Benign Prostatic Hyperplasia · Medical vs Surgery + Approach

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Symptoms/complications + medical response
   Symptom severity / complications / medical response?
   • Mild, not bothersome → Mild → watchful waiting
   • Moderate-severe symptoms, try medical first → Moderate-severe → medical
   • Medical failure or complications (retention/recurrent UTI/hematuria/bladder stone/post-renal injury) → Surgery · approach by prostate volume
2. [End] Mild → watchful waiting
   Mild/not bothersome → watchful waiting + lifestyle (limit evening fluids/caffeine/alcohol, bladder training); periodic IPSS assessment.
3. [End] Moderate-severe → medical
   Medical: alpha-blocker (fast onset); 5-ARI for large glands (>30–40 mL, shrinks the gland, takes months); add an anticholinergic/beta-3 for storage symptoms; PDE5i (tadalafil). Failure/intolerance/progression → surgery.
4. [Decision] Surgery · approach by prostate volume
   Prostate volume?
   • <30 mL (small) → <30 mL → TUIP/minimally invasive
   • 30–80 mL (medium) → 30–80 mL → TURP/laser
   • >80 mL (large) → >80 mL → HoLEP/simple prostatectomy
5. [End] <30 mL → TUIP/minimally invasive
   <30 mL (no median lobe) → transurethral incision of the prostate (TUIP), or minimally invasive UroLift (prostatic urethral lift)/Rezum (water vapor); can preserve ejaculatory function.
6. [End] 30–80 mL → TURP/laser
   30–80 mL → transurethral resection of the prostate (TURP, gold standard) or laser (HoLEP enucleation/PVP photoselective vaporization); small without a median lobe may have UroLift/Rezum; Aquablation is an option.
7. [End] >80 mL → HoLEP/simple prostatectomy
   >80 mL → HoLEP (holmium laser enucleation, not limited by volume) or simple prostatectomy (open/laparoscopic/robotic); PVP/Aquablation are also options.

Source guidelines & references

• Management of LUTS due to BPH, AUA/EAU guidelines

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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