Enlarged Prostate Symptoms: A Guide for Men Over 45
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Enlarged prostate (BPH) symptoms are urinary: a weak or stop-start stream, trouble starting, straining, dribbling at the end, a bladder that never feels empty, sudden urges, going more often, and getting up at night.1 They are common after 45 and are not cancer.4 Being unable to urinate is an emergency; fever or blood in the urine needs a doctor promptly.1,6
Key takeaways
- Prostate growth seen under the microscope reaches 60 percent of men at 60 and 80 percent at 80, but BPH as a health condition affects 29 to 33 percent of men 65 and older.3,1
- Moderate to severe urinary symptoms rise to nearly 50 percent of men by their seventies.3
- The IPSS questionnaire scores symptoms from 0 to 35: 7 or less is mild, 8 to 19 moderate, 20 to 35 severe. A drop of about 3 points is what men notice as a slight improvement.12,3
- Age, prostate size and urine flow together explained only about 13 percent of the differences in symptom scores between men in a Minnesota community study.7
- An enlarged prostate does not raise prostate cancer risk, and early prostate cancer usually causes no symptoms, so symptoms are not a cancer test.4
What an enlarged prostate is, and why it changes how you urinate
The prostate is a small gland that sits below the bladder and in front of the rectum, and it surrounds part of the urethra, the tube that carries urine out of the body. When men are in their 20s, a normal prostate is about the size of a walnut.4 It grows in two phases: it doubles in size early in puberty, and a second, slow growth phase starts around age 25 and continues for the rest of life.1
Benign prostatic hyperplasia (BPH) is the name for a prostate that has grown larger than normal, where the growth is not caused by cancer.1 Because the gland surrounds the urethra, an enlarged prostate can push against the urethra and the bladder.4 That is why the symptoms of an enlarged prostate are urinary symptoms, not a lump you can feel.
This guide is the starting point of our prostate health section: each symptom gets a short summary here and a full article of its own.
What are the symptoms of an enlarged prostate?
The NIDDK lists the typical BPH symptoms as trouble starting a stream or emptying the bladder, a weak or interrupted stream, dribbling at the end of urination, nighttime urination, urgency, frequency, and pain during urination.1 MedlinePlus adds straining, incontinence and, at the severe end, not being able to urinate at all.2
It helps to sort them into two families. Some are about emptying: the urine has trouble getting out. Others are about storing: the bladder feels full too often or too suddenly. The AUA guideline uses the term storage symptoms for the second group.3
Weak urine stream
A stream that is slower and has less force than it used to. The questionnaire simply asks how often you have had "a weak urinary stream."12 The prostate is a common cause, not the only one. Our guide to a weak urine stream covers the other causes and a simple home check.
Trouble starting and straining
Standing at the toilet waiting for the flow to begin, which doctors call hesitancy, or having to push to get it going.1,2,6 The weak stream article covers both.
A stop-start stream
The flow stops and starts again several times while you urinate. Doctors call it intermittency, and it is also one of the seven scored questions.12
Feeling that the bladder is not empty
You finish, and a minute later it feels like there is more to come. The symptom score asks how often you have had "the sensation of not emptying your bladder."12 A quick bladder scan after you urinate, called a post-void residual, shows whether urine is actually being left behind.3 Read more in feeling like your bladder is not empty.
Dribbling after you finish
A few drops that come out after you have zipped up. The NIDDK lists dribbling at the end of urination among the core BPH symptoms.1 Our guide to dribbling after urination explains why it happens and what helps.
Sudden urges
A strong need to go that is hard to put off. Urgency is a storage symptom, and the score asks how often you found it "difficult to postpone urination."12 Bladder problems can cause the same feeling without any help from the prostate,1 which is why we give it its own article: sudden urge to urinate after 50.
Going more often during the day
The symptom score defines frequency as having to urinate again less than two hours after you last went.12 Our article on frequent urination in men over 50 focuses on the daytime pattern.
