BPH (enlarged prostate): making the right decision at the right time
BPH is benign prostatic hyperplasia—a non-cancerous enlargement of the prostate gland. It is extremely common as men age. For many men it causes mild symptoms that remain stable for years. For others, it gradually affects sleep, travel, work, and quality of life. In some cases, it can lead to urinary retention, infections, or strain on the bladder and kidneys. A good BPH plan is not "medicines forever" or "surgery quickly." A good BPH plan is: 1) understand how much obstruction exists, 2) check whether the bladder/kidneys are being affected, and 3) choose a treatment that matches your anatomy, health profile, and priorities.
Quick navigation
- What BPH is (and what it isn't)
- Symptoms: what matters clinically
- When BPH becomes more than a comfort issue
- A sensible evaluation plan (tests that actually matter)
- Treatment options (stepwise, non-sales)
- Procedure options: PAE, Rezum, TURP, HoLEP/ThuLEP—how to think about them
- Recovery expectations (realistic)
- Which page to go to next
- FAQs
What BPH is (and what it isn't)
BPH is:
- A growth of prostate tissue that can narrow the urine passage
- Often slowly progressive
- Treatable, with multiple options
BPH is not:
- Prostate cancer
- A disease where everyone needs surgery
- Something that can be diagnosed only by symptoms
Symptoms and prostate size correlate imperfectly. Some men have a large prostate with mild symptoms; others have a moderate prostate with significant obstruction. That's why evaluation matters.
Symptoms: what matters clinically
BPH symptoms are part of LUTS (lower urinary tract symptoms). Common ones include:
Voiding (flow) symptoms
- Weak stream
- Straining
- Hesitancy (delay before urine starts)
- Intermittent flow
- Dribbling after urination
- Feeling of incomplete emptying
Storage (bladder) symptoms
- Frequency
- Urgency
- Waking at night (nocturia)
Many men think BPH is only a "weak stream" problem. In reality, long-standing obstruction can change bladder behaviour and create urgency/frequency as well. If your main symptoms are urgency/leakage, see also:
When BPH becomes more than a comfort issue
Some men can live comfortably with mild BPH symptoms for years. Others reach a point where the risk of complications becomes more relevant. BPH deserves timely evaluation if you have:
1) Urinary retention
Inability to pass urine, or repeated episodes requiring catheterization. This is not something to ignore.
2) Recurrent UTIs
Incomplete emptying can increase infection risk.
3) High post-void residual (leftover urine)
This is measurable on ultrasound and changes decisions.
4) Bladder changes or kidney strain
- Thickened bladder wall
- Hydronephrosis (kidney swelling due to back pressure)
- Worsening kidney function (in severe/long-standing cases)
5) Quality of life impact
- Waking multiple times at night
- Planning life around toilets
- Fear of retention during travel
- Daily discomfort or fatigue from broken sleep
It is reasonable to treat BPH for quality of life alone. You do not need to "wait until it is unbearable." But you also should not be rushed into invasive treatment without candidacy-based reasoning.
A sensible evaluation plan (tests that actually matter)
A good evaluation aims to answer 3 questions: 1) How much obstruction is there? 2) Is the bladder or kidneys being affected? 3) What options fit your anatomy and health profile?
Step 1: Clinical history and symptom scoring
A clinician will ask:
- Stream strength, straining, incomplete emptying
- Frequency/nocturia and urgency
- Any retention episode
- Infections
- Medications and comorbidities (diabetes, blood thinners)
Often, doctors use standardized symptom scores; these help track progress over time.
Step 2: Urine test
To check: infection, blood (hematuria). If blood is present, evaluation expands.
Step 3: Ultrasound with post-void residual (high-value)
Ultrasound can assess: prostate size (approximate), bladder wall changes, residual urine after voiding, kidney status (hydronephrosis). Residual measurement is one of the most practical objective markers in BPH.
Step 4: Uroflowmetry (in selected cases)
Measures flow rate and pattern, which can support obstruction assessment.
Step 5: PSA in context (when appropriate)
PSA can be elevated in BPH and inflammation. PSA is not a simple "cancer yes/no" test. It is a marker that must be interpreted with: age, prostate size, trends over time, clinical context. Your doctor may also recommend MRI or further tests if needed.
