BPH Management

May 23, 2023
BPH or benign prostatic hyperplasia is the non-cancerous (benign) enlargement (hyperplasia) of the prostate. Essentially, BPH causes the prostate for most men to continue growing unchecked throughout a man’s life if intervention is not exercised. BPH isn’t prostate cancer and it doesn’t cause or lead to prostate cancer; it is simply the natural prostate enlargement that nearly every man if he lives long enough, will be affected by at one point or another. Also called prostatic hyperplasia or benign prostate enlargement, BPH affects the prostate tissue in ways that can cause lower urinary tract symptoms or LUTS in men who it affects. BPH symptoms in the form of LUTS can include increased urinary frequency and urgency, dribbling, weak or interrupted urine stream, frequent urination at night, trouble starting urination, retention, incontinence, starting and stopping, and more. Benign prostatic hyperplasia BPH management includes the proper diagnosis of BPH by a physician and the subsequent watchful waiting, or treatment/therapy of lower urinary tract symptoms brought on by BPH. BPH can be a non-issue or even non-existent for some fortunate men who are not predisposed for one reason or another, but most will eventually experience lower urinary tract symptoms or LUTS that are triggered by prostatic hyperplasia. Since the determination of BPH via the measurement and analysis of lower urinary tract symptoms can only be accomplished when all other possibilities such as a urinary tract infection, prostatitis, kidney stones, bladder obstruction, or prostate cancer are eliminated, an accurate diagnosis is important.


It can be a lengthy process to have benign prostatic hyperplasia diagnosed. The first step taken with benign prostatic hyperplasia or BPH management should include a doctor’s appointment that prompts the asking of many questions by a urologist or healthcare provider of choice. The visit should also include a physical exam which includes a digital rectal exam (DRE) to assess the shape and size of the prostate and to feel for any lumps or bumps that could signify prostate cancer. Additionally, both a blood and urine test may be ordered to rule in our out any other illness that could mimic BPH symptoms. Some questions the doctor may ask, per the International Prostatism Symptom Score Publication (IPSS), include:
  • Over the past month, how often have you had the sensation of not emptying your bladder completely after urinating?
  • Over the past month, how often have you had to urinate again less than 2 hours later?
  • Over the past month, how often have you found you stopped and started again several times while urinating?
  • Over the past month, how often have you found it difficult to postpone urination?
  • Over the past month, how often have you had a weak urinary stream?
  • Over the past month, how often have you had to push or strain to begin urination?
  • Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you awoke in the morning?1
After answering questions posed by the doctor, some questions can be asked of the doctor that may include the following:
  • How will the diagnosis of BPH be eventually determined?
  • Do you feel anything unusual or see any signs of prostate cancer?
  • Are any of my current medications going to impact a diagnosis of BPH?
  • If BPH is determined, will I need watchful waiting, medication, or surgery based on my symptoms?
  • What side effects come with each of these options?
  • If I have more advanced BPH, what treatment option has the least side effects and manages my BPH the best?
After the doctor/patient question and answer session and exam, additional testing may be needed to definitively determine if benign prostatic hyperplasia is present. This testing often includes some or all of the tests below according to the Mayo Clinic:
  • Prostate-specific antigen (PSA) blood test

    PSA is a protein made in the prostate. PSA levels go up when the prostate becomes enlarged. But higher PSA levels also can be due to recent procedures, illnesses, surgery, or prostate cancer.
  • Urinary flow test

    You urinate into a container attached to a machine. The machine measures how strong your urine flow is and how much urine you pass. Test results can show over time whether your condition is getting better or worse.
  • Postvoid residual volume test

    This test measures whether you can empty your bladder fully. The test can be done using an imaging exam called ultrasound. Or it can be done with a tube called a catheter placed into your bladder after you urinate to measure how much urine is left in the bladder.
  • 24-hour voiding diary

    This involves noting how often and how much you urinate. It might be extra helpful if you show you make more than a third of your daily urine at night.2
If the problem is more complex, additional tests may be needed that include:
  • Transrectal ultrasound

    A device that uses sound waves to make pictures is inserted into the rectum. It measures and checks the prostate.
  • Prostate biopsy

    Transrectal ultrasound guides needles that are used to take tissue samples of the prostate. Checking the tissue can help the doctor find out if prostate cancer is present.
  • Urodynamic and pressure flow studies

    A catheter is threaded through the urethra into the bladder. Water — or, less often, air — is slowly sent into the bladder to measure bladder pressure and check how well the bladder muscles work.
  • Cystoscopy

    A lighted, flexible tool is placed into the urethra. It lets a doctor see inside the urethra and bladder. Before this test, you will be given a medicine that keeps you from feeling pain.2


There are many proven treatment options for addressing benign prostatic hyperplasia, from watchful waiting and medication to inpatient and outpatient surgery. With some treatments, the enlarged prostate can go back to normal, but the best treatment for benign prostatic hyperplasia is the treatment that works best for each individual. If the right therapy is chosen to match the desired outcome, then BPH can be dealt with successfully. Benign prostatic hyperplasia is common in older men and if a man lives long enough, he will get BPH unless he is fortunate enough to be a member of the small percentage of men who don’t get BPH. Technology has caught up with BPH to the point where benign prostatic hyperplasia can be cured both short-term and permanently if the right therapy is chosen. However, to leave an enlarged prostate untreated is to potentially risk long-term bladder damage if BPH becomes severe enough. The different levels of treatment for BPH are summarized below.

