The question people most often ask when looking into treatment for benign prostatic hyperplasia (BPH) is, ‘Should I take medication, undergo a procedure, or go straight to surgery?’ While this sequence is not entirely wrong, in reality, not everyone goes step by step in the same order. For some, observation alone is sufficient, while for others, serious discussion about surgery may be necessary from the first consultation.
This article summarizes ‘when’ and ‘on what basis’ each treatment option is being reviewed, for those who already have urinary symptoms and are about to see a doctor, or who is taking medication and wondering about the next steps. Since the initial symptoms themselves have already been covered in other articles, here we will focus on the selection criteria.
Treatment choice is a criterion, not a sequence
The European Association of Urology (EAU) and the American Urological Association (AUA) guidelines do not depict the treatment process as a one-way staircase. Instead, they set several axes together and determine the direction. These axes include the International Prostate Symptom Score (IPSS) and quality of life score, uroflowmetry and post-void residual volume, prostate size and presence of a median lobe confirmed by ultrasound, bladder function, complications such as urinary retention, recurrent urinary tract infections, bladder stones, hematuria, upper urinary tract dilation, and impaired renal function, whether the patient is taking anticoagulants, cardiovascular and anesthesia-related health status, and what the patient prioritizes.
Even if two people have the same IPSS score of 20, the next steps differ between someone who has almost no residual urine and no signs of complications, and someone who has already experienced urinary retention once and is maintaining a catheter. Surgery may not be helpful if bladder function is impaired even when the prostate is not large, whereas in cases of a large prostate with repeated urinary retention, it can be more favorable not to prolong medication treatment. Therefore, the phrase ‘start with medication first’ represents a general guideline, but it is not always the correct answer for each individual patient.
Cases that can be observed through monitoring and lifestyle management
If the symptoms are mild (generally an IPSS of 7 or lower), do not significantly affect quality of life, and the risk of complications such as urinary retention, recurrent infections, bladder stones, or decreased kidney function is low, one can choose regular monitoring instead of starting medication immediately. This approach, called watchful waiting, is not about doing nothing and neglecting the condition, but rather is an active management approach that combines lifestyle adjustments with regular re-evaluations.
The key points of this stage can be summarized in a few ways. Control your intake of fluids, caffeine, and alcohol in the evening, avoid drinking large amounts of water right before bed, and check the ingredients of any cold medicines, antihistamines, or diuretics you are taking. Do not hold in urine excessively, and break up long periods of sitting by moving regularly. Keeping a urination diary for about three days can serve as a baseline for identifying changes in symptoms during later consultations.
Even if observation is appropriate, it is important to set the next visit date. This is because if symptoms noticeably worsen, nighttime urination newly becomes severe, or gross hematuria, increased residual urine sensation, or recurrent urinary tract infections occur, the next steps need to be discussed. The schedule for re-evaluation is the very criterion that distinguishes between observation and neglect.
Situations to Consider Drug Therapy
Medication is considered when symptoms persist to the point of lowering quality of life or when discomfort does not subside with observation alone. The commonly used classes are alpha-blockers and 5-alpha-reductase inhibitors, and if storage symptoms are prominent, antimuscarinics or beta-3 agonists may be used in combination. When erectile dysfunction is present, PDE5 inhibitors may also be considered together. The appropriate combination is determined by comprehensively considering the nature of the symptoms, test results, other medications, and cardiovascular status.
The characteristics of each class are different. Alpha blockers relatively quickly relieve urinary symptoms, but dizziness, low blood pressure, and decreased ejaculate volume may occur. 5-alpha-reductase inhibitors have been reported to suppress progression in cases with a large prostate volume (usually over 30 mL), but it takes time to feel the effect, and symptoms related to sexual function and breasts may appear, so the goals and duration should be discussed in advance. Combination therapy is considered in situations where there is a large prostate and prominent symptoms together.
If the medication suits the patient well, many people maintain a stable condition for a long period with the same prescription. However, when dizziness increases the risk of falls, or changes in sexual function make it difficult to continue taking the medication, when symptoms remain the same or even worsen despite increasing the dose, or when complications such as urinary retention, recurrent infections, hematuria, or bladder stones newly occur, it is time to reassess procedures or surgery. This should be understood not as the ‘failure’ of drug therapy, but rather as the point at which the benefits offered by other options have increased.
Decision Point for Moving to Minimally Invasive Treatment
Minimally invasive treatments are not an intermediate step between medication and surgery, but a separate option with distinct advantages in certain situations. Methods such as Rezūm steam treatment, UroLift, and prostatic artery embolization (PAE) fall into this category, and they are considered with the goal of relatively preserving some sexual functions, like ejaculation, while reducing the burden on prostate tissue and anesthesia.
The situations in which this approach becomes a priority are generally as follows: when the response to medication is insufficient or maintaining medication is difficult due to side effects, when obstruction is confirmed but one wants to postpone the anesthesia burden associated with major surgery, and when preserving ejaculatory function is considered relatively important. On the other hand, if there are bladder stones or uncontrolled hematuria, if the prostate is very large or the median lobe enlargement is prominent, or if there is recurrent urinary retention or severe renal function impairment, the suitability of minimally invasive treatment may be reduced.
The magnitude and duration of effects, as well as the possibility of retreatment, vary depending on the treatment. The EAU guidelines point out that while several minimally invasive treatments improve symptoms and urinary flow, there are cases where the objectively measured improvement is reported to be smaller compared to typical surgery. At the same time, they also explain that side effects related to sexual function are relatively less frequently reported. It is not a matter of one being absolutely better; the criterion for judgment is which burdens one is willing to take on to gain certain benefits.
Absolute and Relative Indications for Considering Surgery
Surgery is the most invasive option, but in situations where it is necessary, delaying it can make it more difficult to restore bladder function. Guidelines clearly mention several situations as indications for surgery. Examples close to absolute indications include recurrent urinary retention that does not improve with medication and catheter management, recurrent urinary tract infections that are not controlled with antibiotics, uncontrolled gross hematuria, bladder stones, and decreased kidney function or upper urinary tract dilation due to difficulty urinating. In these cases, the decision cannot be delayed simply because it is highly invasive.
Relative indications include persistent symptoms that are not sufficiently improved by medication or minimally invasive treatment, or cases where stable relief of obstruction is needed in a large prostate (usually over 80 mL). The surgical methods used are not limited to one. They include transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), photoselective vaporization (GreenLight PVP), open or robot-assisted simple prostatectomy, etc., each of which differs in terms of anesthesia burden, risk of bleeding, hospitalization and recovery time, and degree of changes in ejaculation function.
Which surgery is superior cannot be generalized regardless of the situation. The decision is made by considering factors such as prostate size and shape, use of anticoagulants, cardiovascular and respiratory conditions, anesthesia risks, priority of sexual function, and the burden of possible readmission. When consulting about surgery, it is helpful to check not only the expected effects but also the recovery period, potential changes in ejaculation function, and the possibility of retreatment in advance.
Referenced Medical Information
- European Association of Urology (EAU) Male Non-Neurogenic Lower Urinary Tract Symptoms Guidelines: Disease Management
- American Urological Association (AUA) Clinical Guideline List
- Korean Urological Association Public Health Information: Benign Prostatic Hyperplasia
This article is intended to provide general health information and does not replace diagnosis or treatment. The appropriate treatment should be determined in urology consultations based on individual test results and health conditions.
