Next Lesson - Male Urological Conditions
Core
The prostate is a walnut-sized gland found in the pelvis between the bladder and the penis in men. It is involved in secreting part of the fluid in semen, and for more information on the functions of the prostate gland check out our article on the male reproductive system.
Benign prostatic hyperplasia and prostate cancer are the two main pathologies associated with the prostate. Most men have some BPH by the age of 80. Autopsy studies show that about 70% of men have some prostate cancer by 80, but far fewer, around 1 in 6 to 1 in 8 men in the UK, are diagnosed with it during their life. These two pathologies along with acute bacterial prostatitis will be discussed in this article.
Benign prostatic hyperplasia (BPH) is an increase in the size of the prostate gland without the presence of malignancy. It is characterised by non-cancerous hyperplasia of glandular epithelial and stromal tissue (supporting connective tissue) within the transitional zone of the prostate gland. The majority of elderly men will have some form of BPH by the age of 80 years (source). It is a histological diagnosis as it needs to be differentiated from prostate cancer, but is not routinely investigated for, meaning only symptoms prompt a diagnosis.
Androgens (male sex hormones), such as dihydrotestosterone and testosterone, act on the prostate gland to cause hyperplasia. Dihydrotestosterone is produced from testosterone by the enzyme 5-alpha-reductase and is a more potent androgen. Its production is therefore targeted in the treatment of BPH by 5-alpha-reductase inhibitors, such as finasteride and dutasteride.
- Advancing age
- Family history
- Black ethnicity - studies disagree on whether Black men have a higher risk of BPH
- Obesity
The symptoms that a patient with BPH will typically present with are lower urinary tract symptoms (LUTS), and some of these symptoms can be seen below. The International Prostate Symptom Score can also be used to help determine the severity of the patient’s symptoms.
- Urinary Frequency
- Nocturia - waking at night to pass urine
- Urinary Urgency
- Hesitancy - patients will usually also complain of a poor stream and terminal dribbling. They may also complain of needing to push or strain to urinate
- Incomplete Bladder Emptying - patients will complain of still feeling that the bladder has not fully emptied after voiding (passing urine)
- Prostate Enlargement - the prostate needs to be felt on a digital rectal examination (DRE) to check size, symmetry, smoothness and the sulcus (the groove down the middle of the prostate). BPH often causes smooth, symmetrical enlargement. Hardness or irregularity raises suspicion of prostate cancer, but examination findings overlap and a normal or benign-feeling prostate does not exclude cancer
- Palpable Bladder - patients with BPH may have chronic urinary retention (a bladder that does not empty fully over a long period) due to obstruction of the urethra by the prostate
When investigating benign prostatic hyperplasia, the main aim is to ensure that the cause of the symptoms is BPH and not a more serious pathology like prostatitis or prostate cancer. BPH is first assessed with a urine dipstick, a frequency volume chart and, if appropriate, blood tests. Urine flow tests and imaging are mainly used at specialist assessment or when clinically indicated. Prostate biopsy is not a routine investigation for BPH and is reserved for cases where there is significant suspicion of malignancy.
Urinalysis by urine dipstick and mid-stream urine sample for culture. These tests are used to look for infection (e.g. urinary tract infection, acute bacterial prostatitis) and for haematuria (blood in the urine).
Blood Tests - the main blood test that is performed is a prostate-specific antigen (PSA) blood test. This antigen can be elevated in prostate cancer but is not cancer-specific and may also be raised in BPH or prostatitis. Because prostate cancer can present very similarly, men with LUTS should be offered information, advice and time to decide whether to have a PSA test if their symptoms suggest a blockage from an enlarged prostate, their prostate feels abnormal on DRE, or they are worried about prostate cancer. Urea and electrolytes may also be checked as BPH can cause renal impairment if the patient develops urinary retention.
