Benign Prostatic Hyperplasia (BPH): Guide to Treatment
Medically reviewed by Jamin Brahmbhatt, MD
The treatment of an enlarged prostate, otherwise known as benign prostatic hyperplasia (BPH), typically involves medications like alpha-blockers and 5-alpha reductase inhibitors that help ease lower urinary tract symptoms such as urinary hesitancy, dribbling, straining, or feeling like you're unable to empty your bladder.
Surgery is reserved for people with moderate to severe lower urinary tract symptoms, such as those with urinary retention (the inability to empty the bladder) or severe urgency during day or night. In certain circumstances, however, surgery can be the first-line treatment of BPH.
This article looks at the treatment options for benign prostatic hyperplasia, including what to do if a treatment fails. It also explores lifestyle changes and alternative treatments that may help manage a condition that affects roughly half of all males by age 70.
Photo composite by Lecia Landis for Verywell Health; Getty Images
First-Line Benign Prostatic Hyperplasia Treatment Options
BPH is a progressive condition mainly affecting older males in which the enlargement of the prostate gland impedes the flow of urine through the urethra (the tube through which urine exits the penis), causing an array of lower urinary tract symptoms (LUTS).
BPH cannot be cured but can effectively be managed with treatments. The primary aim of BPH treatment is to alleviate LUTS and improve urinary flow.
The standard first-line treatment of BPH involves different medications that improve urinary voiding (the emptying of the bladder). Less commonly, there are instances when prostate surgery may be a reasonable first-line option.
Who Treats BPH?
An enlarged prostate is typically treated by a specialist of the male reproductive and urinary tracts known as a urologist. Milder cases can be managed by your primary care provider who may refer you to a urologist when standard treatments fail to provide relief.
Medications
Several classes of drugs are commonly prescribed to people with BPH. These may be used on their own (monotherapy) or with other drugs (combination therapy).
Alpha-blockers are the most common choice for the first-line treatment of BPH. They are recommended for the treatment of moderate to severe LUTS and help improve urine flow by relaxing smooth muscles in the prostate gland and bladder neck.
Alpha-blockers license for the use of BPH include:
Cardura (doxazosin)
Hytrin (terazosin)
Rapaflo (silodosin)
Uroxatral (alfuzosin)
Possible side effects of alpha-blockers include headaches, weakness, nasal congestion, orthostatic hypotension (dizzy spells when standing), ejaculation problems, and erectile dysfunction.
Another class of drugs, 5-alpha reductase inhibitors (5-ARIs), may be used on their own but are more commonly prescribed along with an alpha-blocker. They can help prevent the progression of LUTS and/or reduce the need for prostate surgery.
These 5-ARIs work by blocking an enzyme called dihydrotestosterone (DHT) that is responsible for prostate enlargement. By doing so, the drugs can "shrink" the size of the gland by as much as 17%.
The two 5-ARI options approved for use in the United States are:
Proscar (finasteride)
Side effects of 5-ARIs include a loss of libido (sex drive), ejaculation problems, and erectile dysfunction.
Other drugs may be added to the treatment plan for people with severe LUTS and/or to help counter the side effects of alpha-blockers and 5-ARIs. Among them are:
Anticholinergic drugs like Detrol (tolterodine), Ditropan (oxybutynin), Enablex (darifenacin), Sanctura (trospium), Toviaz (fesoterodine), and Vesicare (solifenacin) may be used to treat urge incontinence and nocturia (the need to urinate at night).
Beta-3 adrenoceptor agonists like Myrbetriq (mirabegron) and Gemtesa (vibegron) can also help treat urge incontinence and nocturia as well as other BPH symptoms like urinary frequency (the need to urinate frequently) and urinary urgency (the need to urinate urgently).
Phosphodiesterase-5 (PDE5) inhibitors may be used to treat erectile dysfunction with or without BPH symptoms. Cialis (tadalafil), given in a daily 5-milligram (mg) dose, is the recommended option. Studies suggest that daily Cialis may help improve urinary flow and erection quality.
What Is Jalyn?
Jalyn is a fixed-dose combination drug containing 1.5 mg of dutasteride and 0.4 mg of tamsulosin. The combination of an alpha-blocker and 5-ARI in a single capsule has been shown to improve drug adherence and sustain relief of moderate BPH symptoms in people at risk of progression.