Getting up at night
Nighttime urination is on every list of BPH symptoms, and MedlinePlus singles out getting up two or more times.1,2 It is also the symptom that treatment helps least. The AUA guideline calls nocturia "the one component of the IPSS least likely to improve with any medical treatment."3 We cover what counts as normal and the many non-prostate causes in how many times a night is normal to urinate.
| Symptom | Family | IPSS question | Full guide |
|---|---|---|---|
| Weak stream | Emptying | No. 5 | Weak urine stream |
| Trouble starting, straining | Emptying | No. 6 | Weak urine stream |
| Stop-start stream | Emptying | No. 3 | This page |
| Not emptying fully | Emptying | No. 1 | Bladder not emptying |
| Dribbling after | After urination | Not scored | Dribbling after urination |
| Sudden urge | Storage | No. 4 | Sudden urge to urinate |
| Daytime frequency | Storage | No. 2 | Frequent urination |
| Night urination | Storage | No. 7 | Urinating at night |
How common are enlarged prostate symptoms by age?
You will find figures from 5 percent to 90 percent. They are all correct, because they count different things.
| What was counted | Age group | Result | Source |
|---|---|---|---|
| Prostate growth seen under a microscope at autopsy | Starts at 40 to 45 | 60% at age 60, 80% at age 80 | AUA guideline3 |
| Some prostate enlargement | Over 80 | More than 90% | MedlinePlus2 |
| BPH as a health condition | 40 to 64 / 65 and older | 5 to 6% / 29 to 33% | NIDDK1 |
| Any urinary symptom at all | 45 to 80 | About 90% | AUA guideline3 |
| Moderate to severe symptoms | Men in their 70s | Nearly 50% | AUA guideline, Olmsted County data3 |
| Symptoms plus slow flow, enough to discuss treatment | 50s / 60s / 70s | 17% / 27% / 35% | Jacobsen 19958 |
The last row comes from a random sample of 1,317 men aged 50 to 79 in Olmsted County, Minnesota, who were tested the way the national guidelines of the time recommended: a symptom score above 7 and a peak urine flow below 15 mL per second.8 The figures are from 1995 and from white men only, so treat them as a rough guide, not a precise rate for you.
In a second sample from the same county, 475 men aged 40 to 79, only 4 percent had seen a doctor for urinary symptoms in the past year, and prostate size, flow and symptom scores did a poor job of predicting who went.9
Does a bigger prostate mean worse symptoms?
Only partly. The NIDDK puts it plainly: symptoms "may not be directly related to the size of your prostate." A large prostate may cause few symptoms, while a slightly enlarged one may cause more.1
In the Olmsted County community study of white men aged 40 to 79, age accounted for only 3 percent of the variation in symptom scores. Adding prostate volume and peak urine flow explained only another 10 percent.7 That leaves about 87 percent of the variation unexplained by age, size and flow.
Size is not irrelevant. After adjusting for age, men with a prostate larger than 50 mL had 3.5 times the odds of moderate to severe symptoms, and men whose peak flow was below 10 mL per second had 2.4 times the odds.7
How big is big?
The AUA suggests these working categories (grams and milliliters are used interchangeably): small under 30 g, average 30 to 80 g, large over 80 to 150 g, and very large over 150 g. It uses size mainly to choose between procedures and medicines, not to judge whether your symptoms are real.3
How fast does it grow?
In 631 randomly selected men followed for almost seven years with repeated ultrasound, the prostate grew by an average of 1.6 percent a year. Growth varied widely from man to man and was faster in men who already had larger prostates.10 That slow pace fits symptoms that creep up over years. If yours changed quickly over a few weeks, tell your doctor rather than assuming it is just growth.
How to score your symptoms: the IPSS explained
The International Prostate Symptom Score (IPSS) is the questionnaire the AUA guideline tells clinicians to use at the first visit for bothersome urinary symptoms.3 It started life as the AUA Symptom Index, developed and validated by the AUA in 1992, and the questions are identical.3,11 It is self-administered, so you can score yourself at home.3
The seven questions
Each question covers the past month.12 Questions 1 to 6 are scored from 0 (not at all) through 1 (less than 1 time in 5), 2 (less than half the time), 3 (about half the time), 4 (more than half the time) to 5 (almost always).