Urodynamic Tests - these tests assess how well the bladder and urethra are functioning. There are many different urodynamic tests but some of the urodynamic tests for BPH include:
- Flow Test - this looks at the speed of urine flow over time. A low flow rate may reflect bladder outlet obstruction, weak detrusor (bladder wall muscle) contraction or an insufficient voided volume. Uroflowmetry measures urinary outflow but does not establish obstruction on its own
- Urinary Frequency and Volume Chart - these help to show us how frequently the patient is voiding and how much they are voiding each time, and this helps in deciding the management
Ultrasound Scan - imaging is not routine for men with uncomplicated LUTS. At specialist assessment, a scan of the urinary tract may be used when clinically indicated, for example in chronic retention, haematuria or recurrent infection. It can show the size of the prostate and check other parts of the urinary tract for problems.
Transrectal Ultrasound Biopsy of the Prostate - a biopsy of the prostate may be taken if there is suspicion of malignancy, and one method to access the prostate gland is through the rectum. If a patient has surgery for BPH, then the prostate tissue removed is usually sent off to pathology for histological analysis to check for malignancy.
There are three main parts to the treatment of benign prostatic hyperplasia: lifestyle changes, medication and surgery. The early treatment of BPH aims to reduce the symptoms and slow the growth of the prostate, with later stages of treatment aiming to reduce the size of the prostate through surgery.
An incidental finding of BPH with no clinical features or complications can be managed with reassurance and lifestyle changes. Symptomatic BPH is first treated with lifestyle changes and medication, but if there is severe obstruction or no symptom relief with medication and lifestyle changes then surgery may be indicated.
Lifestyle Changes
- Decrease caffeine, alcohol, carbonated and acidic drink consumption
- Avoiding excessive total fluid intake, particularly in the evening, while maintaining adequate hydration
- Bladder Retraining - retraining involves having a voiding schedule (set times to pass urine) which the patient must follow, with the intervals between voiding increasing every week until intervals of 2-3 hours are reached. Over time, this can help reduce the urgency
- Double Voiding - this is where a patient voids more than once every time they go to the toilet. This helps to empty the bladder completely and can be used in patients who have incomplete bladder emptying
Medication
- Alpha Blockers - these cause relaxation of the smooth muscle within the prostate and bladder neck to allow urine to flow more easily, and relieve the symptoms of BPH
- Examples include tamsulosin, alfuzosin, doxazosin and terazosin
- Side effects include dizziness, sexual dysfunction, diarrhoea, headaches, nausea and vomiting. Alpha blockers can also cause a sudden drop in blood pressure, especially after the first dose or on standing up (postural hypotension). They can cause problems during cataract surgery (floppy iris syndrome), so the eye surgeon must be told
- 5-alpha reductase inhibitors - these help to shrink the prostate by lowering the amount of dihydrotestosterone made in the body, though it takes time (up to 6 months) for the effects to be seen. They inhibit 5-alpha reductase, the enzyme that converts testosterone into the more potent androgen dihydrotestosterone. NICE recommends them for men with LUTS and a prostate estimated to be larger than 30 g (or a PSA above 1.4 ng/ml) who are at high risk of their symptoms getting worse
- Examples include finasteride and dutasteride
- Side effects include sexual dysfunction, breast changes (such as lumps or pain), skin reactions and depression. They also lower the PSA level by about 50% after 6 months of treatment, which must be taken into account when interpreting a PSA result
Surgery
There are many surgical procedures that are used to treat benign prostatic hyperplasia and this article will include some of the main procedures used. Indications for surgery include failed lifestyle and medical management, and urinary retention requiring intervention.
- Transurethral Resection of the Prostate (TURP) - involves inserting a cystoscope (a thin tube with a camera and instruments) into the urethra and then using an electrical current to remove prostatic tissue and increase the urethral lumen size to increase urine flow and relieve symptoms
- Holmium Laser Enucleation of the Prostate (HoLEP) - involves inserting a cystoscope into the urethra and then using a laser to remove prostatic tissue to increase the urethral lumen size
- Prostatectomy - this is the removal of prostatic tissue
- Simple prostatectomy involves removal of only part of the prostate. It is the type of prostatectomy used for benign conditions, but it is not the main BPH operation. NICE recommends open prostatectomy only for very large prostates (estimated to be larger than 80 g), as an alternative to TURP or HoLEP
- Radical prostatectomy involves removal of the entire prostate along with the seminal vesicles (glands that add fluid to semen) and distal vas deferens (the end of the tube that carries sperm), and may also include pelvic lymph node removal. This is usually reserved for prostate cancer and is not usually performed for BPH
Prostate cancer is the most common cancer in men in the UK and the second most common in men worldwide. Around 1 in 6 to 1 in 8 men in the UK will get prostate cancer during their life, and the risk is about 1 in 4 for Black men. (source)
Adenocarcinomas are the most common prostate cancer and there are two main forms of adenocarcinomas: acinar and ductal. Acinar adenocarcinomas originate in glandular cells that line the prostate gland and are the most common type. Ductal adenocarcinomas originate in the cells that line the ducts of the prostate gland and are less common, but they do tend to grow and metastasise faster than acinar adenocarcinomas.
