Enlarged Prostate (BPH): Symptoms, Tests and Medicines Explained by a Pharmacist

He waited until the shop was empty before he came to the counter. A man in his late fifties, he lowered his voice and said, "I'm up four times every night, and when I do go, it takes forever. My wife says it must be my prostate. Is it cancer?" Enlarged prostate symptoms like his are among the most common things men bring to a pharmacist, and the fear behind the question is nearly always the same.

An enlarged prostate, called benign prostatic hyperplasia (BPH), is common, usually not serious and very treatable. This article explains the symptoms, the tests, the medicines I dispense most often, and how to think about the PSA blood test.

What an enlarged prostate is

The prostate is a small gland below the bladder that makes some of the fluid in semen. The tube that carries urine out of the body, the urethra, runs through it. As the prostate grows with age, it can squeeze that tube, and the bladder has to work harder to empty.

The US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) reports that BPH is diagnosed in 5% to 6% of men aged 40 to 64 and 29% to 33% of men aged 65 and over, and calls it the most common prostate problem in men over 50. The NHS says it is usually not serious, is thought to be linked to hormone changes with age, and is not caused by prostate cancer and does not raise the risk of it. Having BPH does not protect you from cancer either, which is why symptoms should be checked.

The NIDDK lists other risk factors: a family history of BPH, heart and blood vessel disease, type 2 diabetes, obesity, chronic kidney disease, erectile dysfunction and not being physically active.

Enlarged prostate symptoms

The NHS describes these as the main symptoms:

• trouble starting to pee, or straining
• a weak flow that stops and starts, and takes longer
• feeling that your bladder is never fully empty
• dribbling after you finish
• needing to pee more often or urgently, including at night

Symptoms usually come on slowly and can worsen with age. The size of the prostate does not always match how bad symptoms feel, and the NIDDK notes that complications can include urinary retention, bladder stones, urinary tract infections, blood in the urine and, in time, kidney problems. You do not have to put up with them.

Infections, prostatitis and prostate cancer can look similar, so see a clinician instead of guessing.

Tests you can expect

The American Urological Association (AUA) guideline starts with a medical history, a physical examination, a symptom questionnaire (the International Prostate Symptom Score, or IPSS) and a urine test. The NHS adds that your doctor may ask you to keep a 3-day diary of what you drink and when you pee, may check your prostate with a rectal examination, and may offer a PSA blood test. Further tests such as a urine flow test, a bladder ultrasound or a camera look inside the bladder (cystoscopy) are done at the hospital when needed.

Bring a list of everything you take. The NHS advises checking whether other medicines might be worsening urinary symptoms, so ask your pharmacist for a review.

What you can do yourself

The NHS suggests these steps first, especially for mild symptoms:

• Cut down on alcohol and caffeine.
• Reduce fluids in the hours before bed or a long outing, but drink normally during the day. Cutting fluids too much can cause infections.
• Eat enough fiber, because constipation makes urinary symptoms worse.
• Keep to a healthy weight.
• Pee again shortly after finishing, relax and avoid straining.
• Gently press along the underside of the penis after peeing to expel the last drops.

Medicines for BPH

Medicines are usually offered when symptoms bother you. Here is how the main ones work and what I tell people at the counter.

Alpha blockers (tamsulosin, alfuzosin, doxazosin, silodosin and others). These relax the muscle at the bladder neck and in the prostate so urine flows more easily. The AUA's 2026 guideline recommends the uroselective alpha blockers (alfuzosin, silodosin or tamsulosin) as an option for bothersome moderate to severe symptoms. Older ones such as doxazosin and terazosin can cause a sudden drop in blood pressure with the first dose, so they're started low and built up exactly as your prescriber directs. The tamsulosin (Flomax) label says to take 0.4 mg about 30 minutes after the same meal each day and not to crush, chew or open the capsule. Dizziness and light-headedness on standing are more common than with placebo, so rise slowly, especially at first. In the label's trials, dizziness affected 14.9% of men on 0.4 mg versus 10.1% on placebo, and abnormal ejaculation (reduced or absent semen on climax) affected 8.4% versus 0.2%. This is not harmful but can worry people, so tell your prescriber.

Two other label warnings matter. Priapism, a painful erection that will not go down, is rare (under 1 in 50,000 patients) and needs emergency care. And intraoperative floppy iris syndrome can complicate cataract surgery, so tell your eye surgeon you take or have taken an alpha blocker.

5-alpha reductase inhibitors (finasteride, dutasteride). These shrink the prostate over months by blocking the hormone that drives its growth. The AUA recommends them when the prostate is enlarged (a volume above 30 g, a PSA above 1.5 ng/mL, or a prostate that feels enlarged on examination), and says they can lower the chance of urinary retention and surgery. The Proscar (finasteride) label lists the downsides. In a 4-year trial, impotence was reported by 8.1% of men on finasteride in the first year versus 3.7% on placebo, and decreased libido by 6.4% versus 3.4%, with rates in years 2 to 4 similar to placebo. The label also notes rare reports of sexual problems continuing after stopping, with the role of the medicine unknown. It lists breast tenderness or enlargement, and reports of depression and suicidal thoughts after launch without proof of cause. Women who are or may be pregnant should not handle crushed or broken tablets.

