Prostate Problems and Urinary Symptoms in Older Men

What the prostate does and why it grows

The prostate produces fluid that nourishes sperm. From about forty onwards, it tends to grow slowly, driven by hormones and ageing. By seventy or eighty, a large share of men have an enlarged prostate, though only some have bothersome symptoms. The size of the gland does not always match the severity of symptoms.

Lower urinary tract symptoms (LUTS)

Doctors group urinary symptoms into three types.

Voiding (emptying) symptoms - Weak or slow stream. - Hesitancy: waiting for the stream to start. - Straining to pass urine. - Intermittent flow: stopping and starting. - Terminal dribbling: leaking after finishing. - A feeling of incomplete emptying.

Storage symptoms - Frequency: passing urine many times in the day. - Nocturia: waking at night to pass urine, once or more. - Urgency: a sudden, strong need, sometimes with leakage. - Urge incontinence.

Post-micturition symptoms: dribbling or a "left-behind" feeling.

These symptoms are called "lower urinary tract symptoms," and they are not specific to the prostate. See incontinence in older adults: causes and types.

Other causes of similar symptoms

• Urinary infection, prostatitis, bladder inflammation; see urinary tract infections in older adults: atypical signs.
• Constipation, which presses on the bladder; see constipation in older adults: fibre, fluids and movement.
• Diabetes, with high sugar causing more urine, and nerve damage affecting the bladder; see diabetes after 60: a home care guide.
• Medicines: some water tablets, some cold and allergy tablets, some sedatives, painkillers, antidepressants and muscle relaxants can cause retention or increase urine; do not stop any yourself; ask the doctor; see medicine side effects families should watch for.
• Heart failure, kidney disease, swollen legs, causing high night urine; see heart failure at home: daily checks and warning signs.
• Sleep apnoea; see sleep apnoea in older adults: signs and next steps.
• Urethral narrowing (stricture), bladder stones, bladder tumours, prostate cancer.
• Nerve problems: stroke, Parkinson's disease, spinal problems, diabetes.
• Caffeine, alcohol and large evening drinks.
• Anxiety and poor sleep.

Home habits that help

These do not replace assessment, but they often ease symptoms.

• Keep a bladder diary for three days: drinks, times and amounts of urine, night visits, leaks, urgency. It shows the pattern and helps the doctor; see bladder training and timed toileting.
• Do not cut fluids overall; dehydration worsens symptoms and infections; spread drinks through the day and reduce them gradually in the two to three hours before bed if the doctor agrees; see hydration for older adults: how much and how to remember.
• Reduce caffeine, fizzy drinks and alcohol, especially in the evening.
• Take time to empty: sit on the toilet if standing is difficult, relax, wait a moment and try again after a minute ("double voiding").
• Avoid delaying urination for long periods.
• Treat constipation.
• Keep warm; cold can increase urgency.
• Keep active, and manage weight.
• Review medicines with the doctor.
• Pelvic floor exercises may help dribbling after urination; see pelvic floor exercises for older adults.
• Make the toilet safe and close: night lights, grab rails, a raised seat; see motion night lights for seniors and raised toilet seat guide.
• Use a urinal or commode at night to reduce falls; see urinals for men and women: bedside use and commode chair guide.
• Use pads or pull-ups for dribbling or urgency as a safety net, while seeking treatment; see pull-ups or briefs: choosing the right product and choosing incontinence products by situation.
• Avoid unproven herbal and "prostate" supplements without advice; some interact with medicines; see supplements and medicine interactions: a safety guide.

Night-time problems and falls

Getting up several times a night is a major cause of falls and fractures in older men. See managing incontinence at night and night-time toilet trips and falls. Practical steps: sit on the bed edge for a minute before standing; keep a light on; clear the path; wear non-slip footwear; and consider a bedside urinal.