The growth of prostate cancer is influenced by androgens, and so these are targeted during the treatment of prostate cancer.
Prostate cancer differs from benign prostatic hyperplasia in two main aspects:
- First, prostate cancer is a malignancy while BPH is a non-cancerous growth of tissue
- Second, prostate cancer most often arises in the peripheral zone of the prostate. This zone is close to the rectum, so a cancer there can often be felt on DRE. BPH affects the transitional zone which is more central within the prostate so the shape can less clearly be felt
- Advancing age
- Family history and genetics - inherited changes (variants) in the BRCA2 gene, and also BRCA1, are associated with an increased risk of prostate cancer
- Black men, including men of African-Caribbean background, have a higher risk of prostate cancer in the UK (source)
The signs and symptoms of prostate cancer can overlap with those of BPH. A hard or irregular prostate on DRE raises concern for malignancy, but a smooth or normal-feeling prostate does not exclude cancer. Patients may not present with any symptoms and instead present to primary care asking to have their prostate and PSA checked, which may lead to the diagnosis of prostate cancer.
- Lower Urinary Tract Symptoms - a common reason for patients to present, although early prostate cancer seldom causes symptoms and LUTS are more often caused by BPH. LUTS include nocturia, urgency, frequency, incomplete emptying, terminal dribble, hesitancy, straining and post-micturition dribble (dribbling of urine shortly after finishing)
- Hard and Irregular Prostate - found during a DRE for symptoms of prostate cancer or incidentally on DRE. The examination also helps to estimate the clinical stage (T stage) of the cancer. This is based on whether the tumour feels confined within the prostate or seems to have spread beyond its capsule
- Weight Loss
- Renal Failure - obstruction of the urethra by the enlarged prostate may result in urinary retention which can cause renal failure if left untreated. Although rare, renal failure may be how a patient with prostate cancer first presents
- Bone Pain - patients with metastatic prostate cancer may have bone metastases, so they present with bone pain. Bone metastases in prostate cancer are osteoblastic (sclerotic), which means they cause bone production rather than bone destruction (osteolytic lesions), as seen in most other cancers. The main bones that prostate cancer spreads to are the pelvis, ribs, femur and spine, though it can spread to the skull and other bones
Image - CT scan showing sclerotic (osteoblastic) vertebral lesions, the bone-forming pattern typical of prostate cancer metastases. The original image source describes this patient as having multiple myeloma, a cancer that usually causes lytic (bone-destroying) lesions instead, so this is an unusual example and not a confirmed case of prostate cancer.
Source by Mikael Häggström; CC0 1.0 public-domain dedication.
Prostate Specific Antigen (PSA) - the serum PSA is an important blood test when investigating prostate cancer as it is used in the referral of patients to urology (the specialty that treats the urinary tract and male genital organs) and in the staging of prostate cancer. It is a useful tumour marker, but it is not specific for prostate cancer because it can be raised in other situations. Screening all men with PSA could cause over-diagnosis and over-treatment, so the UK does not recommend population screening. In March 2026, the UK National Screening Committee recommended targeted screening, with a PSA test every 2 years, for men aged 45 to 61 who have a harmful BRCA2 gene variant and a family history of breast, ovarian, pancreatic or prostate cancer. This programme is not yet running.
