Decision guide
BPH Treatment Options — Decision Guide
How to think through the full menu of BPH treatments based on prostate size, symptom severity, sexual-function priorities, and anesthesia tolerance.
Step 1 — Confirm the diagnosis
IPSS, DRE, urinalysis, PSA where appropriate, uroflow, PVR, and prostate volume by ultrasound (TRUS).
Step 2 — Optimize medical therapy
Alpha-blocker first-line. Add 5-ARI for prostates >40 g. Add tadalafil 5 mg daily if also addressing ED.
Step 3 — If medications fail or are intolerable, consider procedure
Indications: bothersome symptoms despite optimized medical therapy, recurrent urinary retention, recurrent UTIs, bladder stones, gross hematuria from BPH, renal insufficiency from obstruction.
Step 4 — Match procedure to anatomy and priorities
| Priority | Likely best fit |
|---|---|
| Preserve ejaculation, prostate ≤80 g, no major median lobe | UroLift |
| Preserve ejaculation, prostate ≤80 g, may have median lobe | Rezum |
| Anticoagulated, very large prostate, surgery-averse | PAE |
| Durable result, moderate prostate, sexual SE acceptable | TURP |
| Very large prostate (>80–100 g), seeking durable result | HoLEP |
| Very large prostate, endoscopic options not feasible | Robotic simple prostatectomy |
Step 5 — Get a second opinion
A urologist who performs only one procedure can only recommend that procedure. Ask explicitly about alternatives.
Educational content only. Not medical advice. Verify all credentials, licensing, accreditation, and procedure information directly with providers. Sources: Mayo Clinic, Urology Care Foundation, AUA, Cleveland Clinic, NIDDK, AAFP.