- Incomplete emptying: how often have you had the sensation of not emptying your bladder?
- Frequency: how often have you had to urinate less than every two hours?
- Intermittency: how often have you stopped and started again several times when you urinated?
- Urgency: how often have you found it difficult to postpone urination?
- Weak stream: how often have you had a weak urinary stream?
- Straining: how often have you had to strain to start urination?
- Nocturia: how many times did you typically get up at night to urinate? Scored 0 for none up to 5 for five times or more.
What your total means
| Total score | Category | How the guidelines approach it |
|---|---|---|
| 0 to 7 | Mild | Watchful waiting plus lifestyle changes is an option when symptoms do not affect quality of life |
| 8 to 19 | Moderate | If bothersome, the AUA recommends offering an alpha blocker |
| 20 to 35 | Severe | Same medicine options; procedures are discussed if medicines do not help enough or complications appear |
The score bands come from the IPSS form itself.12 Watchful waiting is described by the NIDDK, and the alpha blocker recommendation is AUA Guideline Statement 10.1,3 In the Minnesota data, men scoring above 7 were 3.4 times as likely to have sought care in the past year as men in the mild range.9
The eighth question: bother
The IPSS comes with one extra question that is scored separately: "If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?" The answers run from 0 (delighted) to 6 (terrible).3 A score of 12 that does not bother you and a score of 12 that ruins every night out are different problems, which is why the AUA calls for shared decision-making.3
How much of a drop actually counts
In a Veterans Affairs trial of 1,218 men, researchers matched score changes against how the men said they felt after 13 weeks of treatment. An average drop of about 3 points was what men experienced as a slight improvement, 5.1 points as a moderate one and 8.8 points as a marked one. Men who started with higher scores needed bigger drops to feel the same benefit.3 The AUA guideline adds that a treatment should not be continued if a man is neither satisfied nor showing a lower score.3 The same yardstick works for anything you try: score yourself before, and again after the trial period.
Is it BPH or prostate cancer? What a symptom does not mean
- BPH is not cancer and does not lead to it. The National Cancer Institute states that an enlarged prostate does not increase a man's risk for prostate cancer.4
- Urinary symptoms can come from something other than cancer. The CDC notes that symptoms like a weak stream or trouble emptying may be caused by conditions that are not cancer, such as an enlarged prostate.5
- No symptoms does not mean no cancer. Early-stage prostate cancer does not usually cause symptoms, according to the NCI, and the CDC says most prostate cancers do not cause symptoms early on.4,5
- The two can exist together. The NIDDK lists prostate cancer, along with bladder problems, urinary tract infections and prostatitis, among the conditions that can cause the same symptoms as BPH.1
Put together, that means your urinary symptoms are not a cancer test in either direction. Screening is a separate decision. The US Preventive Services Task Force recommends that men aged 55 to 69 make an individual decision about PSA screening with their clinician, and recommends against routine screening at 70 and older. That recommendation dates from 2018 and the Task Force lists it as being updated.13 Our article on what age men should get a PSA test compares the guidelines side by side.
One PSA detail that catches men out. Finasteride and dutasteride, two common BPH medicines, shrink the prostate and cut PSA readings by roughly 50 percent. The AUA guideline tells clinicians to double the measured PSA in men taking them, and notes that failing to do so has been linked to delayed cancer diagnosis.3 If you take one of these drugs, make sure whoever orders your PSA knows it.
Red flags: when to see a doctor this week, or today
The NIDDK says to tell a health care professional right away if you:1
- cannot urinate at all;
- have painful, frequent and urgent urination together with fever and chills;
- have blood in your urine;
- have great discomfort or pain in your lower belly or urinary tract.
MedlinePlus adds passing less urine than usual, back or side pain, and pus in the urine.2 The first item is an emergency: acute urinary retention, where you suddenly cannot urinate and often have severe lower belly pain, "can be life threatening," according to the NIDDK.6 If that happens, go to urgent care or an emergency room instead of waiting for an appointment.