Surgery
Prostate surgery is generally indicated for people with complications of BPH, including poor kidney function, recurrent urinary tract infections (UTIs), recurrent kidney stones, and gross hematuria (visible blood in urine). It may also be considered when conservative treatments for urinary retention fail.
According to the American Urological Society, there are circumstances in which surgery may be a reasonable early option for BPH treatment. This includes treating people who want to avoid taking drugs daily or those who have experienced intolerable side effects.
Individuals who initially present with BPH complications may also be referred to a urologist for surgery as a first-line treatment option.
Surgical options include:
Transurethral resection of the prostate (TURP): This involves the insertion of a narrow scope (called a cystoscope) into the urethra to access the prostate gland and remove excess tissues with electrocautery (heat) or laser technology.
Simple prostatectomy: This surgery is typically used to remove a very large prostate gland either with open surgery (involving a scalpel and large incision), laparoscopy (involving small incisions with specialized scopes and tools), or robotic surgery.
Transurethral incision of the prostate (TUIP): This is a simpler form of TURP, commonly used when the prostate gland is smaller. Rather than removing large sections of the prostate gland, one or two small cuts are made to improve the urinary flow.
Transurethral vaporization of the prostate (TUVP): This procedure, similar to TURP, uses a high-voltage electrical current to vaporize prostate tissues. This causes less bleeding and postoperative swelling.
Holmium laser enucleation of the prostate (HoLEP): This surgery, similar to TURP, uses a specialized laser to remove prostate tissues, after which a separate instrument cuts the tissue into easily removable fragments.
Prostatic urethral lift (PUL): This minimally invasive surgery also uses a cystoscope to access the prostate but, instead of cutting away tissues, separates the lobes of the prostate gland to improve urinary flow.
Water vapor thermal therapy (WVTT): This minimally invasive surgery, similar to TURP, ablates (destroys) prostate tissues with thermal energy in the form of super-heated steam.
Prostate artery embolization (PAE): This involves the insertion of a narrow tube called a catheter into an artery in your wrist or groin. The catheter is then threaded to the prostate gland, where it injects chemicals that reduce blood flow, causing the gland to gradually shrink.
Prostate gland surgery can cause side effects. Some, like blood in urine, pain with urination, or difficulty urinating, are temporary. Others like erectile dysfunction, urinary incontinence, and retrograde ejaculation (when you ejaculate into the bladder rather than out of your penis) may be longer-lasting or permanent.
Related: Long-Term Risks of Prostate Surgery
BPH Therapies vs. Surgery
The choice between medications or surgery for the treatment of BPH is a highly personal one. While upfront surgery offers better relief of LUTS, it is also more risky and has a higher rate of sexual side effects.
On the other hand, the prolonged use of BPH medicines can also cause sexual side effects in as many as 7% of users. While the drugs are less costly, they can delay surgical treatments. This delay can increase the risk of postoperative complications once surgery is performed.
Fortunately, newer and less invasive procedures like HoLEP, PUL, WVTT, or PAE have greatly reduced the risk of postoperative complications even among older adults with extremely large prostate glands.
In the end, there is no one-size-fits-all solution for BPH. The treatment needs to be individualized, taking into account multiple factors like your age, symptoms, pregnancy intentions, insurance coverage, co-occurring medical conditions, and the size and rate of growth of your prostate.
Speak with your urologist about any concerns you have about BPH treatments. There may be alternatives to explore that are more appropriate for you as an individual. If in doubt, do not hesitate to seek a second opinion from a qualified specialist.
How Successful Is BPH Treatment?
Drug therapies for BPH vary in their effectiveness. Studies have shown that the combination of an alpha-blocker and 5-ARI in people with moderate LUTS reduces the risk of BPH progression by 66% compared to having no treatment.
When used on their own, the drugs are only modestly effective. By way of example, alpha-blockers, considered the backbone of medical therapy, are 50% effective in alleviating LUTS and 40% effective in improving urinary flow.
One of the problems is that people with BPH are often prescribed monotherapy when more effective combination therapies may be used. A 2016 study from the University of Montreal found that of 1,120 adults diagnosed with BPH, 87.6% were prescribed monotherapy either in the form of an alpha-blocker (69.9%) or a 5-ARI (26.6%).
