Prostate Health Guide: BPH, PSA Screening, and When to Actually Worry

Your prostate is a walnut-sized gland at the base of your bladder that you'll never think about until it starts causing problems. And at some point, it almost certainly will. By age 60, approximately 50% of men have benign prostatic hyperplasia (BPH). By age 85, that number reaches 90%. Meanwhile, prostate cancer is the second most common cancer in American men.

The challenge is separating the common and annoying (BPH) from the rare and dangerous (aggressive prostate cancer) from the common and debatable (low-grade prostate cancer that may never need treatment). This guide breaks down what you need to know.

BPH: The Enlarged Prostate

Benign prostatic hyperplasia is non-cancerous growth of the prostate gland. As the prostate enlarges, it compresses the urethra (which runs through the center of the prostate), obstructing urine flow.

Symptoms

The International Prostate Symptom Score (IPSS) categorizes BPH symptoms into two groups:

Storage symptoms:

• Frequency — urinating more than 8 times in 24 hours
• Urgency — sudden, compelling need to urinate
• Nocturia — waking 2 or more times at night to urinate
• Urge incontinence — leaking before reaching the toilet

Voiding symptoms:

• Weak stream
• Hesitancy — difficulty starting urination
• Intermittency — stream stops and starts
• Straining to urinate
• Incomplete emptying — feeling like the bladder isn't empty after urinating
• Post-void dribbling

When to Treat

Not all BPH needs treatment. Mild symptoms that don't significantly impact quality of life can be monitored with "watchful waiting" — annual reassessment without medication.

Treatment is appropriate when symptoms affect quality of life, disrupt sleep, or create complications (urinary retention, recurrent UTIs, bladder stones, or kidney damage from back-pressure).

Medication Options

Alpha-blockers (first-line for moderate symptoms):

• Tamsulosin (Flomax) — most commonly prescribed, prostate-selective
• Alfuzosin (Uroxatral) — well-tolerated
• Silodosin (Rapaflo) — most prostate-selective, fewer blood pressure effects
• Doxazosin, terazosin — older, less selective, more blood pressure effects

How they work: Relax smooth muscle in the prostate and bladder neck, improving urine flow within days to weeks. They don't shrink the prostate.

Side effects: Orthostatic hypotension (dizziness when standing), retrograde ejaculation (semen goes into the bladder instead of out — harmless but noticed), nasal congestion.

5-alpha reductase inhibitors (for larger prostates):

• Finasteride (Proscar) — 5mg daily
• Dutasteride (Avodart) — 0.5mg daily

How they work: Block conversion of testosterone to dihydrotestosterone (DHT), which drives prostate growth. Actually shrink the prostate by 20-30% over 6-12 months.

Side effects: Decreased libido (2-6%), erectile dysfunction (3-5%), decreased ejaculate volume, breast tenderness. These side effects resolve in most men after discontinuation. Finasteride reduces PSA by approximately 50% — your doctor must account for this when interpreting PSA results.

Combination therapy: Alpha-blocker + 5-alpha reductase inhibitor is more effective than either alone for men with large prostates and significant symptoms. The MTOPS and CombAT trials showed combination therapy reduced progression and need for surgery.

Tadalafil (Cialis) 5mg daily: FDA-approved for both BPH and erectile dysfunction. Relaxes smooth muscle in the prostate and bladder. A convenient option for men with both conditions.

Anticholinergics/beta-3 agonists: For men with predominantly storage symptoms (urgency, frequency) when alpha-blockers aren't sufficient. Mirabegron (Myrbetriq) is commonly used.

Surgical Options (When Medications Fail)

• TURP (transurethral resection of the prostate) — The gold standard surgical treatment. Effective but carries risks of retrograde ejaculation (75%), bleeding, and erectile dysfunction (5-10%).
• UroLift — Implants that hold open the prostatic urethra. Minimally invasive, preserves sexual function. Best for moderate-sized prostates.
• Rezum (water vapor therapy) — Steam injections that shrink prostate tissue. Office procedure with preservation of ejaculatory function.
• GreenLight laser — Vaporizes prostate tissue with good outcomes and less bleeding than TURP.
• Aquablation — Robotic, water-jet-based tissue removal guided by ultrasound. Preserves ejaculatory function better than TURP.

