BPH / LUTS Management & Procedure Chooser
Managing BPH is a stepwise decision, not a single treatment — least to most invasive, escalating only as symptoms, bother, and complications demand.
The big picture
Managing BPH is a stepwise decision, not a single treatment. You move from least to most invasive — watchful waiting, then medical therapy, then surgery — escalating only as symptoms, bother, and complications demand. And when surgery is needed, there is no longer one operation: the choice is driven by prostate size, the patient's bleeding risk, their wish to preserve ejaculation, and surgeon expertise. This lesson is the map through that decision.
The framework: assess and risk-stratify (IPSS, the workup) → conservative/medical ladder → the surgical/minimally-invasive procedure chooser by prostate size and patient factors → recognise the absolute indications and emergencies.
Mechanism pathway
Tap any step to see why it happens.
Interactive — BPH treatment calculator
Diagnostic algorithm
Each step answers one question. Tap to expand.
Procedure chooser
TUIP (bladder-neck incision)
Excellent for small glands.
TURP
FitsThe long-standing benchmark for average glands; becomes less suitable as size rises. Monopolar risks TUR syndrome; bipolar (saline) avoids it.
PVP / GreenLight
FitsPhotoselective vaporisation (laser) — less bleeding; suits anticoagulation.
HoLEP / ThuLEP
FitsHolmium/thulium enucleation; size-independent and low bleeding — suits anticoagulation, and rivals simple prostatectomy without an incision.
PUL (Urolift)
FitsProstatic urethral lift; preserves ejaculation/erection; less symptom improvement than resective surgery.
WVTT (Rezum)
FitsWater-vapour thermal therapy; preserves sexual function.
Simple prostatectomy (open/robotic)
Removes the adenoma; reserved for very large glands (e.g. >80 g). HoLEP is the endoscopic alternative.
Ejaculation preservation: men who specifically want to preserve ejaculatory (and erectile) function can be offered PUL (prostatic urethral lift / Urolift) or WVTT (water-vapour thermal therapy / Rezum) — a greater likelihood of preserving sexual function, at the cost of less symptom improvement. TUR-syndrome caution: monopolar TURP uses hypotonic irrigant (risk rises with gland >45 cc and resection >90 min); bipolar uses saline and avoids it.
Board traps
Stepwise: watchful waiting → medical → surgery. Don't medicate the unbothered man.
5-ARIs only help enlarged prostates and halve the PSA (double it to interpret).
Combination (alpha-blocker + 5-ARI) prevents progression/retention in moderate-severe disease with an enlarged gland (MTOPS/CombAT).
Procedure by size: TUIP (<30 cc) · TURP (30–80 cc) · HoLEP / simple prostatectomy (>80 cc).
Can't stop anticoagulation → HoLEP / ThuLEP / PVP (less bleeding).
Wants ejaculation preserved → PUL (Urolift) or WVTT (Rezum).
Monopolar TURP → TUR syndrome (gland >45 cc, resection >90 min); bipolar uses saline and avoids it.
Absolute indications (retention, recurrent UTI, stones, haematuria, renal insufficiency) → operate regardless of IPSS.