Benign Prostatic Hyperplasia (BPH) - Causes, Symptoms and Medication

What is Benign Prostatic Hyperplasia ?

Benign prostatic hyperplasia (BPH) — also called benign enlargement of the prostate — is a non-cancerous increase in the size of the prostate gland that commonly occurs in ageing men.

The prostate is a small gland located below the bladder and around the urethra (the tube that carries urine out of the body). In BPH, the prostate gradually enlarges and can press on the urethra, making it harder to pass urine.

Causes / Risk factors of BPH

The exact cause is not completely known, but these factors increase the chance of developing BPH:

1. Ageing (most important)

• Rare before age 40.
• Common after age 50.
• Frequency increases with advancing age.

2. Hormonal changes

• Changes in testosterone and dihydrotestosterone (DHT) levels with ageing.
• DHT stimulates growth of prostate tissue.

3. Family history

• Having a father or brother with BPH increases risk.

4. Obesity

• Excess body weight is associated with larger prostate size and worse symptoms.

5. Diabetes and metabolic syndrome

• Insulin resistance and metabolic changes may contribute to prostate growth.

6. Lack of physical activity

• Sedentary lifestyle is linked with higher risk.

7. Cardiovascular disease and hypertension

• Men with heart disease or high blood pressure may have a higher incidence of BPH.

8. Chronic inflammation of the prostate

• Long-term inflammation may play a role in some men.

9. Diet

• Diets high in saturated fat and low in fruits and vegetables may be associated with increased risk, though evidence is not completely conclusive.

Symptoms of BPH

Symptoms are mainly urinary symptoms and are often divided into storage and voiding symptoms.

A. Storage symptoms (bladder symptoms)

• Frequent urination during the day
• Nocturia (waking at night to pass urine)
• Urgency – sudden strong urge to urinate
• Urge leakage or occasional incontinence

B. Voiding symptoms (passing urine)

• Difficulty starting urination (hesitancy)
• Weak urine stream
• Slow urine flow
• Intermittent stream (stops and starts)
• Straining to pass urine
• Dribbling at the end of urination
• Prolonged time to empty the bladder

C. After urination

• Feeling that the bladder has not emptied completely
• Post-void dribbling (urine leakage after finishing)

Symptoms that suggest complications

Seek medical attention if you develop:

• Sudden inability to pass urine (acute urinary retention)
• Severe lower abdominal pain with a full bladder
• Blood in urine
• Fever with urinary symptoms
• Recurrent urinary tract infections
• Bladder stones
• Swelling of legs, reduced urine output, or signs of kidney problems

Early vs late symptoms

Line of treatment of Benign Prostatic Hyperplasia (BPH) with mechanism of action

Treatment of BPH is aimed at relieving urinary obstruction, improving urine flow, reducing symptoms, and preventing complications. Management is usually stepwise, starting with lifestyle measures and progressing to medicines and procedures when needed.

Stepwise treatment approach

1

Mild symptoms → Watchful waiting + lifestyle measures

2

Moderate symptoms → Medical therapy

3

Persistent symptoms / enlarged prostate → Combination therapy

4

Failure of medicines or complications → Minimally invasive procedure or surgery

1. Watchful waiting and lifestyle modification

Used for men with mild symptoms.

Measures

• Reduce evening fluid intake
• Limit caffeine and alcohol
• Timed voiding / bladder training
• Avoid excessive decongestants (pseudoephedrine) and some antihistamines
• Weight reduction and regular exercise

Mechanism

These measures reduce urine production, decrease bladder irritation, and improve bladder emptying habits, thereby reducing urinary frequency and nocturia.

2. Alpha-1 adrenergic blockers (first-line drugs)

Common drugs

• Tamsulosin
• Silodosin
• Alfuzosin
• Doxazosin
• Terazosin

Mechanism of action

• Block α1-adrenergic receptors in the smooth muscle of the prostate, bladder neck, and prostatic urethra.
• This causes smooth muscle relaxation, lowering urethral resistance.

Clinical effect

• Improves urine flow within days to weeks.
• Reduces hesitancy, weak stream, and incomplete emptying.
• Does not significantly shrink prostate size.

3. 5-alpha-reductase inhibitors (5-ARIs)

Common drugs

• Finasteride
• Dutasteride

Mechanism of action

• Inhibit 5-alpha-reductase enzyme, which converts testosterone → dihydrotestosterone (DHT).
• Lower DHT levels in the prostate.

Clinical effect

• Gradual shrinkage of prostate tissue.
• Reduces risk of acute urinary retention and need for surgery.
• Best for enlarged prostates (>30–40 mL).
• Benefit appears after 3–6 months.

