Benign Prostatic Hyperplasia (BPH): Causes, Symptoms and Treatment

Benign prostatic hyperplasia (BPH) — commonly called an enlarged prostate — is the non-cancerous proliferation of prostate glandular and stromal tissue that causes bladder outlet obstruction and lower urinary tract symptoms (LUTS). It is the most common urological condition in ageing men: more than 50% of men have histological BPH by age 60, rising to over 90% by age 85. While not all men with BPH develop significant symptoms, approximately 25–30% of men over 50 have LUTS severe enough to affect quality of life.

BPH is distinct from prostate cancer — it is a benign condition with no malignant potential. However, prolonged severe obstruction can lead to chronic urinary retention, recurrent urinary tract infections, bladder diverticula, bladder stones, and ultimately obstructive nephropathy and renal impairment if left untreated.

Anatomy and How BPH Causes Obstruction

The prostate gland surrounds the urethra at the base of the bladder. It is divided into zones: the transition zone — immediately surrounding the urethra — is the site of BPH; the peripheral zone is where prostate cancer predominantly arises.

As BPH develops, the transition zone enlarges progressively, compressing the urethra — narrowing and lengthening it, increasing urethral resistance, and forcing the bladder detrusor muscle to work harder to expel urine. Over years:

1. Detrusor hypertrophy — the bladder muscle thickens and becomes overactive (causing urgency and frequency) to overcome resistance
2. Detrusor decompensation — with prolonged obstruction, the bladder muscle weakens, causing incomplete emptying and post-void residual urine accumulation
3. Bladder trabeculation and diverticula — chronic high-pressure voiding causes structural bladder changes
4. Obstructive nephropathy — in severe cases, high bladder pressures cause hydroureter and hydronephrosis, threatening renal function

Why Does BPH Develop?

The exact cause is multifactorial, but two factors are essential:

• Ageing — the universal risk factor; BPH does not occur in castrated men or before puberty
• Androgens — specifically dihydrotestosterone (DHT), the active metabolite of testosterone formed by the enzyme 5-alpha reductase type 2 within prostate cells; DHT drives prostate cell proliferation. This is why 5-alpha reductase inhibitors (5-ARIs) effectively reduce prostate volume.

Additional risk factors:

• Family history (first-degree relative with BPH — significantly increased risk)
• Obesity and metabolic syndrome — insulin resistance and elevated IGF-1 promote prostate cell growth
• Diabetes mellitus — insulin-like effects
• Cardiovascular disease — shared pathophysiology with metabolic syndrome

Oestrogen may also play a role in BPH development — as testosterone declines with age, the oestrogen:testosterone ratio rises, potentially sensitising prostatic stroma to androgen stimulation.

Symptoms — Lower Urinary Tract Symptoms (LUTS)

BPH-related LUTS are classified into two groups:

Storage (Irritative) Symptoms

Caused by detrusor overactivity and bladder hypersensitivity:

• Urinary urgency — sudden compelling desire to void that is difficult to defer
• Frequency — voiding more than 8 times in 24 hours
• Nocturia — waking more than once per night to void; highly disruptive to sleep quality
• Urge incontinence — involuntary urine leakage associated with urgency

Voiding (Obstructive) Symptoms

Caused by urethral obstruction:

• Hesitancy — difficulty initiating urination; prolonged wait before flow begins
• Weak stream — reduced urinary flow rate (normal >15 mL/s; obstructed often <10 mL/s)
• Intermittency — urine flow that stops and starts during voiding
• Straining — needing to push or strain to initiate or maintain voiding
• Terminal dribbling — prolonged dribbling at the end of urination
• Incomplete emptying — sensation of incomplete bladder emptying; significant post-void residual

Post-micturition Symptoms

• Post-void dribbling — involuntary loss of urine immediately after completing voiding

Complications of Severe BPH

• Acute urinary retention (AUR) — sudden complete inability to void; painful; requires emergency urethral catheterisation; occurs in approximately 2–3% of men with symptomatic BPH per year; can be precipitated by anticholinergic drugs, alcohol, dehydration, or prostatic infection
• Chronic urinary retention — painless, progressive inability to empty the bladder; large post-void residuals (>300–500 mL); risk of overflow incontinence, recurrent UTI, and obstructive nephropathy
• Recurrent UTI — residual urine is a culture medium for bacteria
• Bladder stones — urinary stasis leads to crystallisation
• Haematuria — from engorged prostatic venous channels; typically microscopic

IPSS Score

The International Prostate Symptom Score (IPSS) is the validated symptom questionnaire used universally to quantify LUTS severity and guide treatment decisions:

• 0–7: Mild symptoms — watchful waiting
• 8–19: Moderate symptoms — pharmacological therapy
• 20–35: Severe symptoms — surgical treatment consideration
• Plus quality-of-life question (0–6)

Diagnosis

Digital Rectal Examination (DRE)

Assessment of prostate size, consistency, and symmetry. BPH produces a smooth, symmetrical, firm, rubbery enlargement. Nodularity or firmness should prompt consideration of prostate cancer.