Step 6: Advanced evaluation when indicated
- Cystoscopy if anatomy needs direct assessment or if hematuria concerns exist
- Imaging/MRI in selected scenarios
A responsible approach does not over-test. But it also does not guess.
Treatment options (stepwise, non-sales)
BPH treatment choices depend on: symptom severity and impact, residual urine and obstruction degree, prostate anatomy/size, comorbidities (bleeding risk, cardiac status, anesthesia risk), patient goals: minimal invasiveness vs durability vs speed of relief.
Pathway A: Watchful waiting (for mild, stable symptoms)
Appropriate when: symptoms are mild, residual urine is low, no complications. The plan usually includes lifestyle adjustments and monitoring.
Pathway B: Medicines (common first-line)
Medicines can: relax the prostate/bladder neck to improve flow, reduce prostate size over time in selected cases. This is not "failure." It is often the right first step when safety markers are stable.
Pathway C: Procedures (when appropriate)
Procedures are considered when: symptoms are significant, medicines are inadequate or not tolerated, complications exist (retention, infections, high residual, kidney strain), patient priorities favour procedural relief. The right procedure is chosen by candidacy, not by marketing.
Procedure options: how to think about PAE, Rezum, TURP, HoLEP/ThuLEP
1) PAE (Prostate Artery Embolization)
What it is: a minimally invasive approach that reduces blood supply to prostate tissue, leading to shrinkage over time in selected cases. Often considered when: you want a minimally invasive option, you have a risk profile where endoscopic surgery may be less desirable, anatomy and imaging support candidacy. Important limitations: not ideal for everyone, improvement may be gradual, some anatomical patterns respond less predictably.
2) Rezum
What it is: a minimally invasive therapy using water vapour to treat obstructing tissue in selected prostate patterns. Often considered when: symptoms are moderate, anatomy is suitable, goals align with this approach. Important limitations: candidacy depends on prostate characteristics, temporary symptom flare can occur during healing.
3) TURP
What it is: an established endoscopic surgery that removes obstructing tissue. Often considered when: obstruction is significant, you need more definitive, quicker relief, prostate size/anatomy suits TURP.
4) HoLEP / ThuLEP (laser enucleation variants)
What they are: endoscopic laser procedures that remove obstructing tissue efficiently in appropriate settings. Often considered when: prostate anatomy/size suggests a durable enucleation approach, the goal is long-term relief with a well-established pathway.
A practical way to choose (what I would advise a family member)
If you want a clear decision process, start with these questions:
- Is there high residual urine, retention history, infections, or kidney strain? If yes, you likely need a more definitive obstruction-relieving strategy.
- What is your prostate anatomy/size and where is the obstruction? This affects candidacy for minimally invasive options vs endoscopic surgery.
- What is your health profile (bleeding risk, blood thinners, anesthesia risk)? This affects procedural risk selection.
- What matters most to you? Fastest relief? Least invasive approach? Maximum durability? Minimizing catheter time?
A good clinician will help you align the choice to your goals without bias.
Recovery expectations
After minimally invasive options (PAE/Rezum)
Recovery differs by option and patient health, but some general guidance:
- Improvement may be gradual (especially PAE)
- Temporary urinary symptoms during healing can occur (especially Rezum)
- Follow-up is important to track response
After endoscopic surgery (TURP/HoLEP/ThuLEP)
- Catheter may be required for a period based on case specifics
- Temporary urgency/burning can occur during healing
- Most men return to routine activities in a staged manner
A good plan includes: clear warning signs, expected timelines, follow-up checkpoints. This is how outcomes remain smooth.
Which page should you go to next?
If you're here because of symptoms (weak stream, straining, incomplete emptying)
If urgency/frequency/nocturia dominates
If you want to understand specific procedures
If you have recurrent UTIs
Talk to a doctor (quietly, without pressure)
If you're in Mumbai or Pune and you want a candidacy-based plan, send: ultrasound report (prostate size + residual urine if mentioned), urine report, PSA history (if done), your symptom pattern (day vs night, urgency, retention episodes). A doctor-led team will guide you toward: the next best test (if needed), and the least invasive effective option for your situation.