Book a routine visit, rather than an urgent one, if your symptoms bother you, your score is 8 or higher, or anything has changed quickly over weeks rather than years.
What the doctor will check
AUA Guideline Statement 1 says the clinician should take a medical history, do a physical exam, use the IPSS and run a urinalysis.3
- History and medication list. Including sexual history and every medicine you take, because some common medicines can make symptoms worse.2,3
- Urinalysis. It cannot diagnose BPH, but it rules out other causes by looking for bacteria, blood, white cells, glucose or protein.3
- Digital rectal exam and PSA. The NIDDK lists both among the standard prostate tests.1
- Post-void residual. A quick bladder scan after you urinate, showing how much is left behind. The AUA lists it as optional at the first visit.3
- Uroflowmetry. You urinate into a device that measures the flow. A peak flow under 10 mL per second has a specificity of 70 percent for obstruction, so it is a useful clue but not a verdict on its own.3
What happens if you leave it alone?
The NIDDK describes watchful waiting as a reasonable choice when the prostate is only slightly enlarged and symptoms do not affect quality of life.1 But BPH can progress, and the NIDDK lists urinary retention, blood in the urine, urinary tract infections, bladder stones and kidney disease as possible complications.1
The most urgent complication is acute urinary retention. The AUA guideline cites Olmsted County data showing an incidence of 6.8 episodes per 1,000 person-years overall, rising to 34.7 per 1,000 person-years in men aged 70 and older with moderate to severe symptoms.3 That is roughly 0.7 percent a year for the average man in the study and about 3.5 percent a year for an older man with significant symptoms.
What helps first, with real evidence
The AUA calls lifestyle and behavioral changes "reasonable first-line treatments for all patients."3 What the guideline and the NIH sources recommend:
- Move fluids earlier. Limit drinks before bed or before a long drive, but spread fluids through the day rather than cutting back overall.2,3 Our guide to the best drinks for an enlarged prostate gets specific.
- Limit caffeine and alcohol, especially after dinner. The AUA describes both as mild diuretics.2,3
- Watch bladder irritants. The AUA mentions highly seasoned or irritating foods.3 See foods to avoid with an enlarged prostate.
- Stay active and manage weight. The AUA lists increased physical activity and weight loss, and the NIDDK names inactivity as a BPH risk factor.1,3 Our article on walking for prostate health looks at the studies.
- Use Kegels and bladder techniques. The AUA mentions Kegel exercises at the moment of urgency, timed voiding and double voiding.3 See Kegel exercises for men over 50.
- Avoid constipation. It is on the AUA's list of straightforward changes.3
- Check your cold and allergy pills. MedlinePlus advises avoiding over-the-counter decongestants and antihistamines.2
Medical treatments, and where supplements fit
A summary of the AUA guideline, not advice. Do not stop or change a prescribed medicine without your doctor.
Alpha blockers
The AUA recommends offering alfuzosin, doxazosin, silodosin, tamsulosin or terazosin for bothersome, moderate to severe symptoms.3 They relax the muscles in the bladder neck and prostate so urine flows more easily.1 Tamsulosin is the generic name of Flomax.15 If you are wondering what could stand in for it, read our natural alternatives to Flomax review first.