PSA (Prostate-Specific Antigen)

Serum PSA is routinely measured in men with LUTS — elevated PSA may reflect large prostate volume (BPH raises PSA proportionally to volume), prostatitis, or prostate cancer. PSA density (PSA divided by prostate volume) and age-specific PSA ranges help distinguish BPH from cancer.

PSA in BPH also serves as a predictor of BPH progression — PSA >1.5 ng/mL predicts higher risk of AUR and surgical need, informing decision to use 5-alpha reductase inhibitors.

Uroflowmetry

Non-invasive measurement of urine flow rate and pattern during voiding. Obstruction reduces maximum flow rate (Qmax) below 10–15 mL/s and may show a prolonged, plateau-shaped flow curve. Voided volume must be >150 mL for reliable interpretation.

Post-Void Residual (PVR) Measurement

Bladder ultrasound immediately after voiding measures residual urine volume. PVR >100–150 mL indicates incomplete emptying; PVR >300 mL suggests significant retention and increases complication risk.

Prostate Volume Assessment

Transrectal ultrasound (TRUS) or abdominal ultrasound accurately measures prostate volume. Volume guides treatment choice:

• <30 mL: alpha-blockers alone usually sufficient
• 30–80 mL: alpha-blocker ± 5-ARI

• 80 mL or >100 mL: 5-ARI beneficial; larger prostates may need surgical treatment with enucleation rather than TURP

Urodynamics (Pressure-Flow Studies)

Invasive study measuring bladder pressure and flow simultaneously — distinguishes bladder outlet obstruction (BOO) from detrusor underactivity (weak bladder muscle); essential before surgical treatment in men with uncertain diagnosis or previous pelvic surgery.

Cystoscopy

Endoscopic inspection of the urethra, prostate, and bladder under local or general anaesthesia. Directly visualises prostatic lobar anatomy, urethral calibre, bladder neck, bladder trabeculation, diverticula, and stones; essential before minimally invasive surgical therapies.

Renal Ultrasound and Creatinine

In men with large PVR or suspected obstructive nephropathy — to assess upper tract dilatation and renal function.

Treatment

Treatment is guided by IPSS severity, prostate volume, PSA, uroflowmetry, PVR, and quality of life impact.

Watchful Waiting

For mild LUTS (IPSS 0–7) with no complications — monitoring with annual reassessment. Lifestyle advice:

• Fluid management — reduce evening fluid intake; avoid caffeine and alcohol
• Bladder training — urge suppression techniques
• Double voiding — a second void 5–10 minutes after the first
• Avoid bladder-irritating medications (diuretics, anticholinergics)

Alpha-Blockers (α1-Adrenergic Receptor Antagonists)

First-line pharmacological treatment for moderate-to-severe LUTS regardless of prostate size. Relax smooth muscle in the prostate, bladder neck, and urethra — rapidly reducing outflow resistance.

Examples: tamsulosin (selective α1A), silodosin (highly selective α1A), alfuzosin, doxazosin (also treats hypertension)

• Onset of action: 1–2 weeks; full effect by 4–6 weeks
• Reduce IPSS by approximately 30–40%; improve Qmax by 15–30%
• Side effects: postural hypotension (particularly non-selective agents), dizziness, retrograde ejaculation (particularly tamsulosin, silodosin — in 10–30%; permanent but harmless)
• Do not reduce prostate volume or prevent disease progression

5-Alpha Reductase Inhibitors (5-ARIs)

Block conversion of testosterone to DHT within the prostate — gradually reduce prostate volume by 20–25% over 6–12 months. Indicated for men with large prostates (>30–40 mL by volume or PSA >1.5 ng/mL as a proxy).

Examples: finasteride (5 mg daily), dutasteride (0.5 mg daily — blocks both type 1 and 2 isoenzymes)

• Take 6–12 months for full effect
• Reduce long-term risk of AUR by 57% and need for surgery by 55% (PLESS trial)
• Side effects: sexual dysfunction (erectile dysfunction, reduced libido, reduced ejaculation volume) in approximately 5–8%; gynaecomastia; reduce PSA by approximately 50% (must double PSA for prostate cancer screening interpretation)
• Combination alpha-blocker + 5-ARI (e.g., tamsulosin + dutasteride — CombAT and MTOPS trials) is more effective than monotherapy for men with large prostates and significant symptoms; the alpha-blocker can be withdrawn after 6–12 months if 5-ARI achieving symptom control

PDE5 Inhibitors

Tadalafil 5 mg daily is approved for LUTS/BPH — reduces smooth muscle tone in the prostate and bladder via cGMP pathway; mild improvement in IPSS and Qmax; useful in men with co-existing erectile dysfunction.

