The Prostate Paradox: Why Some Men Suffer and Others Don't

Men come to me with the same question, phrased in slightly different ways. Usually after their mate mentioned something at the pub, or after their brother started getting up three times a night. "My PSA's gone up a bit. Should I be worried?" Or: "I'm fifty-eight. Is this just how it is now?"

The strange thing about prostate enlargement - benign prostatic hyperplasia, or BPH for short - isn't that it happens. It's that it happens to almost everyone, but only bothers some people. By the time men hit their seventies, nearly all of them have an enlarged prostate if you look at it under a microscope. But only about half actually notice it affecting their life.

Which raises an uncomfortable question: what's the difference between the men who end up struggling to pee and the ones who don't?

Size Isn't Everything (Actually)

Here's where medicine gets counterintuitive. You'd assume that a bigger prostate means worse symptoms. Logical enough. But when researchers actually measured prostate size against symptom severity, the correlation was modest at best. Some men with prostates the size of golf balls barely notice. Others with minimal enlargement are miserable.

The problem isn't just growth. It's where that growth happens, how the tissue responds, and what's happening in the surrounding structures. The prostate sits wrapped around the urethra - the tube carrying urine from the bladder. When the inner zone of the prostate enlarges (what we call the transitional zone), it compresses that tube directly. Even a small amount of growth there can cause significant obstruction. Meanwhile, the outer zones can balloon without causing much trouble at all.

But there's more going on than just mechanical squeezing.

The Bladder's Response: A Muscle Under Pressure

When your prostate starts obstructing urine flow, your bladder doesn't just accept it passively. It fights back. The bladder is essentially a smooth muscle - the detrusor muscle, if we're being specific - that contracts to push urine out. When it meets resistance from prostate compression, it responds the same way any muscle does under chronic strain: it gets bigger and stronger.

This is bladder hypertrophy - a thickening of the bladder wall. At first, this compensation works reasonably well. The bladder generates more force, and you still manage to empty it, even if the stream is weaker. But over time, that thickened muscle becomes less elastic. The bladder can't expand as easily to hold urine, which means you feel the urge to go more frequently. The muscle also becomes irritable - more prone to involuntary contractions that create sudden, intense urges.

Eventually, if the obstruction is severe enough, the bladder muscle starts to fail. It becomes overstretched, weak, unable to contract effectively. Urine pools in the bladder after you finish peeing (what we call post-void residual), creating a breeding ground for infection and potentially damaging the kidneys if it backs up far enough.

This is why early intervention matters. Once the bladder remodels itself - once those structural changes set in - they're harder to reverse, even if you later reduce the obstruction.

Why Symptoms Fluctuate: The Role of Tone

BPH symptoms aren't constant. Most men notice they're worse at certain times: first thing in the morning, after sitting for long periods, after a couple of drinks, when they're stressed. This variability isn't just psychological. It has to do with smooth muscle tone.

The prostate and bladder neck contain alpha-1 adrenergic receptors - proteins that respond to adrenaline and noradrenaline. When these receptors are activated (by stress, cold weather, certain medications), the smooth muscle contracts, tightening the bladder neck and prostate. This increases resistance to urine flow, even if the prostate size hasn't changed.

This is why alpha-blockers - medications like tamsulosin or alfuzosin - work so well for some men. They don't shrink the prostate. They relax the smooth muscle, reducing the dynamic component of obstruction. It's like loosening a clenched fist around the urethra.

But alpha-blockers don't work for everyone. If the obstruction is purely mechanical - if the prostate tissue has physically narrowed the urethral lumen beyond what muscle relaxation can compensate for - you won't get much relief from tone reduction alone.

The Inflammation Variable

Go back to Part 1 of this series, and you'll remember that chronic inflammation plays a significant role in driving prostate growth. But inflammation also affects symptoms directly, independent of size.

When prostate tissue is inflamed, it becomes swollen, congested, more sensitive. Men often describe a vague discomfort in the perineum (the area between the scrotum and anus), a feeling of incomplete emptying, or pain with urination. These aren't purely obstructive symptoms - they're inflammatory ones.

This is where the line between BPH and chronic prostatitis (inflammation of the prostate) gets blurry. Many men have elements of both. And it's one reason why anti-inflammatory approaches - whether through diet, supplements, or in severe cases, medication - can sometimes improve symptoms even when the prostate size doesn't change much.

I've noticed something else too, though it's harder to quantify. Men who are chronically stressed, who sleep poorly, who've had recurrent urinary tract infections - they seem to have more trouble. Not always. But often enough that I suspect the prostate's inflammatory state is more dynamic than we've traditionally assumed. It's not just a matter of fixed structural changes. It's a tissue that responds to what's happening elsewhere in the body.

The Microbiome Connection (Yes, Really)

This is newer territory, and we're still figuring it out. But the prostate isn't sterile. It has its own microbial community - bacteria that live there as part of normal biology. Recent studies suggest that disruptions in this microbiome (what researchers call dysbiosis) might contribute to both inflammation and BPH progression.