- Situations where the PSA can be raised include urinary infection, recent ejaculation, vigorous exercise such as cycling, prostate inflammation, urinary retention and a recent prostate biopsy. DRE has minimal effect on PSA levels
- As the serum PSA can be raised by other causes, the test may need to be delayed to prevent a false positive reading. Current UK advice is that a PSA test should not be done within 48 hours of ejaculation or vigorous exercise, within 6 weeks of a urinary infection, or within 6 weeks of a prostate biopsy
Transrectal Ultrasound Biopsy of the Prostate (TRUSP) - biopsy of the prostate is taken under ultrasound guidance, and is taken through the rectum. It is done under local anaesthetic. In current UK practice, a multiparametric MRI scan (an MRI that combines several types of image) is done first, and a biopsy is offered if the MRI shows a suspicious area (a Likert score of 3 or more). Samples are usually taken both from the suspicious area seen on MRI (targeted biopsy) and from the rest of the prostate (systematic biopsy), and are used to determine the Gleason score.
Transperineal Biopsy - this is a biopsy of the prostate taken through the perineum (the skin between the scrotum and the anus). It can be done under local anaesthetic or general anaesthetic, and it allows access to the anterior prostate (the front part of the prostate). As with TRUSP, the samples are used to determine the Gleason score.
MRI Scan - the first line imaging used to look at the size of the prostate and stage the disease locally. Assessment of distant metastases usually requires other imaging modalities.
CT Abdo-Pelvis and Staging CT Scan - CT of the abdomen and pelvis can be used to look for distant metastases. For staging the tumour and nearby lymph nodes, NICE suggests CT only for people who cannot have an MRI.
Bone Scan (radionuclide bone scintigraphy) - used to look for any bone metastases. A bone scan may be used if a patient has bone pain, a high serum PSA or higher-risk disease. It is not routinely offered to people with lower-risk localised prostate cancer (Cambridge Prognostic Group 1 or 2).
Patients are referred to urology using a suspected cancer pathway referral (for an appointment within 2 weeks, the two-week wait). The aim is for cancer to be diagnosed or ruled out within 28 days of referral. Referral is made if the prostate feels malignant on digital rectal examination (for example, hard and irregular). It should also be considered if a man with possible symptoms of prostate cancer has a PSA level above the threshold for his age.
The Gleason Score is used to grade prostate cancer. The score is from 6-10, with a high score indicating less differentiation and more abnormal cells. On prostate needle biopsy, the predominant cancer pattern grade is added to the highest other pattern grade in the samples, using grades 3 to 5. If only one pattern is present, its grade is counted twice. In current practice, the lowest score reported for prostate cancer is 6. Gleason scores are also grouped into grade groups 1 to 5, which are used in UK risk groups. For example, Gleason 6 is grade group 1, 3+4=7 is grade group 2 and 4+3=7 is grade group 3.
- For example, a patient may have a Gleason Score of 9 meaning one of the tumour areas is a grade 4 while the other area is a grade 5.
- The Gleason score is often written as a sum of two numbers rather than a single number. On needle biopsy, these are the predominant pattern and the highest other pattern in the samples. For example, a score of 3+4 differs from 4+3 because the first number represents the predominant pattern. A 4+3 cancer generally has a worse outlook than 3+4, because the more abnormal pattern is the main one.
The management of prostate cancer is discussed in a multidisciplinary team (MDT) meeting, where specialists from different fields plan care together. Treatment depends on the risk group of the prostate cancer. Low-risk prostate cancers may not need immediate treatment and can be closely monitored instead.
Prostate cancer is risk stratified (sorted into risk groups) depending on the PSA, Gleason score (or grade group) and T stage. In the UK, NICE uses five Cambridge Prognostic Groups (CPG 1 to 5), from lowest to highest risk. Active surveillance is offered for CPG 1 and is an option for CPG 2 and some people with CPG 3. Radical treatment (surgery or radiotherapy) is offered for higher-risk groups, and active surveillance is not offered for CPG 4 and 5.
Treatment is split into localised, locally advanced and metastatic treatment.
Patients with low-risk prostate cancer may not need immediate treatment. Instead, they can have active surveillance or watchful waiting, which are two different strategies. Active surveillance aims to cure: the cancer is monitored, and radical treatment is offered if it shows signs of progressing. Watchful waiting aims to control rather than cure the cancer, and is for people who do not want curative treatment or for whom it is not suitable.