How doctors assess

A visit usually includes:

• History: symptoms, their effect on life, medicines, other illnesses, fluid habits. A symptom score questionnaire (such as the International Prostate Symptom Score) may be used.
• Bladder diary.
• Examination: abdomen (for a full bladder) and a gentle rectal examination to feel the prostate, done with consent and privacy.
• Urine test for infection or blood.
• Blood tests: kidney function, sugar and sometimes PSA (prostate-specific antigen).
• Ultrasound to check how well the bladder empties and the kidneys.
• Flow test (uroflowmetry), and in some cases further tests such as cystoscopy or urodynamics, by a urologist.

PSA: a decision to discuss

PSA is a protein made by the prostate that can rise in BPH, infection, after catheterisation or exercise, and in prostate cancer. A raised PSA does not mean cancer, and a normal PSA does not exclude it. Routine screening of all men is debated worldwide because it can lead to overdiagnosis and overtreatment of slow-growing cancers, but it may help some men, especially those with symptoms, a family history or a good general health and longer life expectancy. The decision to test should be shared between the man and his doctor, with an explanation of the benefits, limits and possible follow-up. Do not be pressured into or away from a test; ask the questions that matter to your father.

Treatment options, in general terms

The doctor chooses based on symptoms, bother, prostate size, other health problems and the person's wishes.

• Watchful waiting with lifestyle advice for mild symptoms.
• Medicines of different types may be offered to relax the bladder neck and prostate muscle, to shrink the prostate, or to calm an overactive bladder; each has side effects, such as dizziness, low blood pressure on standing, sexual side effects or dry mouth, and some interact with other medicines. Do not start, stop or share any of them without the doctor. Dizziness with medicines raises the fall risk; see dizziness when standing: postural hypotension in older adults.
• Minimally invasive procedures and surgery to remove or reduce prostate tissue for severe symptoms, retention, recurrent infections, bladder stones or kidney problems.
• Catheters: a short-term catheter may be used to relieve retention; long-term catheters are an option for those unfit for surgery; see catheter care basics for families.
• Prostate cancer, if found, is managed by specialists with a range of options including active surveillance, depending on age, health and cancer type.

Urinary retention: know the signs

Acute retention: sudden inability to pass urine, with a painful, swollen lower abdomen, restlessness, sweating and an urge to pass urine that cannot be satisfied. This is an emergency: go to the hospital at once or call 112. A catheter is needed to drain the bladder.

Chronic retention: the bladder never empties fully, causing frequent small passes, dribbling, a distended lower abdomen, repeated infections, confusion, tiredness, swollen legs and kidney damage. It may be painless. See a doctor promptly.

Other red flags

Seek urgent help (call 112 or go to hospital) for: - Inability to pass urine, with pain or a swollen lower abdomen. - Fever with chills, shaking, back or loin pain, or confusion with urinary symptoms (possible kidney infection or sepsis); see fever in older adults: why it can be subtle and when to call. - Heavy bleeding in the urine with clots. - Sudden leg weakness or numbness with loss of bladder or bowel control (possible spinal compression). - Severe pain in the testicle or lower abdomen.

See a doctor within days for: - Blood in the urine, even once. - Burning or pain on passing urine. - New or worsening leakage, frequent infections. - Pain in the bones or back, unexplained weight loss, tiredness. - Persistent difficulty or a dramatic change in stream. - Erectile or ejaculatory changes that worry him.

See when to see a doctor about bladder or bowel changes.

Emotional side

Many men are embarrassed to discuss urination and sexual side effects, and may delay seeing a doctor for years. Approach the subject kindly, offer to go along, and let the doctor see him alone if he prefers; see talking about incontinence with a parent without shame and intimacy and sexual health in later life. Watch for low mood, anxiety and withdrawal from social events because of toilet worries; see depression in older adults.

When to ask a professional

See the family doctor or a urologist for any bothersome or new urinary symptom, blood in the urine, recurrent infections or a decision about PSA. Ask a pharmacist about medicines that affect urination. Ask a continence nurse about products and routines. Seek emergency care for retention, sepsis signs or heavy bleeding; call 112.