Men with more severe BPH tend to have different bacterial profiles in their prostatic fluid compared to men with minimal symptoms. Higher levels of certain inflammatory bacteria (like Escherichia, Streptococcus, and Staphylococcus species), and lower levels of potentially protective ones (like Lactobacillus).

What's causing what? That's still unclear. Does an imbalanced microbiome trigger inflammation that drives BPH? Or does BPH create conditions that favor certain bacteria? Probably both. It's a feedback loop, like so much of this.

But it suggests something useful: that protecting or restoring a healthy prostate microbiome might be part of prevention or treatment. Which brings us back to things like chronic low-grade infections, antibiotic overuse, diet (particularly fermented foods), and sexual activity - all of which can influence microbial communities.

The Sexual Activity Question

Men ask about this more than you'd expect. Usually indirectly. "Does... activity... make it better or worse?"

The data is mixed, but there's some evidence that regular ejaculation might be mildly protective. Not dramatically so - it's not going to reverse BPH - but possibly enough to slow progression. The proposed mechanism is that ejaculation clears prostatic fluid, reducing stagnation and potentially lowering the risk of inflammation and infection.

But here's where it gets messy. Some studies show an association, others don't. And "regular" is hard to define - what counts as regular for a thirty-year-old isn't the same as for a seventy-year-old. I suspect the benefit, if it exists, is modest and probably more relevant for younger men trying to prevent BPH in the first place rather than treat it once it's established.

What's clearer is that prolonged abstinence, particularly combined with arousal without release, can cause congestion in the prostate - a buildup of fluid that creates discomfort and might worsen inflammatory symptoms temporarily. So in that sense, yes, regular activity probably helps symptom management for some men.

The Surgical Decision: When Is It Actually Necessary?

Most men with BPH don't need surgery. Medications, lifestyle changes, and watchful waiting manage symptoms adequately for the majority. But surgery becomes necessary when:

1. Recurrent urinary retention - when the prostate blocks urine flow completely, requiring a catheter to drain the bladder. This is an emergency initially, but if it keeps happening despite medication, surgery is the next step.

2. Bladder stones - chronic incomplete emptying allows minerals to crystallize in stagnant urine, forming stones that cause pain and bleeding.

3. Recurrent UTIs - persistent residual urine becomes a breeding ground for bacteria.

4. Kidney damage - if back-pressure from obstruction damages the kidneys (hydronephrosis, or swelling of the kidneys from backed-up urine), intervention is urgent.

5. Intolerable symptoms despite maximal medical therapy - when quality of life is significantly impaired, and medications aren't helping enough.

The most common surgical procedure is TURP (transurethral resection of the prostate) - essentially coring out the inner obstructing tissue through the urethra. It's effective. About 85% of men notice significant symptom improvement. But it's not without trade-offs: retrograde ejaculation (semen goes into the bladder instead of out) happens in most men post-operatively, erectile function can be affected in some cases, and there's a small risk of incontinence.

Newer minimally invasive procedures (laser ablation, steam therapy, prostatic urethral lift) offer less dramatic recovery times and fewer side effects, but often with slightly lower efficacy. The right choice depends on prostate size, symptom severity, and what a man is willing to risk or tolerate.

What You Can Actually Control

The frustrating truth is that BPH is partially inevitable. If you live long enough, your prostate will enlarge to some degree. But how much it bothers you - and whether it progresses rapidly or slowly - is influenced by factors you can modify.

From Part 1, you already know the metabolic angle: controlling weight, managing blood sugar, reducing systemic inflammation through diet and exercise. Those aren't prostate-specific interventions, but they affect prostate health indirectly, probably through their effects on insulin signaling and inflammatory cytokines.

Beyond that:

• Limit alcohol and caffeine - both irritate the bladder and increase urgency.
• Avoid decongestants and antihistamines - they activate alpha receptors, worsening symptoms.
• Don't hold urine for extended periods - bladder overdistention can weaken the detrusor muscle over time.
• Empty your bladder completely - take your time, lean forward slightly if it helps, and wait an extra ten seconds after you think you're done.
• Consider saw palmetto or beta-sitosterol - some evidence suggests mild benefit, though not as strong as prescription medication. Worth trying if you're early stage and want to avoid drugs.

And perhaps most importantly: don't ignore worsening symptoms. Men often wait too long, assuming it's just age, until they're in retention or have developed bladder stones. Early intervention - whether medical or surgical - prevents complications and preserves bladder function.

The Real Question

The question isn't "Will my prostate grow?" It almost certainly will. The real question is whether you'll be one of the men who barely notices, or one who struggles. And while genetics plays a role, metabolic health, inflammation, and early management make a difference.

Some days I think we understand this better than we used to. Other days I'm less certain. Medicine has a way of humbling you like that.