clinical features
Prostatic enlargement can cause problems with bladder emptying and bladder filling. As men age and the prostate enlarges increasing numbers of men develop urinary symptoms. Figure 1 shows how the enlarged prostate can cause urethral obstruction. 

Urethral obstruction can make it difficult to begin urination and many men find that they have to bear down as though they were trying to open their bowels in order to begin urinating. The urinary stream is reduced and is often less than 15 ml/second, whereas in healthy men the stream is around 60 ml/second (Liu et al, 2016). The stream can be intermittent, there may be a feeling of incomplete bladder emptying, and dribbling after urination is common (Yang et al, 2019). If the prostate is particularly large the man may feel as though he is constipated because the prostate is pressing on the rectum. 

Bladder obstruction leads to trabeculation – thickening of the bladder wall. There is a loss of collagen and muscle fibres, which affects the bladder’s ability to contract effectively and increases the residual urine (the amount of urine left in the bladder after voiding) (Fusco et al, 2018). Inability to empty the bladder completely can lead to large amounts of urine being retained in the bladder. This reduces the working capacity of the bladder and can lead to chronic infection, feelings of urgency, urge incontinence and night-time incontinence. 

Prostatic problems develop gradually and may become increasingly severe if left untreated. Many men are embarrassed by prostatic problems or concerned about possible surgery and do not seek early treatment (Emberton et al, 2008). Voiding problems may be discovered if the man develops acute urinary retention and seeks medical attention, while in other cases chronic urinary retention is discovered when a man has a clinical examination. 

Prostatic problems can lead to a range of lower urinary tract symptoms, which can be categorised as symptoms relating to storage of urine, voiding symptoms or post void symptoms (Table 2) (Abrams et al, 2002). 


Figure 1. Normal and enlarged prostates and how they affect bladder emptying
Table 2. Lower urinary tract symptoms caused by benign prostatic hyperplasia
Storage symptoms


 
Increased frequency
Urgency
Incontinence
Bladder pain
Voiding symptoms





 
Hesitancy
Straining
Weak stream
Intermittent stream
Dysuria
Terminal dribbling
Acute or chronic urinary retention
Post-void symptoms
 
Feeling of incomplete emptying
Dribbling after micturition
(Categorised according to Abrams et al, 2002)
Assessment and investigations 
The aims of screening, assessment and investigation are to identify men who have lower urinary tract symptoms and, if present, to determine their severity. It is important to be aware that some men with large prostates do not have symptoms while other men with smaller prostates can experience severe symptoms. Figure 2 illustrates the normal screening, assessment and investigation process. 
 
Men can find discussing lower urinary tract symptoms very embarrassing so it can be helpful to begin the assessment process by giving the man the option of completing the International Prostate Symptom Score (IPSS)/American Urological Association Symptom Index online or on paper before the first consultation (Barry et al, 2017) (https://www.uptodate.com/contents/calculator-american-urological-association-aua-urinary-symptom-score). The score checks the following symptoms:
  • Incomplete emptying
  • Frequency
  • Intermittency
  • Urgency
  • Weak stream
  • Straining
  • Nocturia


Figure 2. The screening, assessment and investigation process
Each category can be scored from 0 to 5 and the total score indicates symptom severity. A score of 0–7 indicates mild symptoms, 8–19 moderate and 20–35 severe symptoms. 

Level one investigation is screening for lower urinary tract symptoms. This is usually involves completing the IPSS although policy may vary across organisations. Level two investigation is carried out by a registered nurse and consists of history taking and a physical examination. This often determines if continence problems are caused by prostatic hypertrophy or bladder problems or a combination of both. The physical examination includes a bladder scan to check for residual urine, the amount of urine left in the bladder after the person has voided. These scans were once considered an area of specialist practice, but as scanners have become more readily available and easier to use, they are often carried out by non-specialist nurses. 

Men who have bothersome lower urinary tract symptoms should be asked to complete a urinary frequency–volume chart for at least 3 days. It is helpful to have this completed before the first consultation. 

Level three and level four assessments are carried out by a nurse specialist, a nurse consultant or doctor with specialist expertise. The digital rectal examination (DRE) is usually required to allow the clinician to assess prostate size and contour, evaluate for nodules, and detect areas suggestive of malignancy (Ng et al, 2024).

Any constipation or faecal impaction should be treated. Constipation can cause retention in a man who is otherwise able to drain his bladder effectively. Blood tests should be carried out to check renal function and serum prostate-specific antigen (PSA) levels to provide an indication of prostate volume and the possible presence of carcinoma (National Institute for Health and Care Excellence, 2025). 

Urinalysis is carried out to check for possible infection, renal problems and diabetes. Urine is sent for culture and sensitivity if there are indications of infection. The specialist will determine if further investigations such as abdominal, renal or transrectal ultrasound are required. These help determine bladder and prostate size and the degree of hydronephrosis (if any) in patients with urinary retention or signs of renal problems. Endoscopy and cystoscopy may be required if stricture, foreign body or malignancy is suspected. These additional investigations are not normally required if the man has uncomplicated lower urinary tract symptoms. 