- Active Surveillance - patients are monitored on a schedule to check for progression of prostate cancer. This can be with a PSA test, MRI scan, DRE or biopsy
- Watchful Waiting - patients are given symptomatic and conservative treatment until the patient develops local or systemic symptoms of prostate cancer. This is a symptom-guided approach to treatment with the aim of maintaining the patient’s quality of life
It is important to understand the difference between active surveillance (when the patient is brought back on a schedule for investigation without waiting for a change in symptoms) and watchful waiting (when the patient is investigated only when they have symptoms).
Localised Treatment - the main aim of treatment is to prevent morbidity and mortality from prostate cancer.
- Radical Prostatectomy - the surgical removal of the prostate, seminal vesicles and surrounding tissue. This might include removal of the pelvic lymph nodes if unsure about lymphatic involvement
- Radical prostatectomy can either be laparoscopic (keyhole), open or robotic surgery
- Side effects of prostatectomy include erectile dysfunction and stress urinary incontinence (leaking urine when coughing, sneezing or straining)
- External Beam Radiotherapy - radiotherapy beams targeted at the prostate cancer
- Brachytherapy - radioactive seeds are implanted transperineally into the prostate to destroy the prostate cancer with radiotherapy from within
- Cryotherapy - use of freezing cold gases to destroy cancer cells. Thin needles are put into the prostate and then cold gases are put into the prostate to kill the cancer cells. NICE does not recommend cryotherapy for localised prostate cancer other than in clinical trials, so it is not a standard treatment
Locally Advanced Treatment - the main aim of treatment is to prevent or delay morbidity and mortality from prostate cancer.
- Radical Prostatectomy - with locally advanced treatment, radical prostatectomy is followed by adjuvant radiotherapy and adjuvant androgen deprivation therapy
- External Beam Radiotherapy - with locally advanced disease, radiotherapy is usually given with androgen deprivation therapy (hormone therapy that lowers testosterone), which can be started before (neoadjuvant) and continued during or after (adjuvant) the radiotherapy
Metastatic Treatment - the main aim of treatment is symptomatic relief and prolong survival as metastatic disease is incurable. The prostate is typically not removed or treated in metastatic prostate cancer unless it is causing severe symptoms. An exception is men who are newly diagnosed with metastatic prostate cancer and have a low metastatic burden (a small number of metastases, with none in organs such as the liver or lungs). In these men, adding radiotherapy to the prostate to their hormone therapy improves survival. In England, this is available on the NHS as a routine treatment option.
- Castration - this helps to decrease the level of testosterone in the body and slow the growth of prostate cancer. Castration is either surgical or by hormones
- Hormonal castration uses either a LHRH agonist or a LHRH antagonist. LHRH (luteinising hormone-releasing hormone, also called GnRH) is made by the hypothalamus and acts on the pituitary gland, which then releases the hormones that drive testosterone production
- LHRH agonists, such as goserelin, act like LHRH and cause continuous stimulation of LHRH receptors in the pituitary. This first increases testosterone, but the receptors then become down-regulated (less responsive), so the pituitary releases less of these hormones and testosterone falls. LHRH agonists are typically used in combination with an anti-androgen (a drug that blocks the action of androgens) at first to block the effects of this initial rise in testosterone (tumour flare)
- LHRH antagonists, such as degarelix, block LHRH receptors in the pituitary. This lowers testosterone quickly, without the initial rise seen with agonists
- Chemotherapy - docetaxel, started alongside androgen deprivation therapy, increases survival of patients with newly diagnosed metastatic prostate cancer. It is also used if the prostate cancer has relapsed or is castration-resistant (keeps growing despite low testosterone)
- Newer hormonal drugs - enzalutamide (with androgen deprivation therapy), apalutamide (with androgen deprivation therapy, if docetaxel is not suitable) and darolutamide (with docetaxel) are NICE-recommended options for hormone-sensitive metastatic prostate cancer (cancer that still responds to lowering testosterone)
- Radiotherapy - patients may undergo radiotherapy directed at the prostate to relieve urinary symptoms. It can also be targeted at metastases to relieve pain
- Bone Metastases Treatment - if a patient has painful bone metastases then palliative radiotherapy (aimed at relieving symptoms) can be given to relieve the pain. Bisphosphonates (drugs used to strengthen bone), such as zoledronic acid, may be considered in hormone-relapsed (castration-resistant) disease to prevent or reduce bone complications such as fractures. They can also help bone pain that other treatments have not controlled. They are not used to prevent bone metastases from developing
Prostatitis is inflammation of the prostate gland. There are different types of prostatitis which include acute bacterial prostatitis, chronic bacterial prostatitis, non-bacterial prostatitis and prostatodynia (a condition with symptoms of prostatitis with no visible inflammation). Today, chronic prostatitis without proven infection is usually called chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and this is by far the most common type of prostatitis. Acute bacterial prostatitis accounts for up to 10% of cases. It is the type covered in this article because it is a bacterial infection that needs antibiotic treatment.
