Dear Dr G,

I am emailing you about a strange problem that is happening to me as I turn 50.

I am a healthy chap who exercises and watches my diet regularly.

Thankfully, my wife and I still have strong libido, and I guess mine must be derived from high levels of testosterone from a healthy lifestyle.

I recently started waking up at night to urinate and struggled with the stream.

In addition to waking my wife, the inaccuracy of my nighttime relief that sometimes ends up on the toilet seat also annoys her.

As a result, I was dragged to see a urologist, who reckoned I had the age-associated benign prostatic hyperplasia (BPH).

I was put on some medicine, which gradually helped with my urination issue. However, I am sad to say I am now struggling with my libido.

My wife and I used to have sex twice a week, but now we struggle with doing it once a month. Even my erection is weaker than before.

I am really curious and would like to put Dr G on the spot for advice on why I am trading stronger urinary flow for weaker libido.

Firstly, what exactly is BPH, and how does it affect the urinary flow?

I read somewhere that prostate size is affected by high levels of testosterone. Is there a direct correlation between levels of testosterone and prostate enlargement?

Shouldn’t high testosterone induce a better erection?

The doctor said the medicines are to shrink the prostate. Does that mean my testosterone is lowered, too?

Please help.

Yours truly,

Weak William

The prostate is a walnut-size organ in the pelvis that starts small at birth (1.5g) and remains so throughout childhood. During early puberty, it becomes active in producing ejaculates and increases in size via an androgen-dependent pubescent growth phase. It grows from 10g to an average of 20g in young adults.

The second selective growth phase of the inner zones occurs in approximately 50% of men by age 50 and 90% of men older than 80. The causes of this growth are unknown, and pathologically recognised as benign prostatic hyperplasia (BPH), clinically noted as benign prostatic enlargement (BPE) that induces bladder outlet obstruction.

A fun fact is that the prostate will continue to grow despite the rest of the body shrinking with age. BPH commonly affects men with advancing age. The gradual overgrowth results in the compression of the urethra, causing obstruction and leading to various urinary symptoms. These include poor urinary flow and hesitancy in initiation, as well as dribbling and straining at the end of the void.

In addition, the post-void residual urine also results in urination frequency during the day and night. When the symptoms become worse, it can even result in urgency and urge incontinence. Urinary troubles are generally a good barometer of age in men. Scientists have known of the importance of testosterone in prostate pathology, but the exact correlation is largely unknown.

It is often cited that men who are castrated do not experience problems associated with BPH. However, serum testosterone has also been shown to decrease in men with age by approximately 2% to 3% annually. The process of BPH, however, continues as men age despite the fact that their serum testosterone decreases.

On the other hand, some men also do not encounter problems with BPH despite undergoing testosterone replacement therapy. In fact, many studies have demonstrated there was no significant correlation between serum testosterone levels and BPH in many individuals. The real hormonal change responsible for BPH is the active component of dihydrotestosterone (DHT). This active form of testosterone induces the proliferation of the prostate gland cells.

Several other factors have also been identified as potential contributors to BPH, including hormonal imbalance, particularly the ratio between oestrogen and testosterone, which is considered more significant in the development of BPH. Genetic factors also play a role in predisposing certain individuals to BPH.

Lastly, lifestyle choices, such as a sedentary lifestyle, obesity, smoking and excessive alcohol consumption have been associated with an increased risk of BPH.

Various treatment options are available to address prostate enlargement. Lifestyle modifications, medication, or surgical procedures may be recommended depending on the severity of symptoms. Oral medications such as finasteride and dutasteride, known as 5-alpha reductase inhibitors, are used to reduce the active form of testosterone.

Sadly, the reduction of the active form of testosterone will also have an impact on the libido in men. Therefore, many men who are taking this treatment face the issue of weakening libido. Some even describe worsening erection. Another fun fact about the prostate is that the active form of testosterone is also responsible for male pattern baldness. Therefore, the medicine can also have a positive impact on hair growth.

BPH is a complex condition influenced by multiple factors, rather than testosterone level itself. While the connection between testosterone and BPH remains somewhat elusive, research continues to shed light on the mechanisms at play. Having knowledge of the pathogenesis and effective treatment strategies allows men to take proactive steps to maintain overall health and enjoy a fulfilling sex life despite the ageing prostate.

Celine Dion once said: “There is no such thing as ageing, but maturing and knowledge.”

So when men experiencing problems with enlarging prostate and dwindling testosterone due to its treatment put Dr G on the spot for a solution, his view is: “When it comes to the ageing prostate, maturing and knowledge will allow men to trade off certain troubling urinary symptoms with some sexual function, though sometimes the medicine may also yield an unexpected surprise in your crowning glory”.

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