Red flags
Red flag symptoms (signs and symptoms from all body systems that suggest a possible serious illness or disease) can be general, e.g. weight loss or fatigue, or specific, e.g. haematuria, and alert the clinician to potentially sinister pathology (Ramanayake and Basnayake, 2018; Healthcare Improvement Scotland, 2023). Red flags in relation to lower urinary tract infections include unexplained haematuria, lower back pain, bone pain, and weight loss. On rectal examination the prostate may feel hard and irregular. 

If cancer is suspected the man should be referred using a suspected cancer pathway referral for an appointment within 2 weeks (National Institute for Health and Care Excellence, 2025). 
Risk factors
Modifiable and non-modifiable risk factors affect the development of and progression of BPH (Table 3).

Ageing is non modifiable and almost 50% of men aged 50 years or older and 80% of males over the age of 80 years suffer from lower urinary tract symptoms as a consequence of BPH (Egan, 2016; Lim 2017). 

Ethnicity affects risk. Men of Asian ethnicity are least likely to develop BPH, men of Caucasian ethnicity have higher risk factors and men of African or Afro-Caribbean ethnicity are at greatest risk (Yeboah, 2016), thought to be because of a combination of genetic susceptibility and socioeconomic factors. People of lower socioeconomic status are at greater of developing a number of conditions including cardiometabolic syndrome and these can increase the risks of BPH and its severity (Wiedemer et al, 2021). There is a genetic component to BPH and the risk of developing BPH quadruples if the man has a first degree relative with BPH (Ng et al, 2024). 
Table 3. Modifiable and non-modifiable risk factors
Modifiable Non-modifiable
Obesity Age
Inactivity Ethnicity
High levels of circulating insulin  Genetic predisposition 
Testosterone and dihydrotestosterone (DHT) levels  
Diabetes
 
Excess alcohol  
Excess caffeine  
Tobacco use  
Diet is thought to affect the development of BPH. A diet rich in beta-carotene, carotenoids, and vitamin A is thought to reduce risks and symptoms. Excessive alcohol, heavy caffeine intake, and taking high-dose vitamin C supplements increase both the risk of developing BPH and its symptoms (Bradley et al, 2017).

Obesity is associated with decreased physical activity and increases the risk of BPH by increasing the risk of metabolic syndrome (a known risk factor), increasing inflammation and disrupting hormone levels (Gacci et al, 2015; Ng et al, 2024). Metabolic syndrome refers to conditions that include hypertension, glucose intolerance/insulin resistance, and dyslipidaemia. Men with metabolic syndrome and obesity have significantly larger prostates than other men, but the reasons for this are not yet known (Gacci et al, 2015).
Diabetes, particularly poorly controlled diabetes requiring the use of antidiabetic medications and especially insulin, increase the risk and severity of BPH and lower urinary tract symptoms (Nygård et al, 2023). 

Testosterone and DHT are androgens – endogenous steroid hormones. DHT, the most potent androgen hormone, is formed by 5α-reductase enzymes converting testosterone to DHT. DHT plays a vital role in the sexual development of males and affects male physiology throughout the lifespan. DHT is also the primary androgen responsible for facial hair, body hair, pubic hair, and prostate growth. Excessive levels of DHT are associated with BPH, prostate cancer and male pattern baldness (Kinter et al, 2023). Many risk factors are modifiable while others are not.

Lifestyle as medicine
When BPH is diagnosed there are three options: watchful waiting, medication or invasive procedures. Not all men who have BPH experience bothersome symptoms (Speakman et al, 2015). When a man has mild to moderate symptoms that are not overly bothersome ‘watchful waiting’ may be used. This involves annual check-ups blood and urine tests and lifestyle changes (Chughtai et al, 2016) (Table 4). 
Table 4. Addressing modifiable lifestyle risk factors
Risk Action and rationale
Obesity
 		 Weight loss to reduce pressure on the bladder, reduce the risk of diabetes and metabolic syndrome
Inactivity
 		 Improve activity levels to strengthen muscles and reduce risks of metabolic syndrome
High levels of circulating insulin If at risk of developing diabetes enrolling in a diabetes prevention programme
Diabetes If type 2 diabetes consider remission programme 
Excess alcohol 
 		 Reduce alcohol use as this irritates the bladder and leads to weight gain
Excess caffeine
 		 Reduce caffeine use as caffeine irritates the bladder and worsens symptoms 
 
Tobacco
 
 Enrol in smoking cessation programme as nicotine irritates the bladder and cough associated with smoking worsens symptoms
Avoid constipation To prevent straining
Medication 
Two types of medicine are used to treat BPH – alpha-blockers and 5 alpha-reductase inhibitors. 

