Enlarged Prostate (BPH)

Reviewed by Mr Neil Haldar – August 2026

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An enlarged prostate, often referred to as benign prostatic hyperplasia (BPH) or benign prostate enlargement, is a common non-cancerous condition in older men. It can narrow the urethra and cause urinary symptoms such as a weak stream, hesitancy, frequency, urgency, nocturia and incomplete bladder emptying. Not all urinary symptoms are caused by the prostate, so assessment is important before deciding whether treatment should involve lifestyle changes, medication or a procedure such as TURP or Aquablation.

Benign prostatic hyperplasia (BPH) becomes increasingly common with age, particularly after 50. Most men are managed successfully with lifestyle changes and medication; surgery is reserved for those with bothersome symptoms despite medical therapy, recurrent retention, or complications.

If you have urinary symptoms but have not yet been told that an enlarged prostate is the cause, my Specialist LUTS & Urinary Symptoms Clinic provides a structured diagnostic assessment.

The gold-standard surgical treatment is transurethral resection of the prostate (TURP) — a 60-year, evidence-based operation that remains the reference standard against which all newer techniques are compared. TURP delivers durable, definitive symptom relief with the longest-published outcomes of any BPH procedure.

For very large prostates (over 120 ml), which are better suited to enucleation, Mr Haldar refers patients to specialist HoLEP colleagues. For patients unfit for surgery or who prefer to avoid an operation, he refers them for prostatic artery embolisation (PAE). This deliberate scope ensures every patient is matched to the right technique for their situation.

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About Mr Neil Haldar

Mr Neil Haldar is a Consultant Urological Surgeon at Buckinghamshire Healthcare NHS Trust with 20+ years’ experience in prostate surgery — including TURP and aquablation of the prostate

His private BPH practice is built around the gold-standard surgical technique: TURP. Where the clinical situation calls for a different approach, Mr Haldar refers transparently:

• HoLEP (Holmium laser enucleation of prostate) for very large prostates over 120 ml
• PAE (prostatic artery embolisation) for patients unfit for surgery or who prefer to avoid an operation

This evidence-based, scope-clear approach ensures each patient receives the technique best matched to their prostate size, fitness, and priorities.

GMC: 3683914 | BUPA Platinum Consultant | MBBS MD FRCS (Eng) FRCS (Urol)

See Mr Haldar’s Patient reviews

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What Is BPH?

Benign prostatic hyperplasia (BPH) — also called benign prostatic enlargement (BPE) — is the non-cancerous growth of the prostate gland that occurs in the majority of men with age. It is not cancer and does not turn into cancer.

The prostate sits below the bladder and surrounds the urethra. As the gland enlarges, it can squeeze the urethra and obstruct urine flow, producing the characteristic urinary symptoms of BPH. Over time, the bladder muscle can become overactive or weakened as it works against the obstruction.

Key Facts

Prevalence in men in their 60s	Around 50%
Prevalence in men in their 80s	Around 80%
Most common urological condition in men over 50	Yes
Risk of progression to cancer	None — BPH is not pre-cancerous
Effective medical and surgical treatments	Available and widely used

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Symptoms of BPH

BPH symptoms — collectively called lower urinary tract symptoms (LUTS) — fall into three categories:

Category	Symptoms
Voiding (obstructive)	Weak or slow stream, hesitancy, intermittency, straining, prolonged voiding, terminal dribbling
Storage (irritative)	Frequency, urgency, nocturia, urge incontinence
Post-voiding	Sense of incomplete emptying, post-void dribbling

Most men experience a mixture across all three categories. The pattern often points to whether obstruction (voiding) or bladder overactivity (storage) is the dominant problem.

The International Prostate Symptom Score (IPSS) is a standard 7-question tool that quantifies symptoms objectively (mild 0–7, moderate 8–19, severe 20–35).

When to Seek Assessment

You should arrange a urology consultation if you have:

• A persistently weak urinary stream
• Getting up more than twice a night to pass urine
• Frequency of more than 8 times in 24 hours
• A feeling of incomplete bladder emptying
• Urgency or urge incontinence
• Symptoms that have failed first-line GP treatment
• A combination of LUTS and a raised PSA
• An IPSS score of 8 or higher
• Recurrent UTIs (in men, this often suggests obstruction)

Urgent (Same-Day) Attention

Seek same-day medical attention if you have:

• Inability to pass urine (acute urinary retention) — a urological emergency requiring catheterisation
• Severe pain
• Fever or sepsis symptoms with urinary infection
• Visible blood in the urine with clots

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What Causes BPH?

BPH is driven primarily by hormonal changes that occur with age:

• Age-related hormonal change — particularly the conversion of testosterone to dihydrotestosterone (DHT) by 5-alpha reductase
• Genetic factors — family history increases risk and may cause earlier onset
• Obesity and metabolic syndrome — linked to higher rates and faster progression
• Sedentary lifestyle — linked to faster progression

BPH is not caused by: sexual activity, stress, or “holding on” to urine.