Acute bacterial prostatitis is an uncommon condition that can occur in adult men of any age, with higher incidence in younger and older age groups. The main cause is Escherichia coli but other causes include Proteus, Klebsiella, Enterobacter, Serratia and Pseudomonas. Some sexually transmitted infections (STIs) can cause prostatitis, though this is less common than the other causes. Acute bacterial prostatitis can become chronic if the infection is not treated.
Acute bacterial prostatitis is usually caused by bacteria entering the prostate from the urinary tract, and many of these risk factors make this easier.
- Phimosis - difficulty retracting the foreskin
- Intraprostatic ductal reflux - the backward flow of urine, which may carry bacteria, from the urethra into the ducts of the prostate
- Unprotected sex
- Urinary tract infection
- Indwelling catheter
- Transurethral biopsy or surgery - transurethral procedures involve using the urethra to access the bladder, prostate or kidneys
- Prostate biopsy
- Immune deficiency
- Lower urinary tract symptoms - dysuria, urgency, frequency, incomplete emptying, terminal dribble, hesitancy, straining and post-micturition dribble.
- Fever
- Malaise
- Perineal or suprapubic pain
- Urethral discharge
- Tender and enlarged prostate (prostate massage should be avoided in acute infection)
- Inguinal lymphadenopathy
The first investigations that should be undertaken are a midstream urinalysis and a urine culture. The urinalysis is used to look for white blood cells in the urine while the urine culture is used to determine the bacteria and its antibiotic sensitivities. These are the two main investigations and are used together with the history to confirm the diagnosis.
Other investigations may be used in the diagnosis of acute bacterial prostatitis and to look for complications. Blood tests, including blood cultures and a full blood count, can be used to look for infection and check kidney function. Screening for sexually transmitted infections (an STI screen) should be considered, particularly in men at risk. A transrectal prostatic ultrasound scan or a CT scan may be used to assess for a prostatic abscess (a collection of pus in the prostate). These are especially indicated in immunocompromised patients (people with a weakened immune system), who are at higher risk of an abscess.
The main treatment for patients with acute bacterial prostatitis is a prolonged course of antibiotics. NICE recommends a 14-day course, then a review to decide whether to stop or continue for a further 14 days. First-choice oral antibiotics are the fluoroquinolones ciprofloxacin or ofloxacin, guided by urine culture results. Fluoroquinolones can rarely cause disabling and long-lasting side effects, such as tendon damage, so patients are told to stop the drug at the first signs of these. Trimethoprim is used if a fluoroquinolone is not appropriate, and levofloxacin is a second-choice option after specialist advice. The patient should also be advised to increase fluid intake and take analgesia as necessary.
If acute bacterial prostatitis persists and becomes chronic then the patient needs to be referred to urology for further investigations and treatment. Patients can also be referred to urology if there is suspicion of an underlying urological condition or if they have a pre-existing urological condition.
Men with suspected chronic bacterial prostatitis should be referred to urology. While they wait, they can be given a longer course of antibiotics, such as trimethoprim or doxycycline for 4 to 6 weeks. An alpha blocker may also be given if the patient has troublesome LUTS.
Edited by: Dr. Maddie Swannack
Uploaded by: Dr. Thomas Burnell
Reviewed by: Dr. Marcus Judge
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