4. Combination therapy

Example

• Tamsulosin + Dutasteride
• Tamsulosin + Finasteride

Mechanism

Combines two complementary actions:

Clinical effect

• Faster symptom relief plus long-term reduction in disease progression.
• Preferred in men with moderate–severe symptoms and enlarged prostate.

5. Phosphodiesterase-5 inhibitor

Drug

• Tadalafil 5 mg once daily

Mechanism of action

• Inhibits PDE-5, increasing cGMP levels.
• Causes relaxation of smooth muscle in the lower urinary tract, prostate, bladder neck, and pelvic blood vessels.

Clinical effect

• Improves urinary symptoms.
• Particularly useful when BPH coexists with erectile dysfunction.

6. Drugs for predominant storage symptoms

If urgency, frequency, and nocturia persist despite good urine flow.

A. Antimuscarinic agents

• Solifenacin, Tolterodine, Oxybutynin

Mechanism

Block muscarinic (M3) receptors in the bladder detrusor muscle → reduce involuntary bladder contractions.

B. Beta-3 agonist

• Mirabegron

Mechanism

Stimulates β3 receptors in detrusor muscle → bladder relaxation during filling phase.

Clinical effect

Improves urgency, frequency, and urge incontinence.

7. Management of acute urinary retention

Immediate treatment

• Urethral catheterisation to drain the bladder.

Followed by

• Start an alpha blocker and attempt a trial without catheter (TWOC) after a few days.

Mechanism

Catheter provides immediate decompression; alpha blocker reduces outlet resistance to facilitate subsequent voiding.

8. Minimally invasive procedures

Used when medicines are inadequate or not tolerated.

9. Surgical treatment (gold standard for severe BPH)

Indications: recurrent retention, recurrent UTI, bladder stones, haematuria due to BPH, renal impairment, or severe symptoms despite medication.

A. TURP — Transurethral resection of the prostate

Mechanism

Resects obstructing prostatic tissue through the urethra, creating a wider channel.

B. HoLEP — Holmium laser enucleation

Mechanism

Laser enucleates enlarged adenomatous tissue from the surgical capsule.

C. Laser vaporisation (PVP)

Mechanism

Laser vaporises obstructing tissue.

D. Open or robotic simple prostatectomy

Mechanism

Removes large adenomatous prostate tissue directly, usually for very large glands.

Quick comparison of drug classes

Commonly used drugs in BPH

1. Alpha-1 blockers (most commonly used)

These are usually the first choice for men with bothersome urinary symptoms.

Tamsulosin

• Most widely prescribed.
• Better prostate selectivity, less effect on blood pressure.

Silodosin

• Very selective for prostate α1A receptors.
• Strong effect on urine flow.

Alfuzosin

• Good symptom relief with relatively less ejaculatory dysfunction.

Doxazosin / Terazosin

• Useful when the patient also has hypertension.

Main action: Relax smooth muscle in the prostate and bladder neck, improving urine flow within days.

2. 5-alpha-reductase inhibitors

Used when the prostate is significantly enlarged.

Finasteride

• Blocks type II 5-alpha-reductase.

Dutasteride

• Blocks type I and type II enzymes.
• Produces a greater reduction in DHT.

Main action: Reduce DHT levels, gradually shrinking the prostate over months.

3. Combination therapy (very common in practice)

Common combinations:

• Tamsulosin + Dutasteride
• Tamsulosin + Finasteride
• Silodosin + Dutasteride

Used in men with moderate–severe symptoms and enlarged prostate.

4. Tadalafil

Dose commonly used

• 5 mg once daily

Particularly useful when BPH coexists with erectile dysfunction.

5. Drugs for storage symptoms (urgency, frequency, nocturia)

Added when these symptoms persist despite alpha-blocker therapy.

Antimuscarinics

• Solifenacin
• Tolterodine
• Oxybutynin

Beta-3 agonist

• Mirabegron

Major brands of these drugs relevant in India with their Manufacturer.

Most commonly used in practice: Urimax (Tamsulosin) and Silodal (Silodosin).

5‑alpha reductase inhibitors (reduce prostate size)

Very common: Dutas (Dutasteride).

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Combination therapy (widely prescribed for moderate–severe BPH)

These combinations are among the most frequently prescribed BPH products in India.

PDE‑5 inhibitor (BPH with erectile dysfunction)

Drugs used when urgency/frequency predominates

Antimuscarinics

Beta‑3 agonist

Major Brands

Tamsulosin

Urimax — Cipla

Silodosin

Silodal — Sun Pharma

Dutasteride

Dutas — Dr. Reddy’s

Finasteride

Finast — Dr. Reddy’s

Tamsulosin + Dutasteride

Urimax‑D — Cipla

Silodosin + Dutasteride

Silodal‑D — Sun Pharma

Tadalafil 5 mg

Megalis — Macleods

Solifenacin

Soliten — Sun Pharma

Mirabegron

Mirago — Intas

Important precautions

1. Do not ignore worsening symptoms

Contact your doctor if you develop:

• Sudden inability to pass urine
• Severe lower abdominal pain
• Blood in urine
• Fever with burning urination
• Recurrent urinary tract infections
• Swelling of legs or reduced urine output

These may indicate urinary retention or another complication.

