Testosterone and the bulging prostate

Dear Dr G,

I am emailing you about a strange problem that my husband has been experiencing since he turned 50.

He is usually a healthy chap who exercises and watches his diet regularly.

My husband and I both have a very strong libido, which I often guess must derive from high levels of testosterone from his healthy lifestyle.

Shortly after his fiftieth birthday, my husband started waking up at night to urinate. Judging from the time it takes for him to urinate, I think he is struggling with the stream.

Apart from putting up with his night time urination which wakes me up too, I am immensely annoyed that he is spraying urine all over the toilet seat.

Despite having a strong appetite for sex, my husband is sadly also having difficulty maintaining firm erection during sex now.

I asked him to pay the doctor a visit, and the Urologist reckoned he has Benign Prostatic Hyperplasia (BPH).

I am curious to put Dr G on the spot for some answers.

What exactly is prostate BPH and how does it affect the urinary flow?

I read somewhere prostate size is affected by high levels of testosterone, is there a direct correlation of levels of testosterone and prostate enlargement?

Shouldn’t high testosterone induce a better erection?

How does prostate enlargement cause Erectile Dysfunction?

Yours truly,

Confused Claudia

The prostate is a walnut size organ in the pelvis which starts small at birth (1.5g) and remains so throughout childhood.

During early puberty, the prostate becomes active in producing ejaculate and increases 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 older than 80 years.

The aetiology of this growth is unknown and pathologically recognized as Benign Prostatic Hyperplasia (BPH) and clinically noted as Benign Prostatic Enlargement (BPE) inducing Bladder Outlet Obstruction (BOO).

Benign Prostate Hyperplasia (BPH) commonly affects men with advancing age.

The gradual overgrowth results in the compression of the urethra causing BOO, leading to various urinary symptoms.

These include poor urinary flow, hesitancy in initiation, dribbling and straining at the end of void. In addition, the post-void residual urine also result in day and night time frequency of urination.

When the symptoms become worse, it can also cause urgency and urge incontinence.

Scientists have known of testosterone's importance in prostate development and pathology, but the exact cause and effects of this non-cancerous enlargement is largely unknown. It is often noted men who are castrated do not experience problems associated with BPH.

However, serum testosterone has also been shown to decrease in men with age by approximately 2%–3% annually.

The process of BPH, however, continues as men age and despite the fact their serum testosterone decreases. On the other hand, some men also do not encounter problems of BPH despite Testosterone replacement therapy.

In fact, many studies have demonstrated there was not a significant correlation of serum testosterone levels with BPH in many individuals.

The real hormonal changes responsible for BPH is due to 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.

Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.

The prostate enlargement exerts pressure on the urethra also disrupt normal blood flow.

The blood vessels responsible for engorging the penis during sexual arousal impeded, leading to difficulties in achieving and maintaining an erection.

While BPH itself does not directly cause erectile dysfunction (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 erectile dysfunction, lifestyle modifications, 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 the common medications that can resolve both issues at the same time, effectively killing two birds with one stone.

BPH is a complex condition influenced by multiple factors, rather than testosterone levels itself.

While the connection between testosterone and BPH remains somewhat elusive, research continues to shed light on the mechanisms at play.

Having knowledge of the pathogenesis and effective treatment strategies allowing men to take proactive steps to maintain overall health and enjoying a fulfilling sex life, despite the ageing prostate.

When men facing experiencing problems withs bulging prostate and dwindling testosterone put Dr G on the spot for a solution, all that needs to be said is that there is such a thing as ageing BPH and despite the dwindling testosterone, knowledge of the treatment strategies can potentially fill two needs with one deed!