The prostate after 40: what's normal, what's treatable and when to see a doctor

You have to get up at night to pee. The stream is weaker, and afterwards it feels like you haven't fully emptied. The worrying thought — "what if it's cancer?". Almost always it's something else — common, benign and very treatable.

What's happening

With age, the prostate gets bigger in almost all men. This is benign enlargement (BPH), and on its own it isn't a disease. It needs treatment when the symptoms bother you, get in the way of life or threaten the bladder and kidneys.

Symptoms come in two kinds:

• storage — often, urgently, getting up at night;
• voiding — a weak stream, straining, a stop-start flow, not emptying fully.

It's not cancer

Urinary symptoms almost always come from benign enlargement, while early prostate cancer usually causes no symptoms. So "having symptoms" doesn't mean "cancer", and "no symptoms" doesn't mean "safe". Benign enlargement doesn't raise the risk of cancer.

Getting up at night — not always the prostate

If you get up more than twice a night, and you also snore and feel sleepy during the day, the cause may be sleep apnea. More in the article "Sleep after 40".

What works — about as strong as medicines

The strength is in combining the steps, not in any single one:

• drink less in the evening and before bed;
• less coffee — it makes urgency and frequency worse;
• an evening without alcohol;
• go to the toilet on a schedule, "double voiding" — wait and try once more;
• pelvic floor exercises.

Your waist. Extra fat around the waist and a poor response to sugar push the prostate to grow. Reducing your waist is the most powerful goal.

What about "prostate" supplements?

• Saw palmetto is the best-selling supplement, but in rigorous studies it's no better than a placebo.
• Beta-sitosterol, pygeum, pumpkin seed oil, nettle — old, small studies that haven't been repeated.
• Vitamin E raised the risk of prostate cancer in the largest trial. Selenium has no benefit and is harmful for those who already get enough. High doses of zinc over a long time are linked to dangerous forms of cancer.

"Prostate complexes" are often made of exactly these. The main danger is lost time before real help.

What a doctor can offer

There are tablets that quickly ease urination and tablets that shrink the prostate. The second kind has two important points: they lower PSA by about half (your doctor needs to take this into account), and they can lower mood — tell your doctor straight away if that happens. There's one medicine that helps both the prostate and erections, but it must not be combined with nitrates. You choose with a urologist, based on your priorities.

PSA — a personal decision

PSA is tested after a conversation with a doctor: there's a benefit, but a small one, and plenty of unnecessary biopsies and worry. PSA is also raised by causes that aren't cancer: an enlarged prostate, inflammation, recent ejaculation. If prostate cancer runs in your family or you're of African descent — discuss it earlier.

Be careful with cold medicines

"Blocked nose" remedies with pseudoephedrine or phenylephrine and "night-time" tablets with diphenhydramine can cause urinary retention. Newer allergy medicines are safer.

When to see a doctor — urgently

• You can't pee — this is an emergency.
• Blood in the urine, even once.
• Repeated urinary tract infections.
• Pain in the bones or back together with weight loss.
• Numbness in the groin or weakness in the legs.
• Pain in the groin, pelvis or during ejaculation — this isn't an enlarged prostate and needs a separate assessment.

What to try this week

• Your last big glass of liquid — 2–3 hours before bed.
• Coffee only in the morning, an evening without alcohol.
• A few minutes of pelvic floor exercises every day.

This is general information, not a prescription. Tests and treatment are chosen by a doctor.