Anticholinergics / Beta-3 Agonists

For persistent storage LUTS (urgency, frequency, nocturia) despite alpha-blocker — add anticholinergic (solifenacin, tolterodine) or beta-3 agonist (mirabegron) to address detrusor overactivity. Use with caution in men with significant PVR (>150–200 mL) — risk of precipitating acute retention.

Surgical Treatment

Indicated for: severe symptoms refractory to medical therapy; AUR; recurrent UTI; bladder stones; renal impairment from obstruction; significant PVR.

Transurethral Resection of the Prostate (TURP)

The gold standard surgical procedure for prostates 30–80 mL. A resectoscope is passed through the urethra; the obstructing transition zone is resected using electrocautery (monopolar or bipolar) chip by chip. The standard surgical reference procedure against which all others are compared.

• 80–90% improvement in IPSS; significant Qmax improvement
• Day-case or 1–2 night inpatient
• Retrograde ejaculation in 75–90% (permanent but harmless)
• Bipolar TURP (saline irrigation) has lower risk of TUR syndrome (dilutional hyponatraemia) than monopolar
• Risk of erectile dysfunction approximately 5–10%; urinary incontinence approximately 1–2%

Transurethral Enucleation (HoLEP / ThuLEP / BipolEP)

Holmium laser enucleation of the prostate (HoLEP) — the preferred technique for large prostates (>80 mL) and increasingly for standard-sized prostates; enucleates the adenoma in anatomical planes using a holmium or thulium laser, then morcellates the tissue. Advantage: size-independent, high efficacy, durable outcomes, lower haemorrhage risk, shorter catheterisation time. Requires expert laser training; standard at high-volume centres.

Open/Robotic Simple Prostatectomy

For very large prostates (>100–150 mL) — laparoscopic or robot-assisted enucleation of the adenoma; rarely required where HoLEP is available.

Minimally Invasive Surgical Therapies (MIST)

For men wishing to preserve sexual function (particularly ejaculation):

• UroLift (Prostatic Urethral Lift) — tiny implants deployed transurethral to retract obstructing lateral lobes; no tissue removal; preserves ejaculation in nearly all; suitable for lateral lobe obstruction without median lobe; reversible
• Rezūm (Water Vapour Thermal Therapy) — convective water vapour injected into the prostate; induces localised cell death; reduces prostate volume; office procedure; ejaculation preserved
• Aquablation (AQUABEAM robotic system): robotic high-velocity waterjet ablation guided by real-time ultrasound imaging; size-independent; preserves ejaculation better than TURP; excellent outcomes for complex anatomy

BPH and Prostate Care in China

China's urology centres offer comprehensive BPH assessment and treatment:

• Full LUTS assessment: IPSS scoring, uroflowmetry, post-void residual ultrasound, prostate volume assessment, PSA, and urodynamics
• HoLEP (holmium laser enucleation): minimally invasive laser enucleation for all prostate sizes; experienced laser urologists at major centres; same-admission procedure
• Bipolar TURP: safe, saline-based transurethral resection at all major centres; high case volumes
• UroLift and Rezūm: ejaculation-preserving minimally invasive options available at specialist urology centres
• Combination pharmacotherapy: full alpha-blocker and 5-ARI formularies; combination therapy initiated and monitored
• Cost: care in China is generally less expensive than UK private treatment, but the hospital prices each case individually — ask us for the written quote before you commit.
• Full English care navigation from assessment through surgical planning and post-operative follow-up

Contact a ChinaMedicalTour care navigator to arrange a BPH assessment, uroflowmetry, or prostate surgery consultation.

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Medical content based on MSD Manuals and international BPH guidelines (EAU, AUA). Evidence reviewed 2025.

Frequently Asked Questions

Can overseas urological patients receive a preliminary review of imaging and lab results?

Yes. Multiparametric prostate MRI, urinary CT scans, ultrasound reports, and PSA or urinalysis findings can be reviewed through pre-consultation coordination with senior Chinese urologists.

What minimally invasive urological procedures are evaluated in Chinese tertiary centers?

Urology departments evaluate laser prostate enucleation (HoLEP/ThuLEP), flexible ureteroscopic stone lithotripsy, transurethral resections, and robotic laparoscopic urological surgery.

How are appointments and hospital fee quotations confirmed for international patients?

Hospital consultations and surgical schedules are confirmed directly with the department, with all medical fees paid directly to the treating public hospital according to published counter schedules.