National Institute for Health and Care Excellence (2024) guidance recommends that men with moderate to severe lower urinary tract symptoms should be offered a selective alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin). Alpha-blockers minimise the muscle tone in prostate stromal smooth muscle and bladder neck tissue which improves urinary flow and storage, increasing IPSS symptom scores by 4–6 points (Ng et al, 2024; British National Formulary, 2025). Alpha-blockers do not alter the progression of BPH or reduce the risk of acute urinary retention (Emberton et al, 2008). Selective alpha-blockers specifically designed for prostate are tamsulosin, alfuzosin and silodosin. They work quickly to relieve symptoms – within 3 days symptoms abate, and maximal effect is reached within 2 weeks (Ng et al, 2024).

Common side effects of selective alpha-blockers include first dose hypotension, the risk of floppy iris syndrome if cataract or glaucoma surgery is planned, hypotension and postural hypotension (British National Formulary, 2025). They should be used with caution and careful monitoring in older men (Mansbart et al, 2022). Alpha-blockers should be used cautiously in patients requiring cataract or glaucoma surgery, seeking advice from the person’s ophthalmologist. 

Selective alpha-blockers may be inappropriate in older men who have persistent postural hypotension, i.e. recurrent drop in systolic blood pressure ≥20 mmHg (O’Mahony et al, 2015; Curtin et al, 2021). Selective alpha-blockers can also interfere with the ability to ejaculate and cause nasal congestion. 

Non-selective alpha-blockers, such as terazosin and doxazosin, are also effective in relieving prostatic issues but are much more likely to cause generalised side effects such as orthostatic hypotension (Nachawati et al, 2025). 

In order to reduce the risk of first dose hypotension men are often advised to take the first dose just before they go to sleep, so that any hypotensive effects have worn off by the time he wakes. However, others suggest is that it is given first thing in the morning so that the patient is fully alert and less likely to fall if blood pressure drops. If the man is taking antihypertensive medication, he may be advised to omit a dose on the day he starts taking the selective alpha-blocker. 

It is important to be aware that tamsulosin can be bought from pharmacies under certain circumstances, so you should check if the man is already taking tamsulosin sold as Flo-max.

Men prescribed alpha-blockers should be reviewed at 4–6 weeks after initiation and then every 6–12 months. Symptoms and quality of life should be reviewed and the clinician should check if the man is experiencing any adverse effects of treatment (National Institute for Health and Care Excellence, 2024).
National Institute for Health and Care Excellence (2024) recommend that a man who has BPH symptoms, whose prostate is estimated to weigh more than 30 g or who has a PSA level over 1.4 ng/ml, and is deemed to be at high risk of progression, should be given a 5α-reductase inhibitor. There are two 5α-reductase inhibitors, finasteride and dutasteride, which are considered equally effective (Nickel et al, 2011). They block the conversion of testosterone to DHT, which shrinks the enlarged prostate by up to 30%. As the prostate shrinks, urinary flow rates improve. They can be given alone or in combination with an alpha blocker. 5α-reductase inhibitors take a long time to work – it is usually 3 months before any improvement is noted, so when symptoms are very bothersome an alpha blocker is often prescribed as well. 

5α-reductase inhibitors are useful if the prostate is particularly large, if flow rates are very low and if the person is unable to tolerate an alpha blocker. They are used if prostate problems cause haematuria because they reduce blood supply and haematuria ceases when the prostate is not engorged with blood. 5α-reductase inhibitors reduce serum PSA levels, prostate volume, urinary symptoms and the need for surgery (Roehrborn et al, 2004). 

Side effects include impotence (in 19% of cases), gynaecomastia, headache, and dizziness. Male baldness, a result of high levels of DHT, is often reversed and many men develop thicker hair. If the drug is stopped, symptoms return (British National Formulary, 2025). 
Practice point or safety alert
Women of childbearing age and pregnant women should avoid all exposure to 5α-reductase inhibitors, including handling tablets. When a tablet is crushed or broken the drug can be absorbed through the skin. Exposure during pregnancy can cause abnormalities of the external genitalia of a male fetus (British National Formulary, 2025).
Alongside other medications, anticholinergic medicines may also be offered to treat symptoms of overactive bladder (National Institute for Health and Care Excellence, 2024), although the author has reservations about this for two reasons. Men with BPH are at risk of developing urinary retention and anticholinergics add to that risk, and anticholinergics have a high cholinergic burden and can impair cognition in the ageing brain (Bishara, 2023; King and Rabino, 2025). 

Conclusions 
Although 3.2 million men have BPH they are not all affected to the same extent. Some men may not experience any symptoms, while others may experience mild symptoms that respond to lifestyle changes and careful monitoring. Some men experience more bothersome symptoms and may require medication while others require minimally invasive and invasive treatments. The second part of this series will explore minimally invasive and invasive treatments for BPH. 

BPH symptoms can have a huge effect on a man’s quality of life and men can find it very difficult to seek treatment. The clinician, regardless of gender, needs to be very sensitive to the man’s feelings and to establish an open and honest dialogue so that any symptoms can be addressed. 

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