What Really Causes Prostate Enlargement (And What You Can Actually Do About It)

There's a quiet anxiety that settles into men somewhere around their fifties. Not about mortality exactly - though that's there too - but about whether they'll still be able to pee properly in ten years. It's rarely spoken about directly. More often, it surfaces in passing comments at barbecues or sideways questions during check-ups: "My dad had trouble with his prostate. Am I going to end up like that?"

The answer isn't as simple as yes or no. But it's also not predetermined fate.

The Prostate: A Gland That Won't Stop Growing

The prostate is a walnut-sized gland that sits just beneath the bladder, wrapped around the urethra - the tube that carries urine out of the body. In adolescence and early adulthood, the prostate grows steadily, driven by androgens like testosterone. But here's where it gets interesting: as men age, their testosterone levels usually decline. You'd think the prostate would follow suit. Instead, it keeps growing.

This is called benign prostatic hyperplasia (BPH) - a noncancerous enlargement of prostate cells - and it affects most men eventually. By age 60, about half of men have some degree of BPH. By 85, that number climbs to 90%. The symptoms are familiar: weak urine stream, hesitancy before starting, getting up multiple times at night to pee, sometimes urgency that feels impossible to ignore.

The question isn't really "Will my prostate grow?" It's more like: "How much will it grow, and will it bother me?"

The Testosterone Paradox

To understand BPH, you need to understand how testosterone works in the prostate. Testosterone itself doesn't directly fuel prostate growth - not the way you might think. Instead, an enzyme called 5-alpha reductase converts testosterone into dihydrotestosterone (DHT) - a more potent androgen that binds strongly to androgen receptors in prostate cells. DHT concentrations in the prostate are about ten times higher than testosterone levels in the blood.

This is why some BPH medications - like finasteride or dutasteride - work by blocking 5-alpha reductase. Less enzyme activity means less DHT, which can slow or even shrink prostate growth in some men.

But here's the paradox: even as testosterone declines with age, the prostate continues to enlarge. So androgens aren't the whole story. They're necessary for prostate development in youth, yes. But the continued growth in older men? That's driven by something else.

The Real Culprits: Inflammation, Metabolic Chaos, and a Vicious Cycle

BPH isn't just about hormones. It's about an imbalance - more cell growth than cell death. In a healthy organ, these two processes are in equilibrium. In BPH, that balance tips toward proliferation.

What drives this?

1. Inflammation

Chronic, low-grade inflammation appears to play a major role. This can come from multiple sources: bacterial or viral infections, autoimmune processes, urine refluxing back into prostate ducts, or even disruptions in the prostate's microbiome - the bacteria that naturally live there. (Yes, the prostate has a microbiome. We're still learning what a "healthy" one looks like.)

When inflammation kicks in, immune cells release chemical messengers called cytokines - particularly interleukin-6 (IL-6). These cytokines then stimulate growth factors like fibroblast growth factor 2, which tells prostate cells to multiply.

But here's where it gets messy. As new tissue grows, it needs oxygen. If it doesn't get enough - what we call a hypoxic environment - the cells start releasing reactive oxygen species (ROS), which are essentially inflammatory molecules. This creates more inflammation, which drives more growth, which creates more hypoxia, and the cycle repeats.

It's self-sustaining. Once it starts, it's hard to stop.

2. Metabolic Syndrome

This is where things get interesting - and where prevention becomes possible.

Metabolic syndrome is a cluster of conditions: diabetes, high blood pressure, high cholesterol, and obesity. They're all linked by underlying metabolic dysfunction, largely driven by diet, physical inactivity, and insulin resistance.

The data here is striking:

• Diabetes increases BPH risk by 125%.
• Diabetes increases lower urinary tract symptoms (LUTS) by 95%.
• A BMI above 35 significantly increases the likelihood of prostate enlargement compared to a BMI under 25.

Why? Because metabolic syndrome doesn't just affect your heart or pancreas - it affects every organ, including the prostate. Insulin resistance, chronic inflammation, elevated blood glucose, and oxidative stress all create an environment where prostate cells proliferate unchecked.

