Dear Dr G,

I have turned 60 and am a healthy chap who exercises and watches his diet regularly.

Shortly after my 60th birthday, I started waking up at night to urinate. However, I often struggle to drain the pipe and only have a weak stream and dribbling.

Although it only used to happen at night, the problem is now affecting me in daytime.

I also get sudden urges to urinate and I have been caught out where I could not make it to the toilet in time!

Additionally, despite having a strong libido, I am having difficulty maintaining an erection during sex.

My urologist reckons I suffer from benign prostatic hyperplasia (BPH).

What exactly is BPH and why is urinary flow affected?

I read somewhere prostate size is affected by testosterone – is there a direct correlation of the hormone’s levels in the body and prostate enlargement?

How does prostate enlargement cause erectile dysfunction?

Is this all to do with the ageing process and can I avoid this at all?

Yours truly,

Ageing Adam

The prostate is a walnut-sized gland located between the bladder and the rectum. It surrounds the urethra and plays a key role in male fertility by producing seminal fluid.

The prostate starts off small in size at birth (1.5 g). Only during early puberty does it become active, producing ejaculate and increasing in size via an androgen-dependent pubescent growth phase from 10g to an average of 20g in young adults.

A second selective growth phase of the inner zones occurs in approximately 50% of men by age 50, and 90% of men above 80.

The aetiology is pathologically recognised as BPH and clinically noted as benign prostatic enlargement (BPE) inducing bladder outlet obstruction (BOO).

The exact cause of BPH is not fully understood but age-related hormonal shifts, chronic inflammation and genetic predisposition are known to play roles. BPH commonly affects men with advancing age. The gradual overgrowth results in the compression of the urethra and obstructs it. Symptoms of this include poor urinary flow, hesitancy in initiation, dribbling and straining at the end.

Additionally, the post-void residual urine also results in frequent urination – both daytime and night time – and in severe cases also causes urgency and incontinence.

Scientists know of testosterone’s importance in prostate development and pathology but the exact cause and effects of this non-cancerous enlargement is largely unknown. However, castrated men do not experience problems associated with BPH.

The process of BPH, however, continues as men age, despite the fact their serum testosterone decreases by approximately 2%–3% annually.

On the other hand, some men do not encounter BPH despite testosterone replacement therapy. In fact, many studies demonstrate there is no significant correlation between serum testosterone levels with BPH in many individuals.

The real hormonal change responsible for BPH is the increase in the active component of dihydrotestosterone (DHT). This active form of testosterone induces proliferation of the prostate gland cells.

Several other factors have been also identified as potential contributors to BPH. These include hormonal imbalance, particularly the ratio between oestrogen and testosterone 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.

As for erectile dysfunction (ED), an enlarged prostate can exert pressure on the urethra and disrupt normal blood flow. The blood vessels responsible for engorging the penis during sexual arousal can be impeded, leading to difficulties in achieving and maintaining an erection.

While BPH itself does not directly cause ED, its presence and associated symptoms can indirectly contribute to the development of this condition. The frustration and anxiety caused by the urinary symptoms associated with BPH can also negatively impact a man’s sexual confidence and performance.

Fortunately, various treatment options are available to address both prostate enlargement and ED. Lifestyle changes, medication or surgical procedures may be recommended depending on the severity of symptoms. In fact, oral medications such as long-acting Phosphodiesterase 5 Inhibitors (PDE5-I) are common medications that can resolve both issues at the same time.

If such treatment fails, there are surgical options such as the gold standard of transurethral resection of the prostate (TURP), laser prostatectomy and open or robotic prostatectomy for very large prostates.

BPH is a complex condition influenced by multiple factors rather than testosterone levels alone. While the connection between testosterone and BPH remains 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.