5-alpha reductase inhibitors
Finasteride and dutasteride shrink the prostate by about 15 to 25 percent over six months. For symptom relief, the AUA recommends them only for men with a demonstrably enlarged prostate (over 30 g on imaging, PSA above 1.5 ng/mL, or enlargement felt on exam), and it also recommends them to reduce the risk of retention and future surgery.3 Clinicians are told to discuss sexual side effects before starting, and to account for the halved PSA described above.3
Tadalafil
A daily 5 mg dose of tadalafil should be discussed as an option for urinary symptoms, whether or not a man also has erectile dysfunction.3
Procedures
Options range from office-based minimally invasive treatments to surgery. The AUA lists kidney problems, refractory retention, recurrent infections, recurrent bladder stones and persistent bleeding caused by BPH as reasons procedures are considered.3
Supplements: what the evidence shows
No supplement is a treatment for BPH, and none should come first or replace the visit above. Saw palmetto, the most studied ingredient, is "probably not helpful" for BPH symptoms according to the National Center for Complementary and Integrative Health. Two NIH-funded trials, one at up to three times the usual dose, found no improvement.14 The AUA guideline reaches the same conclusion from the STEP and CAMUS trials, and notes that many studies of other ingredients have serious design weaknesses.3
If your checkup is clean and you still want to try something, tell your doctor first so it can be checked against your prescriptions. Our comparisons of saw palmetto vs pygeum, natural remedies graded by evidence and prostate supplements vs medication show what each option has and has not shown. The saw palmetto dosage guide, the beta-sitosterol review and how to read a prostate supplement label cover the rest. Use your IPSS score as the scoreboard: a drop smaller than about 3 points is below what men notice as even a slight improvement.
If your doctor has ruled out the red flags and you still want to try a supplement, check the label first: what is in it, at what dose, and whether that dose matches what the studies used. Our guide shows how to do that with any bottle in about a minute.
A practical plan for this week
- Today: check the red flags above. If any apply, call your doctor today.
- Tonight: take the seven IPSS questions and the bother question. Write down the total and the date.
- This week: move fluids earlier, limit caffeine and alcohol after dinner, walk daily, and check your cold and allergy pills.
- If you wake at night: keep the three-day bladder diary from our nighttime urination guide.
- Book the visit if your score is 8 or more, the symptoms bother you, or something has changed fast. Bring your score, diary and medication list.
- Re-score in 4 to 12 weeks after any change, the AUA's follow-up window after starting treatment.3
Every symptom, explained
Each symptom above has its own in-depth guide, with the causes, the tests and what helps. Pick the one that sounds most like yours.
Understanding your symptoms
Frequently asked questions
What are the first signs of an enlarged prostate?
The first signs are usually small changes in how you urinate: a stream that is weaker or slower to start, needing to go more often, getting up at night, or a few drops of dribbling after you finish. The NIDDK lists trouble starting a stream, a weak or interrupted stream, dribbling at the end, nighttime urination, urgency and frequency as typical BPH symptoms. Because the prostate grows slowly, about 1.6 percent a year on average in one community study, these changes tend to creep up over years.
At what age do enlarged prostate symptoms usually start?
Prostate tissue growth that can be seen under a microscope starts around age 40 to 45, according to the American Urological Association guideline, but symptoms usually show up later. The NIDDK estimates BPH affects 5 to 6 percent of men aged 40 to 64 and 29 to 33 percent of men 65 and older. In a Minnesota community study, 17 percent of men in their fifties, 27 percent in their sixties and 35 percent in their seventies had symptoms and slow enough flow to discuss treatment.
Can an enlarged prostate turn into prostate cancer?
No. The National Cancer Institute states that BPH is not cancer and that an enlarged prostate does not increase a man's risk for prostate cancer. The two can exist at the same time, though, and early prostate cancer usually causes no symptoms at all. That is why urinary symptoms are not a cancer test in either direction, and why PSA screening is a separate conversation to have with your doctor.
What is a normal IPSS score?
The International Prostate Symptom Score adds up seven questions scored 0 to 5, for a total from 0 to 35. A score of 7 or less is classed as mild, 8 to 19 as moderate and 20 to 35 as severe. There is no single normal number, because most men past 45 have some symptoms, but a score of 7 or less falls in the mild band, where a clinician may suggest watchful waiting if the symptoms do not affect your quality of life. A separate quality of life question, scored 0 to 6, captures how much the symptoms bother you.
When are enlarged prostate symptoms an emergency?
Get care right away if you cannot urinate at all, have severe pain or swelling in your lower belly, have fever and chills with painful, urgent urination, see blood in your urine, or notice you are passing much less urine than usual. The NIDDK states that acute urinary retention, the sudden inability to urinate, can be life threatening. Waiting to see if a supplement works is never the right move with any of these signs.
