Getting Up at Night to Pass Urine? What an Enlarged Prostate Actually Means

Most men over 50 notice it gradually. The stream is weaker than it was. It takes a few seconds to start. You get up once a night, then twice. You finish, and a minute later it feels like you did not quite finish.

This is usually an enlarged prostate, and the first thing worth saying is the thing most men are actually afraid of: an enlarged prostate is not cancer, and it does not turn into cancer. They are two different conditions that happen to involve the same gland.

Urology consultation ₹1,000 with Dr. Irsad Ali, MCh Urology. Clinic open 8 am to 9 pm, Monday to Saturday. Call 8800844793.

What is actually happening

The prostate sits below the bladder, and the tube you pass urine through runs straight through the middle of it. From about the age of 40 the gland slowly grows. When it grows inward, it squeezes that tube.

So the symptoms are mechanical, not mysterious. A narrower pipe gives a weaker stream. A bladder that has to push harder becomes thicker and more irritable, which is why urgency and night-time trips often arrive before the weak stream does.

The medical name is benign prostatic hyperplasia — BPH. The word in the middle, benign, is the important one.

The symptoms, in the order men usually notice them

• Getting up at night to pass urine, once or more

• A weaker stream than you remember

• Waiting a few seconds for it to start

• Stopping and starting mid-stream

• Feeling you have not emptied completely

• Needing to go again soon after going

• A sudden urge that is hard to put off

You can score this yourself before you see anyone. The International Prostate Symptom Score is a seven-question form used by urologists worldwide, it takes two minutes, and it turns a vague complaint into a number between 0 and 35. Bring the score with you. It makes the consultation faster and it gives you something to compare against in six months.

Broadly: 0–7 is mild, 8–19 is moderate, 20–35 is severe.

It is not prostate cancer

This deserves its own section because it is what keeps men out of the clinic.

An enlarged prostate and prostate cancer are different diseases. Having one does not cause the other, and does not protect you from the other either. They can both be present in the same man, which is precisely why the point of seeing someone is to sort out which you are dealing with rather than to assume.

Early prostate cancer usually causes no symptoms at all. So the man with a weak stream is not the man most at risk — he is simply the man who has a reason to come in and get checked. That is a good thing, not a frightening one.

What we are not going to tell you

Walk into any pharmacy and you will be offered a prostate supplement. Saw palmetto is the common one, usually sold at a price that suggests it works.

The two largest trials both found it no better than placebo.

The STEP trial, published in the New England Journal of Medicine in 2006, randomised 225 men with moderate to severe symptoms to saw palmetto or placebo for a year. Neither symptom scores nor urine flow rates differed meaningfully.

The CAMUS trial, published in JAMA in 2011, tested whether the problem was simply the dose. It took 369 men and escalated from 320 mg to 640 mg to 960 mg a day over 18 months. At three times the usual dose, still no better than placebo.

It appears to be safe. It just does not appear to do anything. We are not going to sell it to you, and we would rather you spent the money on the consultation.

When this needs seeing quickly

Go to a hospital emergency department the same day if you suddenly cannot pass urine at all despite a full and painful bladder. This is acute retention, it is the one genuine emergency in this condition, and it needs a catheter rather than an appointment.

Make an appointment soon, rather than eventually, if you have:

• Blood in the urine

• Repeated urine infections

• Pain passing urine that keeps coming back

• Dribbling or leaking you did not have before

• Symptoms that have changed quickly over weeks rather than slowly over years

Slow change over years is the usual pattern. Fast change is worth a look.

The tests, and what they cost

Urology consultation ₹1,000

PSA (total) ₹760

Ultrasound, single-part abdomen ₹640

Ultrasound, whole abdomen ₹1,200

A first visit usually involves your symptom score, an examination including a prostate examination, a PSA blood test, and an ultrasound to look at the prostate size and — importantly — how much urine is left behind after you pass it. That last measurement, the post-void residual, often matters more than the size of the gland itself.

Free home sample collection is available for the blood test.

The PSA trap worth knowing about

If you are already taking finasteride or dutasteride — for the prostate, or for hair loss — tell whoever orders your PSA.

These drugs lower the PSA reading by roughly half after six to twelve months. A result that looks reassuringly normal may not be. The convention is to double the measured value before comparing it against the usual range.

A man on finasteride for hair loss, with a PSA of 2.5, is really being told 5.0. Nobody can interpret that correctly if they do not know he is taking it. This is one of the most common avoidable errors in men's health, and it costs nothing to avoid — just say what you are taking.

What treatment actually looks like

Mild symptoms often need no treatment at all. If your score is low and you are not bothered, watchful waiting with a yearly review is a legitimate plan, not a fobbing-off. Cutting fluids in the evening, cutting caffeine and alcohol after dinner, and emptying fully before bed will solve a surprising number of night-time problems on their own.

Medicines are the usual next step. One group relaxes the muscle around the outlet and works within days. Another group slowly shrinks the gland over several months, and is more useful where the prostate is genuinely large. Sometimes both are used together. Both have side effects worth discussing before you start, including an effect on ejaculation that men should be told about rather than discover.

Surgery is for symptoms that medicines have not controlled, or for complications — retention, recurrent infection, bladder stones, or an effect on the kidneys. The two common operations are TURP, which has been the standard for decades, and HoLEP, a laser enucleation that suits larger glands and generally involves less bleeding. Dr. Ali performs both.

Surgery is not done at the clinic. Where an operation is needed, it is carried out at hospital, and your follow-up comes back here.

Frequently asked questions

Does an enlarged prostate mean I will get prostate cancer?

No. They are separate conditions. Having one neither causes nor prevents the other.

Is the prostate examination as bad as people say?

It takes a few seconds, it is uncomfortable rather than painful, and it tells the doctor things no blood test can. Most men are surprised by how brief it is. Avoiding it for years is the more uncomfortable option.

Can I just take medicine without being examined?

Not sensibly. The medicines for this are prescription drugs with real side effects, and more importantly, the symptoms of an enlarged prostate overlap with several other conditions — including a stricture, a stone and an overactive bladder — which need completely different treatment. Treating the wrong thing wastes months.

Will I definitely need surgery eventually?

No. Many men are managed on medicines indefinitely, and some need nothing at all. Surgery is a decision made when symptoms or complications call for it, not an inevitability.

I am 45 and already getting up at night. Is that too young?

It is early but not unheard of, and it is a reason to be assessed rather than to wait. Getting up at night also has causes that have nothing to do with the prostate, including diabetes, heart failure and sleep apnoea. That is part of why it is worth a proper look.

Does cycling or spicy food cause it?

No. Age and hormones drive it. Spicy food and alcohol can irritate the bladder and make existing symptoms more noticeable, which is not the same as causing the condition.

Book an appointment

All Is Well Medical Centre

Shop no. 1, Central Market, Sector B Rd, opposite Vasant Square Mall, Masoodpur, Sector B, Vasant Kunj, New Delhi 110070

Phone: 8800844793 Open Monday to Saturday, 8:00 AM to 9:00 PM

Urology — Dr. Irsad Ali, MBBS, MS (General Surgery), MCh (Urology), NIMS Hyderabad. Consultation ₹1,000.

Medically reviewed by Dr. Irsad Ali, MBBS, MS (General Surgery), MCh (Urology).

This article is general information and is not a substitute for a consultation. If you are unwell, please see a doctor.

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