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Enlarged Prostate Symptoms and How to Score Them with the IPSS

Written by David Shusterman, MD, board-certified urologist, adapted from his book Shrink the Prostate. General information, not medical advice for your situation. Who publishes this site.

The most common symptoms of an enlarged prostate (BPH) are a weak or slow stream, trouble getting started, stopping and starting, straining, a feeling that the bladder never fully empties, needing to go often, sudden urgency and waking at night to urinate. Doctors measure how much these symptoms bother you with the International Prostate Symptom Score (IPSS), a seven-question test scored from 0 to 35: 0 to 7 is mild, 8 to 19 is moderate and 20 to 35 is severe. Your score helps decide whether you need treatment and tracks whether treatment worked.

Why an enlarged prostate causes urinary symptoms

The prostate sits just below the bladder and wraps around the urethra, the tube that carries urine out. As it grows with age, it squeezes that tube like a pinched hose. The bladder has to push harder to get urine through, and over the years its muscle thickens and tires.

Prostate size and symptoms do not always match. Growth that pushes inward toward the channel can cause severe symptoms in a fairly small gland, while some men with large prostates feel fine for years. That is why symptoms need to be measured, not guessed from size.

Voiding symptoms and storage symptoms

Doctors call these lower urinary tract symptoms (LUTS) and sort them into two groups.

Voiding symptoms happen at the toilet:

• Hesitancy: standing and waiting for the stream to start.
• Weak or slow stream, or dribbling.
• Intermittency: the stop-start pattern that turns a quick trip into minutes.
• Straining: having to push to get urine out.
• Incomplete emptying: walking away knowing you will be back soon.

Storage symptoms follow you wherever you are:

• Frequency: needing to go more often than you should.
• Nocturia: waking at night to urinate, often more than once. See waking up at night to urinate.
• Urgency: a strong, sudden need that will not wait.
• Urge incontinence: leaking before you reach the bathroom.

The effects go beyond the bathroom. Men plan their days around restrooms, skip long drives, cut back on fluids, lose sleep and sometimes leave the shared bedroom. Cutting back on fluids can backfire, raising the risk of dehydration, urinary infections and even kidney stones.

The IPSS: how to score your symptoms

The IPSS asks seven questions about the past month. Each is scored from 0 to 5.

1. Incomplete emptying: how often have you felt your bladder was not empty after urinating?
2. Frequency: how often have you had to urinate again less than two hours after you finished?
3. Intermittency: how often have you stopped and started again several times while urinating?
4. Urgency: how often have you found it hard to postpone urinating?
5. Weak stream: how often have you had a weak urinary stream?
6. Straining: how often have you had to push or strain to begin?
7. Nocturia: how many times did you typically get up to urinate between going to bed and getting up in the morning?

For questions 1 to 6, the answers are: 0 not at all, 1 less than 1 time in 5, 2 less than half the time, 3 about half the time, 4 more than half the time, and 5 almost always. For question 7, score 0 for none, 1 for once, 2 for twice, 3 for three times, 4 for four times and 5 for five or more.

Add the seven answers for a total from 0 to 35.

What your IPSS score means

• 0 to 7, mild: watch and measure. Retake the test about every six months and track the trend.
• 8 to 19, moderate: symptomatic enough to act and early enough to protect your bladder and keep all your options open.
• 20 to 35, severe: stop waiting. Not a rushed decision, but a measured one, made soon, with every option on the table.

Pay special attention to question 7. Nighttime urination disrupts sleep, mood and safety faster than any other symptom. If your nocturia answer is 3 or higher, treat that as a reason to act whatever your total says.

Bring your number to your appointment. “I think it is getting worse” is vague; “my score went from 14 to 22 in a year” starts a plan. Retake the test after any treatment, pills or procedure. The drop in your score is an honest measure of whether it worked.

Other tests that complete the picture

Symptoms alone can mislead. Some men under-report and some over-report, so a urologist usually adds objective tests:

• Uroflowmetry: you urinate into a device that measures your stream. A weak, flat curve shows a real blockage.
• Post-void residual: a quick ultrasound of the urine left behind.
• Prostate ultrasound: measures volume in grams and shows the shape, including a median lobe pushing into the bladder.
• Urinalysis and PSA blood test: to check for infection or blood and help assess cancer risk.

Together, these show whether you need treatment and which kind fits. See enlarged prostate (BPH) treatment options.

Warning signs: when to see a urologist soon

BPH is benign, meaning it is not cancer, but untreated blockage can cause real harm. See a urologist promptly if you have:

• Sudden inability to urinate, which needs emergency care.
• Repeated urinary tract infections.
• Blood in the urine.
• A feeling of a full bladder that never empties, or a growing amount of leftover urine on scans.
• Symptoms that keep worsening despite medication.

Long-standing blockage can lead to bladder stones and, in neglected cases, kidney damage from urine backing up. It can also wear out the bladder muscle, and that damage may not fully reverse even after treatment. Measuring early and acting on the numbers is the best protection. This article is general information, not a diagnosis; a urologist can evaluate your symptoms properly.

Frequently asked questions

What are the first signs of an enlarged prostate?

Common early signs are a weaker or slower stream, waiting for the stream to start, needing to go more often and getting up at night to urinate.

What is a normal IPSS score?

A score of 0 to 7 is considered mild. Scores of 8 to 19 are moderate and 20 to 35 are severe.

Does a bigger prostate mean worse symptoms?

Not necessarily. Growth that pushes inward toward the channel can cause severe symptoms in a fairly small prostate, while some men with large glands feel fine for years.

When are prostate symptoms an emergency?

Being suddenly unable to urinate needs emergency care. Blood in the urine, repeated urinary infections or a bladder that never feels empty also call for a prompt visit to a urologist.