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How BPH Is Diagnosed

1. Consultation and Symptom Scoring

Detailed history, IPSS scoring, fluid intake review, medication review, and impact on quality of life.

2. Examination

Abdominal examination plus digital rectal examination to assess prostate size and character, and to identify any features suggestive of cancer.

3. Urine and Blood Tests

• Urine dipstick, microscopy, culture
• Kidney function tests
• PSA test — where appropriate, to help assess prostate cancer risk and guide whether further prostate investigation is required.
• Bladder diary completed at home over 3 days

4. Uroflowmetry and Bladder Scan

A non-invasive flow test combined with an ultrasound bladder scan to measure post-void residual urine. A flow rate of <10 ml/s can support the suspicion of bladder-outlet obstruction.

5. Imaging

• Bladder and renal ultrasound — measures prostate size and checks for hydronephrosis or bladder stones
• Prostate MRI — where the PSA, examination or other findings raise concern about prostate cancer.

6. Flexible Cystoscopy

In selected cases — usually with haematuria or recurrent UTI.

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Treatment Options for BPH

The right treatment depends on symptom severity, prostate size, residual urine, your priorities, and how well first-line approaches have worked.

Approach	Best Suited For	Pros	Cons
Watchful waiting	Mild symptoms (IPSS <8)	No side effects; preserves all options	Symptoms may worsen
Lifestyle changes	Mild–moderate symptoms	No side effects; broader health benefits	Requires sustained behaviour change
Alpha-blockers	Moderate symptoms	Fast onset (within weeks); inexpensive	Dizziness, retrograde ejaculation; does not shrink prostate
5-alpha reductase inhibitors	Larger prostates (>30–40 ml)	Shrinks prostate; reduces retention and surgery risk	Slow onset (3–6 months); may affect libido and erections
Combination therapy	Moderate–severe symptoms with larger prostate	More effective than either drug alone	More side effects
TURP	Failed medical therapy; moderate-to-large prostates	Definitive, durable, best long-term evidence	Inpatient procedure; recovery period; ejaculation usually retrograde
Aquablation	Men with moderate-to-severe BPH symptoms who particularly wish to preserve ejaculation; larger glands in selected cases	Non-thermal robotic waterjet; lower risk of ejaculatory dysfunction than TURP; growing 5-year evidence	Availability varies; not suitable for every anatomy; bleeding and catheterisation are still possible
HoLEP (referred)	Moderate to very large prostates	Suitable for largest glands	Specialist availability
PAE (referred)	Patients unfit for surgery; men preferring to avoid an operation	Avoids general anaesthetic; outpatient	Less durable than TURP; specialist availability

The European Association of Urology (EAU) and NICE guideline CG97 both recommend a stepwise approach: lifestyle and watchful waiting for mild symptoms, medication for moderate symptoms, and surgery for severe or refractory symptoms.

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Lifestyle Changes

Useful for mild symptoms and as adjuncts to medication or surgery:

• Reduce evening fluid intake — helps with nocturia
• Limit caffeine and alcohol — both increase urine production and irritate the bladder
• Bladder retraining — scheduled voiding to reduce urgency
• Pelvic floor exercises — particularly useful for post-micturition dribbling
• Manage constipation — a full rectum can worsen voiding symptoms
• Review medications — diuretics, anticholinergics, and sympathomimetics can worsen LUTS
• Weight loss — obesity is linked to faster BPH progression
• Regular cardiovascular exercise

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Medical Treatment

Alpha-Blockers (Tamsulosin, Alfuzosin, Doxazosin, Silodosin)

First-line medication for most men with bothersome BPH symptoms.

• Mechanism: relaxes the smooth muscle of the prostate and the bladder neck
• Onset: within 1–4 weeks
• Effective in: approximately 60–70% of men
• Side effects: dizziness on standing (postural hypotension), retrograde ejaculation, nasal stuffiness
• Important: Intraoperative floppy iris syndrome — always tell your ophthalmologist if you are due for cataract surgery
• Does not: shrink the prostate or alter long-term BPH progression

5-Alpha Reductase Inhibitors (Finasteride, Dutasteride)

Used for larger prostates and for long-term disease modification.

• Mechanism: block conversion of testosterone to DHT, shrinking the prostate by 20–30% over 6 months
• Onset: 3–6 months for full effect
• Effective for: larger prostates (>30–40 ml); reduces risk of urinary retention and future surgery
• Side effects: reduced libido, erectile dysfunction, ejaculation changes in around 5–10%
• Important: reduces PSA by approximately 50% — this must be remembered when interpreting future PSA results

Combination Therapy

For moderate-to-severe symptoms with a larger prostate, combining an alpha-blocker with a 5-alpha reductase inhibitor (e.g. tamsulosin + dutasteride, available combined as Combodart) is more effective than either drug alone — supported by the landmark MTOPS and CombAT trials.