PSA Screening: The Nuanced Conversation

PSA (prostate-specific antigen) screening for prostate cancer is arguably the most debated topic in preventive medicine. Here's the current evidence and guidelines:

What PSA Is

PSA is a protein produced by both normal and cancerous prostate cells. It's not a cancer marker — it's a prostate marker. PSA can be elevated by:

• Prostate cancer
• BPH (enlarged prostate)
• Prostatitis (inflammation/infection)
• Recent ejaculation
• Vigorous exercise (especially cycling)
• Prostate biopsy or procedures
• Age (PSA naturally rises with age)

Current Screening Guidelines (2026)

USPSTF: Shared decision-making for men aged 55-69. The decision should be individualized. Against routine screening for men 70 and older.

American Urological Association: Shared decision-making starting at age 55 for average-risk men. Consider earlier screening (age 40-55) for high-risk men — African American men, men with first-degree relatives with prostate cancer, and men with BRCA2 mutations.

American Cancer Society: Discussion about screening starting at age 50 for average-risk men; age 40-45 for high-risk men.

The Screening Dilemma

Arguments for screening:

• Catches some aggressive cancers early, when treatment is most effective
• Prostate cancer mortality has declined since PSA screening was introduced
• Appropriate for high-risk men

Arguments for caution:

• High false-positive rate — most elevated PSAs are NOT cancer (only 25-30% of men with elevated PSA who undergo biopsy have cancer)
• Overdiagnosis — many prostate cancers are indolent (slow-growing) and would never cause symptoms or death. Detecting and treating these cancers causes harm without benefit.
• Treatment side effects — surgery and radiation can cause incontinence and erectile dysfunction
• Biopsy risks — pain, bleeding, infection

What an Elevated PSA Means

If your PSA is elevated, don't panic. The next steps depend on the level and context:

• PSA 4-10 ng/mL — The "gray zone." Only about 25% of these men have cancer on biopsy. Additional testing can refine the risk:

- Free PSA percentage — low free PSA (<25%) suggests higher cancer risk

- PSA density — PSA divided by prostate volume (from ultrasound)

- 4Kscore or PHI (Prostate Health Index) — blood tests that better differentiate cancer from BPH

- MRI of the prostate — can identify suspicious areas for targeted biopsy

• PSA >10 ng/mL — Higher probability of cancer. Biopsy typically recommended.
• PSA velocity — A rapid rise (>0.75 ng/mL per year) is concerning regardless of absolute level.
• Age-adjusted ranges — A PSA of 4.0 is more concerning in a 50-year-old than an 80-year-old.

At CORAL, Dr. Kim discusses PSA screening with patients using a shared decision-making approach — explaining the benefits, limitations, and potential consequences so you can make an informed choice rather than having a screening test done automatically without understanding what it means.

When to See a Urologist

Referral to urology is appropriate for:

• PSA elevation that warrants biopsy after risk stratification
• BPH symptoms that don't respond to medication
• Urinary retention (inability to urinate)
• Hematuria (blood in urine) — always needs evaluation
• Recurrent UTIs in men
• Abnormal digital rectal exam
• Consideration for surgical BPH treatment

Prostate Health Basics

Some lifestyle factors may support prostate health:

• Diet — Mediterranean diet patterns, lycopene (tomatoes), cruciferous vegetables. Evidence is associational, not definitive.
• Exercise — Regular physical activity is associated with lower prostate cancer risk and better BPH outcomes.
• Healthy weight — Obesity is associated with more aggressive prostate cancer.
• Avoid excess supplementation — The SELECT trial showed selenium and vitamin E supplementation did NOT prevent prostate cancer and may slightly increase risk.

If you're experiencing urinary symptoms, have questions about PSA screening, or want a prostate health evaluation, [start a visit at coral.clinic/start](https://coral.clinic/start). Dr. Kim provides evidence-based prostate health management and can help you navigate the screening decisions that matter for your specific risk profile.