Finasteride also lowers PSA. The label says PSA falls by about 50% within six months, and that a PSA test after that point should be doubled before comparing it with normal ranges. Tell anyone who orders your PSA that you take it.

Tadalafil 5 mg daily. The AUA says this should be discussed for urinary symptoms whether or not you also have erection problems. It must never be taken with nitrate medicines.

Combination treatment. The MTOPS trial followed 3,047 men for an average of 4.5 years. Disease progression occurred in 17% on placebo, 10% on doxazosin, 10% on finasteride and 5% on both. The researchers calculated reductions in the risk of progression of 39% for doxazosin, 34% for finasteride and 66% for the combination. The AUA recommends combining a 5-ARI with an alpha blocker for men with a demonstrably enlarged prostate. For bladder symptoms such as urgency, an anticholinergic or beta-3 agonist may be added.

Herbal products. A Cochrane review of 27 trials with 4,656 men found that saw palmetto produced no meaningful improvement in urinary symptoms or quality of life, with no increase in side effects. Mention any supplements you use.

Do not stop or change any of these on your own. Ask your prescriber when to review.

When surgery or a procedure is considered

If medicines do not help, symptoms are severe, or complications develop, the NHS and AUA describe options. Repeated infections, bladder stones, kidney problems or retention that does not resolve are further reasons. The most established operation is TURP (transurethral resection of the prostate). Others include laser, steam or water jet treatments and small implants. Some protect ejaculation and erections better than others, so ask. The NIDDK notes that about 10% of people may need more surgery within 20 years.

PSA testing: a balanced view

A PSA blood test measures a protein made by the prostate. It can be raised by cancer, but also by BPH, prostatitis, a urine infection, ejaculation and cycling. The National Cancer Institute says there is no single threshold that separates normal from abnormal, and that about 25% of men who have a biopsy for an elevated PSA are found to have prostate cancer.

Experts agree that this is a decision to make with a clinician, because benefits and harms are closely balanced:

• United States. The US Preventive Services Task Force (2018) says men aged 55 to 69 should make an individual decision about PSA screening (Grade C) and recommends against screening from age 70 (Grade D). For 1,000 men aged 55 to 69 screened over about 13 years, it estimates about 1.3 deaths from prostate cancer avoided and 3 cases of metastatic cancer avoided, against about 240 men getting a positive result and 100 being diagnosed, with over-diagnosis estimated at 20% to 50% of screen-detected cancers. The AUA and Society of Urologic Oncology guideline supports shared decision-making, offering a baseline test between ages 45 and 50, starting earlier (40 to 45) for people at higher risk, including Black men and those with a strong family history, and testing every 2 to 4 years at ages 50 to 69.
• United Kingdom. The NHS says routine PSA testing is not offered, except to people with a faulty BRCA2 gene, but any man can ask his GP about it and discuss the benefits and risks. It advises avoiding ejaculation, strenuous exercise and cycling for 48 hours beforehand, and waiting 4 to 6 weeks after a urine infection.

A high PSA does not mean cancer, and a normal one does not rule it out. If you are in a higher-risk group, mention it.

Questions to ask your doctor or pharmacist

• Are my symptoms likely to be BPH, or do you need to rule out something else?
• Could any of my current medicines or supplements be making my urinary symptoms worse?
• Do I need a PSA test, and what would a result mean for me?
• Which medicine do you recommend, and what are the likely side effects for me?
• How long will it take to work, and when should we review it?
• Will this medicine affect my sex life or ejaculation, and are there alternatives?
• If I need cataract surgery, who should I tell about this medicine?
• When would surgery or a procedure be considered?

If you'd like the full guide, my book Enlarged Prostate Explained goes deeper into BPH symptoms, PSA tests, medicines and treatments, and better nights.

Sources

• NHS. Benign prostate enlargement
• National Institute of Diabetes and Digestive and Kidney Diseases. Prostate enlargement (benign prostatic hyperplasia)
• American Urological Association. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline (2026)
• U.S. Food and Drug Administration. PROSCAR (finasteride) prescribing information
• FLOMAX (tamsulosin) prescribing information. FDA label text via MedLibrary
• McConnell JD, et al. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003;349(25):2387-2398. Summary figures: ScienceDaily report of the NIH release
• Cochrane review of saw palmetto for BPH, summarized in American Family Physician (2024)
• US Preventive Services Task Force. Prostate cancer screening, final recommendation statement (2018)
• American Urological Association and Society of Urologic Oncology. Early detection of prostate cancer guideline
• National Cancer Institute. Prostate-specific antigen (PSA) test; NHS. PSA testing