Other Medications

• Tadalafil 5 mg daily — improves both BPH symptoms and erectile function in selected men
• Anticholinergics (oxybutynin, solifenacin) or mirabegron — for predominantly storage symptoms
• Desmopressin — for refractory nocturnal polyuria in selected cases

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When Surgery Is the Right Step

Surgery is generally indicated when:

• Symptoms remain bothersome despite optimal medical therapy
• IPSS remains in the moderate-to-severe range (>8) on treatment
• Recurrent acute urinary retention has occurred
• Recurrent UTIs are caused by incomplete bladder emptying
• Bladder stones or significant residual urine are present
• Hydronephrosis (kidney swelling) develops
• Recurrent visible haematuria from the prostate
• Patient preference for definitive treatment over long-term medication

NICE NG97 supports referral for surgical assessment whenever symptoms are not adequately controlled by medication.

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TURP — The Gold-Standard BPH Operation

TURP is the most thoroughly evidence-based BPH operation in urology and the reference standard against which every newer technique is measured in clinical trials. It remains the most-performed prostate operation worldwide.

Why TURP Remains the Reference Standard

• 60+ years of clinical experience — the longest evidence base of any BPH operation
• Durable symptom relief — re-treatment rate of approximately 1–2% per year
• Suitable for most prostate sizes (typically 30–120 ml)
• Predictable outcomes — average IPSS reduction of around 70%
• Improves flow rates by approximately 100–150%
• Recommended in EAU and NICE CG97 guidelines as the standard surgical option

How TURP Is Performed

TURP is performed under spinal or general anaesthetic. A resectoscope is passed through the urethra into the prostate, and the obstructing prostate tissue is removed in small chips using an electrically heated wire loop. The chips are flushed out at the end of the procedure and sent for pathological examination — this also allows incidental prostate cancer to be detected.

The operation is performed entirely via the natural urinary passage — no external incisions are needed. A urinary catheter is left in place after surgery to allow the prostate cavity to heal and to flush out any remaining blood.

What to Expect — At a Glance

Anaesthetic	Spinal or general
Operative time	45–90 minutes (depending on prostate size)
Hospital stay	1–2 nights
Catheter duration	24–48 hours
Return to driving	1–2 weeks
Return to desk-based work	1–2 weeks
Return to physical work	4–6 weeks
Return to gym, cycling, sport	4–6 weeks
Time for full recovery	6–8 weeks

Recovery After TURP

Time After Surgery	What to Expect
Days 1–2	In hospital; catheter in place; bladder irrigation; simple oral pain relief
Day 2–3	Catheter usually removed; home the same day or after one night
Week 1	Mild burning when passing urine and visible blood are normal; rest and gentle walking
Week 2	Most men return to driving and desk-based work
Weeks 2–4	Symptoms improve progressively; some urgency and frequency are common as the bladder adjusts
Weeks 4–6	Return to physical work, gym, cycling, and sport
6 weeks	Routine review; bladder symptoms substantially settled in most men
3 months	Full recovery; durable improvement in flow and symptoms

Outcomes from TURP

Outcome	Typical Result
IPSS improvement	Around 70% reduction
Flow rate improvement	Approximately 100–150% increase
Patient satisfaction	Around 80–90%
Re-treatment within 5 years	Approximately 5–10%

Risks and Side Effects

TURP is well-established and generally very safe, but all surgery carries risks. These will be discussed in detail at consultation.

Common, expected:

• Retrograde ejaculation — occurs in around 65–75% of men. Semen flows backwards into the bladder rather than forwards on ejaculation. Sensation of orgasm is preserved; this affects fertility but not sexual enjoyment for most men.
• Mild burning and frequency for 2–4 weeks
• Visible blood in the urine for 1–2 weeks
• Mild urinary urgency in the early weeks

Less common:

• Urinary tract infection — managed with antibiotics
• Bleeding requiring further intervention (<2%)
• Need for re-catheterisation if voiding does not return promptly
• Temporary stress urinary incontinence (usually resolves)

Uncommon but important:

• Urethral stricture (1–3%) — narrowing of the urethra requiring later treatment
• Bladder neck stenosis
• Persistent urinary incontinence (<1%)
• New-onset erectile dysfunction (varies; some studies suggest no significant change vs medical therapy)

Rare:

• Significant bleeding requiring transfusion
• TUR syndrome (now extremely rare with bipolar TURP)

Not sure how the procedures differ? Read my comparison of Aquablation, TURP, HoLEP and PAE.