And here's something I've noticed over the years: men with poorly controlled diabetes often have worse urinary symptoms. Not just because their prostates are larger, but because high blood sugar affects nerve signaling and bladder function. It compounds the problem.

3. Sympathetic Nervous System Upregulation

The prostate has smooth muscle tissue, and its tone is regulated by the sympathetic nervous system - the "fight or flight" system. When sympathetic activity increases (from stress, blood sugar fluctuations, dietary triggers, or obesity), it can make the prostate muscle contract more, worsening symptoms even if the gland isn't significantly enlarged.

This is why alpha-blockers - medications like tamsulosin or alfuzosin - work for BPH. They relax the smooth muscle, improving urine flow without shrinking the prostate.

Genetics: The Hand You're Dealt

Some of this is inherited. BPH can follow an autosomal dominant pattern - meaning if your father had it, there's a good chance you will too. Men who develop severe BPH before age 60, requiring surgery, are more likely to have a genetic component.

But genetics isn't destiny. It just sets the baseline. What you do with your diet, exercise, and metabolic health can shift the outcome significantly.

What You Can Actually Do

So if inflammation, metabolic dysfunction, and smooth muscle tone are the real drivers - what's the play?

1. Avoid Metabolic Syndrome

This is the big one. And it's not sexy advice. It's not a supplement or a biohack. It's boring, basic prevention:

• Control blood sugar. If you're prediabetic or diabetic, work with your doctor to get your HbA1c below 7% (ideally closer to 6%).
• Maintain a healthy weight. Aim for a BMI under 30, ideally under 25.
• Manage cholesterol and blood pressure. These aren't just cardiovascular risks - they're prostate risks too.

The Western diet - high in red meat, processed foods, simple carbs, and sugar - is a direct contributor to metabolic syndrome. A Mediterranean-style diet (more vegetables, fish, whole grains, olive oil) has been associated with lower BPH risk in some studies, though the data isn't definitive.

2. Stay Physically Active

Exercise improves insulin sensitivity, reduces inflammation, and helps maintain a healthy weight. It also modulates the sympathetic nervous system - reducing the "fight or flight" tone that can worsen urinary symptoms.

Even moderate activity - walking 30 minutes a day, five days a week - makes a measurable difference.

3. Consider Medications Early

If you're already developing symptoms, talk to your doctor about 5-alpha reductase inhibitors (like finasteride or dutasteride) or alpha-blockers (like tamsulosin). These don't reverse metabolic dysfunction, but they can slow progression or improve symptoms while you work on the underlying factors.

4. Address Inflammation

This is harder to quantify, but managing chronic infections (like recurrent UTIs or prostatitis), maintaining a healthy gut microbiome, and reducing systemic inflammation through diet and lifestyle all potentially help. We don't have perfect evidence here yet - but the mechanisms make sense.

The Uncomfortable Truth

Here's what I've learned: most men don't want to hear that the solution is "eat better, move more, lose weight." They want a pill. A supplement. A quick fix.

And I get it. Metabolic change is hard. It requires sustained effort, not just once, but indefinitely. But the data is clear - diabetes increases BPH risk by 125%. Obesity compounds it. These aren't small effects.

The men I see who avoid significant prostate issues into their seventies and eighties? They're not special. They're not lucky. They're metabolically healthy. They move. They eat reasonably well. They don't smoke. Their blood sugars are controlled.

It's not glamorous. But it works.

A Final Thought

I sometimes wonder if we've overcomplicated this. BPH feels inevitable because it's so common - but common doesn't mean unavoidable. It just means we've normalised a set of conditions (metabolic syndrome, sedentary lifestyles, poor diets) that drive it.

The prostate is just doing what it's designed to do: responding to its environment. If that environment is inflamed, insulin-resistant, and hypoxic, it grows. If that environment is healthier, it might still grow - but less, and more slowly.

You can't fully prevent prostate enlargement. But you can absolutely influence it. And that might be the difference between peeing normally at 70 or getting up five times a night.

Most men won't think about their prostate until it's a problem. But the time to act is before that happens.

What do you make of this?