Can cold or allergy medicines make prostate symptoms worse?
They can. MedlinePlus advises men with an enlarged prostate to avoid over-the-counter decongestants and antihistamines. If your stream got noticeably weaker during a cold or allergy season, tell your doctor what you were taking. Bring your full medication list to any appointment about urinary symptoms.
Does saw palmetto help enlarged prostate symptoms?
The best evidence says it is probably not helpful. The National Center for Complementary and Integrative Health reports that two NIH-funded trials, one at the standard dose and one at up to three times that dose, found saw palmetto did not improve BPH symptoms. The American Urological Association guideline notes that the STEP and CAMUS trials found no benefit over placebo for symptoms, flow rate or PSA. Get checked first, and read the evidence before you spend money on any bottle.
Sources
- National Institute of Diabetes and Digestive and Kidney Diseases (NIH). Enlarged Prostate (Benign Prostatic Hyperplasia). Last reviewed June 2024. https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/enlarged-prostate-benign-prostatic-hyperplasia
- MedlinePlus Medical Encyclopedia (NIH National Library of Medicine). Enlarged prostate (BPH). https://medlineplus.gov/ency/article/000381.htm
- American Urological Association. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline (2021, amended 2023), unabridged. https://www.auanet.org/documents/Guidelines/PDF/2023%20Guidelines/BPH%20Unabridged%2002-20-24%20Final.pdf
- National Cancer Institute. Understanding Prostate Changes: A Health Guide for Men. Updated May 8, 2024. https://www.cancer.gov/types/prostate/understanding-prostate-changes
- Centers for Disease Control and Prevention. Symptoms of Prostate Cancer. https://www.cdc.gov/prostate-cancer/symptoms/index.html
- National Institute of Diabetes and Digestive and Kidney Diseases (NIH). Symptoms and Causes of Urinary Retention. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention/symptoms-causes
- Girman CJ, Jacobsen SJ, Guess HA, et al. Natural history of prostatism: relationship among symptoms, prostate volume and peak urinary flow rate. Journal of Urology. 1995;153(5):1510-1515. https://pubmed.ncbi.nlm.nih.gov/7536258/
- Jacobsen SJ, Girman CJ, Guess HA, et al. New diagnostic and treatment guidelines for benign prostatic hyperplasia: potential impact in the United States. Archives of Internal Medicine. 1995;155(5):477-481. https://pubmed.ncbi.nlm.nih.gov/7532392/
- Jacobsen SJ, Girman CJ, Guess HA, et al. Do prostate size and urinary flow rates predict health care-seeking behavior for urinary symptoms in men? Urology. 1995;45(1):64-69. https://pubmed.ncbi.nlm.nih.gov/7529448/
- Rhodes T, Girman CJ, Jacobsen SJ, et al. Longitudinal prostate growth rates during 5 years in randomly selected community men 40 to 79 years old. Journal of Urology. 1999;161(4):1174-1179. https://pubmed.ncbi.nlm.nih.gov/10081864/
- Barry MJ, Fowler FJ Jr, O'Leary MP, et al. The American Urological Association symptom index for benign prostatic hyperplasia. Journal of Urology. 1992;148(5):1549-1557. https://pubmed.ncbi.nlm.nih.gov/1279218/
- UCLA Health. International Prostate Symptom Score (I-PSS) patient form, with scoring. https://www.uclahealth.org/sites/default/files/documents/Prostate-EPIC-Symptom-Questionnaire.pdf
- US Preventive Services Task Force. Prostate Cancer: Screening. Final recommendation, May 8, 2018 (update in progress). https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening
- National Center for Complementary and Integrative Health (NIH). Saw Palmetto: Usefulness and Safety. https://www.nccih.nih.gov/health/saw-palmetto
- MedlinePlus (NIH National Library of Medicine). Tamsulosin: Drug Information. https://medlineplus.gov/druginfo/meds/a698012.html