Aquablation — A Newer Ejaculation-Sparing Option

Aquablation is a newer surgical treatment for benign prostatic hyperplasia (BPH) that uses a robotically controlled, high-pressure waterjet to remove obstructing prostate tissue. Unlike TURP or laser surgery, the tissue-removal phase is non-thermal, meaning the prostate tissue is removed mechanically rather than by heat.

The procedure is planned using real-time ultrasound imaging and cystoscopic vision. This allows the surgeon to map the precise area of prostate tissue causing obstruction while aiming to preserve important structures involved in continence and ejaculation.

Aquablation may be particularly relevant for men who:

• have moderate-to-severe urinary symptoms despite medication;
• have a larger prostate, where treatment choice needs careful planning;
• place a high priority on preserving ejaculation;
• want to understand all appropriate surgical options before deciding on treatment.

The main potential advantage of Aquablation is its lower risk of ejaculatory dysfunction compared with traditional heat-based prostate surgery. Many men considering BPH surgery are concerned about retrograde ejaculation, where semen passes backwards into the bladder rather than forwards. Aquablation is designed to reduce this risk, although no operation can guarantee preservation of ejaculation in every patient.

Aquablation also has growing evidence in larger prostates. The WATER II study, which followed men with prostates between 80 and 150 mL, showed durable improvement in urinary symptoms and flow at five years. NICE has also reviewed transurethral water-jet ablation for lower urinary tract symptoms caused by BPH and supports its use with standard arrangements for clinical governance, consent and audit.

Aquablation is not automatically the best option for every man. Suitability depends on prostate size, prostate shape, bleeding risk, medication history, general fitness for anaesthesia, and your priorities around sexual function and recovery. In some cases, TURP, HoLEP, PAE or continued medication may still be more appropriate.

I discuss Aquablation as part of a balanced conversation about BPH treatment. Where appropriate, I can explain how it compares with TURP, HoLEP, and other options, and advise on availability and onward referral.

You can read more in my dedicated guide: Aquablation prostate surgery for enlarged prostate.

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When Mr Haldar Refers Onward

Two clear clinical situations where TURP is not the best technique:

1. Very Large Prostates (>120 ml) → HoLEP

Prostate volume above 120 ml is at the upper end of what TURP can safely manage. For these men, HoLEP (Holmium laser enucleation of prostate) is preferred. It enucleates the entire prostate adenoma rather than resecting tissue piecemeal, which is more effective and safer for very large glands. Mr Haldar refers patients with prostate volumes above 120 ml to specialist HoLEP colleagues.

2. Patients Unfit for Surgery, or Who Prefer to Avoid It → PAE

For patients who are not suitable for surgery (significant cardiac or anaesthetic risk) or who specifically wish to avoid an operation, prostatic artery embolisation (PAE) is a valid alternative. PAE is performed by an interventional radiologist as a day case, blocking the small arteries supplying the prostate to shrink it and relieve symptoms. NICE has reviewed PAE under guidance IPG611 and confirmed it as a treatment option for selected patients. Mr Haldar refers suitable patients to specialist colleagues.

This honest scope-of-practice — TURP for the large majority, with clear referral pathways for HoLEP and PAE — ensures every patient is matched to the technique best suited to their prostate size and overall health.

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Locations

Consultation

Consultations are available at any of Mr Haldar’s clinic sites:

Location	County
The Chiltern Hospital, Great Missenden	Buckinghamshire
The Clementine Churchill Hospital, Harrow	North West London
Princess Margaret Hospital, Windsor	Berkshire
GenesisCare, Windsor	Berkshire
Shelburne Hospital, High Wycombe	Buckinghamshire
Beaconsfield Clinic	Buckinghamshire

The catchment includes south Oxfordshire (Henley, Thame, Wallingford), Buckinghamshire, North West London and east Berkshire.

Frequently asked questions

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Why Choose Mr Neil Haldar?

• 20+ years’ experience in prostate surgery
• TURP specialist — the most evidence-based BPH operation, with 60+ years of clinical experience worldwide
• Honest scope of practice — refers to specialist colleagues for HoLEP (>120 ml prostates) and PAE (patients unfit for surgery)
• Continuity of care from consultation through surgery to follow-up
• Trusted for second opinions and complex cases
• Personal, consultant-led care from start to finish
• Private clinics across Buckinghamshire, Berkshire, London and Oxfordshire
• Surgery at Chiltern Hospital, The Clementine Churchill Hospital and Princess Margaret Hospital
• Recognised by all major UK private health insurers

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Useful Resources

• BAUS Patient Information — TURP
• NHS patient guidance

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Book a Consultation

If you have urinary symptoms, an enlarged prostate diagnosis, or are considering TURP surgery, Mr Haldar would be pleased to help.

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Mr Neil Haldar, MBBS, MD, FRCS (Eng), FRCS (Urol). Consultant Urological Surgeon, Buckinghamshire Healthcare NHS Trust. GMC No: 3683914.

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