Watchful Waiting

For BPH cases where lower urinary tract symptoms are mild, a wait-and-see approach may be the most beneficial, at least to start with. Not all men get a bad case of benign prostatic hyperplasia right away or at all, so it can be monitored and simple lifestyle choices can be implemented to minimize the side effects from LUTS.

Alternative Therapies

During watchful waiting, some men may decide to try a few alternative therapies such as herbal supplements like saw palmetto, pygeum, or stinging nettle to possibly relieve some BPH symptoms. Lifestyle changes such as going to the restroom whenever you have the chance, urinating as soon as you feel the urge, exercising frequently, not drinking too much before bed (especially beverages containing alcohol or caffeine), avoiding cold and sinus medications whenever possible, reducing stress and other lifestyle adaptations can make BPH more bearable.


When watchful waiting has run its course and the next step is desired, BPH medications are often the choice many men make before considering surgery. BPH medications fall into two categories: Alpha-blockers and 5-alpha-reductase inhibitors. Alpha-blockers. Also known as alpha-adrenergic antagonists, these medicines cause the muscles around your bladder to relax, making it easier to urinate. These drugs were originally used to treat high blood pressure. They seem to work best in men with moderately enlarged prostates. Common side effects include decreased ejaculation and low blood pressure. These drugs should not be taken with medications for erectile dysfunction, such as Viagra or Cialis. Alpha-blockers include:3
  • Tamsulosin (Flomax)
  • Alfuzosin (Uroxatral)
  • Terazosin (Hytrin)
  • Doxazosin (Cardura)
Enzyme inhibitors. Also known as 5-alpha-reductase inhibitors, these medicines shrink the prostate gland by reducing the amount of testosterone the body converts into dihydrotestosterone, a hormone that prostate tissue needs to grow. These drugs take longer to work than alpha-blockers. They also lower PSA levels (a high level of PSA can indicate prostate cancer), making it harder to screen for prostate cancer. Enzyme inhibitors include:3
  • Finasteride (Proscar)
  • Dutasteride (Avodart)
  • Botulinum toxin (Botox)
A combination therapy that includes taking an alpha-blocker and an enzyme inhibitor at the same time may be prescribed by a doctor to cover all bases if needed.


Surgery is often the treatment of last resort for some men, but for others, surgery may represent an opportunity to take care of their BPH symptoms more quickly and permanently compared to waiting around for alternative therapies or medication to begin working. Surgery can be especially beneficial for men who are suffering from severe BPH symptoms and could permanently lose the use of their bladder if BPH progresses further. Some popular prostate surgical procedures include but are not limited to, the following treatments which address every size and shaped prostate depending on the limitation of each surgical procedure.
    • Aquablation
    • Laser Enucleation (HoLEP)
    • Prostatectomy (Simple)
    • Robotic Assisted Simple Prostatectomy (RASP)
    • Prostatic Urethral Lift
    • PVP Greenlight Laser
    • Transurethral Incision of the Prostate (TUIP)
    • Transurethral Resection of the Prostate (TURP)
    • Water Vapor Thermal Therapy
Benign prostatic hyperplasia (BPH) management offers a plethora of choices depending on the severity of the prostatic hyperplasia, the size of the prostate, and the desired outcome. Benign prostate enlargement is not prostate cancer, but it can nonetheless present bothersome lower urinary tract symptoms which, left unchecked, can alter behavior, health, and lifestyle if BPH is allowed to dictate its terms. Effectively managing BPH by utilizing the best lifestyle modifications, alternative therapies, BPH medications, or surgery, benign prostatic hyperplasia can be controlled or eliminated for good if the right therapy is chosen. Prostate tissue continues to grow throughout a man’s life and many men will suffer through bothersome BPH symptoms, but it doesn’t have to be this way. Science has now caught up to BPH, and once diagnosed, very effective treatments are available for BPH management.   References:
  1. https://www.med.unc.edu/menshealth/calculator-international-prostatism-symptom-score-ipss/
  2. https://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/diagnosis-treatment/drc-20370093
  3. https://www.stlukes-stl.com/health-content/medicine/33/000018.htm

All surgical treatments have inherent and associated side effects. Individual’s outcomes may depend on a number of factors, including but not limited to patient characteristics, disease characteristics and/or surgeon experience. The most common side effects are mild and transient and may include mild pain or difficulty when urinating, discomfort in the pelvis, blood in the urine, inability to empty the bladder or a frequent and/or urgent need to urinate, and bladder or urinary tract infection. Other risks include ejaculatory dysfunction and a low risk of injury to the urethra or rectum where the devices gain access to the body for treatment. Further, there may be other risks as in other urological surgery, such as anesthesia risk or the risk of infection, including the potential transmission of blood borne pathogens. For more information about potential side effects and risks associated with Aquablation therapy for Benign Prostatic Hyperplasia (BPH) treatment, speak with your urologist or surgeon. Prior to using our products, please review the Instructions for Use, Operator’s Manual or User Manual, as applicable, and any accompanying documentation for a complete listing of indications, contraindications, warnings, precautions and potential adverse events. No claim is made that the AquaBeam Robotic System will cure any medical condition, or entirely eliminate the diseased entity. Repeated treatment or alternative therapies may sometimes be required.

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