Updated: Mar 23, 2021

Dear Dr. K, I’m getting up two to three times a night to pee and the loss of sleep is killing me. What can I do?

Nightly trips to the bathroom to urinate are one of the symptoms of an enlarged prostate or benign prostatic hyperplasia (BPH). Other symptoms include:

  • Frequent or urgent need to urinate

  • Needing to get up a night to urinate-nocturia

  • Urinary hesitancy-you need to stand there for a while before things start to flow

  • Weak stream

  • Dribbling after urination

  • Incomplete emptying of the bladder-feeling like you need to go again

More severe symptoms of BPH are urinary tract infections, bleeding, and urinary blockage.


The prostate is a walnut-sized gland that sits right below the urinary bladder. The urethra (the tube that the urine and semen pass through) goes through the middle of the prostate. If the prostate enlarges it can shut down the flow of urine.

The prostate secretes fluid that mix with the sperm and other fluids to facilitate their passage through the urethra.

The prostate often continues to grow throughout a man’s lifetime. This enlargement can lead to diminished urine flow, even total blockage which requires urgent attention. The cause for this continued growth is unclear. It may be related to a hormone imbalance. One theory is that there is a reversal of the ratio of testosterone and estrogen. (Yes, believe it or not, a man does produce estrogen. I cover that in another blog.) However, its size does not necessarily indicate whether it will cause symptoms. Some men with extremely large prostates have no symptoms, while someone with minimal enlargement will have pronounced symptoms.


Obviously, the primary risk factor is aging. Family history of BPH in close male relatives-father, brothers, uncles-increase the chance of your developing BPH. Medical conditions such as diabetes or heart disease as well as being overweight lead to an increased risk of BPH. Low testosterone levels may also be a factor. DHT (dihydrotestosterone) is also thought to be a causative factor. DHT is produced in the prostate by the conversion of testosterone by an enzyme contained in the cells of the prostate.


The symptoms are usually the first indication that you have BPH. Talk with your doctor about your symptoms. Your doctor will do a digital rectal exam to assess the size of your prostate. This also allows him to check for tenderness or lumps in your prostate. Blood and urine tests will be done to rule out other issues that may mimic BPH. Other tests to evaluate your urine flow and bladder functioning may be done. A cystoscopic exam during which a thin tube attached to a camera is inserted into the penis to examine the bladder and prostate may also be indicated to establish the diagnosis.


Okay so I have BPH. How is it treated?

Treatment will be based on the severity of your symptoms.

The first step in treatment is usually medications. Some of the more common remedies are natural factors derived from plants. The most common is saw palmetto, but there are numerous compounds that are being advertised on TV, on the internet, and in magazines.

The prescription medications can be grouped into two main categories: alpha blockers and 5-alpha reductase blockers. Alpha blockers act by relaxing the muscles in the bladder neck and in the prostate, making urination easier. 5-alpha reductase blockers inhibit the conversion of testosterone to DHT which can cause the cells of the prostate to enlarge. Both of these groups have some side effects and both can cause retrograde ejaculation which is when the semen flows backward into the bladder instead of out the tip of the penis. Cialis, used to treat erectile dysfunction, has also been shown to be effective for BPH symptoms.

In more advanced instances, surgery is needed to provide relief of the symptoms. Typically the surgery involves enlarging the passage through the prostate. This can be done using several different modalities from conventional resection through a scope placed in the penis to resection using laser, infrared, freezing methods. A newer procedure uses a technique to compress the prostate with the placement of special tags through the walls of the prostate.

Low intensity Shock Wave Therapy (LiSWT) offers a non-invasive treatment that can reduce or eliminate the symptoms of BPH. This treatment uses pulsed energy waves to stimulate cellular repair and tissue regeneration. The energy waves are applied directly to the skin overlying the prostate area and to the base of the penis. This has the added benefit of treating ED symptoms.



I am going to deviate from my usual postings and relate my personal experience with BPH. In 2017 I was involved in some pretty intense weight training and diet and fluid manipulation to prepare for a body building competition. After the contest I noticed an increased need to urinate, especially at night. My urologist diagnosed prostatitis and treated me but my symptoms did not resolve. Eventually I wound up needing a laser resection of the enlarged prostate tissue. After several months my symptoms returned. I tried all the usual remedies to no avail. About four months ago I started receiving LiSWT treatment for this. Within the first month I noticed a decrease in the number of times I was getting up at night and going less frequently during the day. Now I am able to sleep all night and need to urinate less often in the day. (By the way, I won first place in my age category-50 and over.)