2. Take medicines exactly as prescribed

• Alpha-blockers (tamsulosin, silodosin) may cause dizziness; rise slowly from bed or a chair.
• Do not stop BPH medicines abruptly without medical advice.

3. Be careful with over-the-counter cold medicines

Avoid or ask a doctor before using medicines containing:

• Pseudoephedrine
• Phenylephrine
• Some antihistamines (chlorpheniramine, diphenhydramine)

These can tighten the bladder neck and worsen urine flow.

4. Limit unnecessary painkillers

Frequent use of some NSAIDs may worsen fluid retention or kidney problems in susceptible people.

5. Regular follow-up

Men on long-term treatment should have periodic review of symptoms, urine flow, and prostate status.

Lifestyle changes that help BPH

Fluid management

During the day

• Drink adequate water (do not deliberately dehydrate yourself).

In the evening

• Reduce fluids 2–3 hours before bedtime.

Avoid large volumes at once

• Sip fluids through the day rather than drinking a litre at one time.

Reduce bladder irritants

Limit especially in the evening:

• Tea
• Coffee
• Energy drinks
• Cola drinks
• Alcohol
• Very spicy foods if they trigger symptoms

These can increase urgency and frequency.

Timed voiding (bladder training)

Try to pass urine every 2–4 hours even if the urge is mild. This prevents overfilling of the bladder.

Double voiding technique

• Urinate normally.
• Wait 20–30 seconds.
• Try to urinate again.

This may reduce residual urine.

Avoid holding urine for long periods

Regularly postponing urination can stretch the bladder and worsen symptoms.

Physical activity

Aim for at least 30 minutes of moderate exercise most days.

Helpful activities:

• Brisk walking
• Cycling with a comfortable seat
• Swimming
• Yoga or stretching

Exercise is associated with better urinary symptoms and weight control.

Weight management

Excess abdominal weight is linked with worse BPH symptoms. Even modest weight loss can help.

Prevent constipation

A full rectum can increase pressure on the bladder outlet.

Increase:

• Fruits
• Vegetables
• Whole grains
• Water intake during the day

Stay physically active.

Pelvic floor relaxation

When urinating:

• Sit down if that helps you relax.
• Take your time.
• Avoid straining hard.

Excess straining can worsen pelvic floor tension.

Sleep-related measures

• Empty your bladder immediately before going to bed.
• Elevate the legs for an hour in the evening if you have leg swelling; this can reduce night-time urination.

Habits that often worsen BPH symptoms

A simple daily routine for a man with BPH

Morning

Walk 20–30 min; take prescribed medicine after breakfast if advised.

Daytime

Drink water regularly; avoid holding urine; void every 3–4 h.

Evening

Reduce tea/coffee/alcohol; lighter dinner; manage constipation.

Before bed

Limit fluids for 2–3 h beforehand; urinate just before sleeping.

When lifestyle measures are enough

Men with mild symptoms often improve substantially with these measures alone. If symptoms remain bothersome after several weeks, medical treatment is usually considered.

Key take-home message

The three lifestyle changes with the greatest day-to-day benefit are:

• Reduce evening fluids
• Limit caffeine and alcohol
• Do not hold urine; use timed voiding and double voiding

Medicines used for Benign Prostatic Hyperplasia with their brand names in India

1. Alpha-1 blockers (first-line medicines)

·        These relax the prostate and bladder neck and give relatively quick symptom relief.

·        Most commonly prescribed: Urimax (Tamsulosin) and Silodal (Silodosin). 1mg BPH products listing .

·        2. 5-alpha reductase inhibitors (reduce prostate size)

·        Used when the prostate is enlarged.

·        Very common: Dutas (Dutasteride). 1mg page 2 .

·        3. Combination medicines (widely used in moderate–severe BPH)

·        These combine an alpha-blocker with dutasteride.

·        Urimax-D contains Tamsulosin 0.4 mg + Dutasteride 0.5 mg and is marketed by Cipla. Apollo Urimax-D .

·        4. Medicine used when BPH coexists with erectile dysfunction

·        5. Medicines added when urgency/frequency is prominent

·        Antimuscarinics

·        Beta-3 agonist

·        Sun Pharma lists Soliten, Roliten, Silodal, Silodal-D, and Tamdura in its Indian urology portfolio. Sun Pharma India products .

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