Efficacy of Prostate Surgery
To date, surgery—mainly in the form of TURP—remains the gold standard of BPH treatment. Compared to medications, TURP is better able to sustain symptom relief, increase urinary flow, and reduce the need for retreatment.
A 2021 study from Europe suggests that TURP can increase urine flow by 74.2% and alleviate LUTS by as much as 91%. This is more or less in line with other studies that have reported an 85% reduction in BPH symptoms following TURP.
Alternative (Nondrug) BPH Treatments
Herbal remedies are commonly marketed to people with an enlarged prostate, but few large-scale studies are available to support the health claims. With that said, several remedies have shown promise and may be beneficial to those who might otherwise avoid drug therapies.
Alternative options include:
Saw palmetto: This plant belonging to the palm family is thought to suppress DHT and, by doing so, help shrink the prostate in the same way as a 5-ARI.
Selenium: This essential mineral sourced from meat, fish, and dairy tends to be low in people with BPH. Selenium supplementation is conversely thought to reduce the risk of BPH.
Lycopene: This plant-based compound which gives food like tomatoes and watermelon their red color has antioxidant effects that may prevent cellular changes that lead to BPH.
There is some evidence of a benefit. A 2018 study in BJU International found that the combination of saw palmetto, selenium, and lycopene was "non-inferior" to Cialis 5 mg in improving BPH symptoms.
Another study published in the journal Prostate in 2014 found that saw palmetto, selenium, and lycopene combined with Flomax was more effective than Flomax alone in alleviating LUTS in adults with BPH.
Related: Herbs for an Enlarged Prostate
Persistent Enlarged Prostate Symptoms: Next Course of Treatment
Even with gold standard treatments like TURP, roughly 1 in 20 people who undergo surgery will experience BPH regrowth, leading to a second surgery later in life. The risk of this appears to be the same regardless of the type of surgery used.
A 2023 study in Prostate Cancer and Prostatic Disease involving 43,147 people surgically treated for BPH found that the retreatment rate was largely the same for TURP (5.3%), PUL (5.9%), WVTT (6.2%), and other common surgical interventions.
In the end, there is no standard approach to the surgical retreatment of BPH. The decision to treat—and how to treat—is ultimately a shared decision in which the benefits and risks are weighed by both you and your healthcare provider.
Related: Causes of Overactive Bladder in Males
Other Ways to Support Prostate Health
Certain lifestyle changes can be beneficial to your health and well-being if living with BPH. The following should be a part of your treatment plan regardless of the severity of your condition:
Increase your physical activity: Even moderate-intensity exercise like brisk walking can help ease BPH symptoms. A 2015 study found that people who exercised one or more hours per week were 13% less likely to report nocturia and 34% less likely to report severe nocturia.
Manage your fluid intake: Though you need to drink the recommended amount of water each day to maintain good health, try to reduce your fluid intake before bedtime to avoid the need for nighttime urination.
Follow a time voiding schedule: To better avoid urinary urgency, go to the bathroom every two hours to empty your bladder. Try not to go more than three hours without visiting the toilet.
Limit alcohol and caffeine: Caffeine not only acts as a diuretic (removes fluids from the body) and as a bladder irritant, but it may also stimulate hormones like DHT that give rise to BPH.
Pee in a sitting position: Urinating in a seated rather than standing position may help with urinary hesitancy or retention. Doing so improves urinary flow, decreases the time it takes to empty the bladder, and reduces the amount of urine left in the bladder after urination.
Summary
Benign prostatic hyperplasia (BPH), or an enlarged prostate, is treated with medications like alpha-blockers and 5-alpha reductase inhibitors that reduce lower urinary tract symptoms, improve urinary flow, and help slow BPH progression.
Other prescription drugs like Cialis (tadalafil) and Myrbetriq (mirabegron) or herbal medicines like saw palmetto may be used to support treatment.
Surgery is generally advised when conservative treatments fail or complications (like recurrent UTIs) develop. It may also be used if a person wants to avoid daily drug treatment or has experienced intolerable side effects.
While surgery is more effective in alleviating BPH symptoms, it carries a higher risk of sexual side effects and requires treating again in 1 of every 20 cases.
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