BPH: When Is Medication Enough, and When Is Surgery Needed?

Nearly every man in his seventies has some prostate enlargement, and many have symptoms from it. So the useful question is rarely whether the prostate has grown. It usually has. The question is whether it is doing enough harm to treat, and if so, how.

Size Is Not the Point

A big prostate does not always cause big problems. A 30 g gland sitting in the wrong place can block more than a 90 g one growing outwards. What matters is how much the flow is blocked, and what that is doing to the bladder and kidneys.

Three questions decide the treatment.

• How much does it bother you? Measured by the IPSS score, plus one question about quality of life. That last one often matters more than the score.
• Is the bladder emptying? Measured by flow rate and how much urine is left behind.
• Are the kidneys affected? Measured by creatinine and an ultrasound.

Scoring the Symptoms

The IPSS asks seven questions about the past month. Each scores 0 to 5.

Score	Severity	Usual approach
0–7	Mild	Habits and review. Tablets rarely needed
8–19	Moderate	Tablets are usually started
20–35	Severe	Tablets tried, surgery more likely

It is a tool, not a verdict. A man scoring 9 who is up four times a night may need help sooner than one scoring 16 who barely notices.

When Habits Are Enough

For mild symptoms these are often all that is needed. They are worth doing even alongside tablets.

• Drink more earlier in the day, less in the evening. This alone helps night-time trips.
• Cut evening tea, coffee and alcohol.
• Ask about your water tablets, and when you take them.
• Treat constipation. A full bowel really does make passing urine harder.
• Wait a few seconds after you finish, then try again.
• Check cold and allergy remedies. Many can stop the flow altogether.

The Tablets

• Alpha-blockers: Tamsulosin, silodosin, alfuzosin. They relax the muscle at the outlet, so the flow improves within days. They do not shrink the gland. They can cause dizziness on standing, and reduced or dry semen, which reverses when you stop. Tell your eye surgeon before cataract surgery.
• Finasteride and dutasteride: These actually shrink the gland, by about a fifth over six to twelve months. Best for larger prostates. They lower the risk of retention and of eventually needing surgery. They also halve your PSA reading, so later results must be read with that in mind. A PSA that rises despite them needs attention. A few men notice an effect on libido.
• Both together: For a larger gland with troublesome symptoms. Better at preventing things getting worse, but you get both sets of side effects.
• Bladder-calming tablets: Added when urgency continues after the blockage is treated. Used carefully, with the residual urine watched.
• Daily tadalafil: An option where erection problems coexist.

When Surgery Is Not a Choice

For most men, having surgery is about quality of life. In these situations it is not — the risk of waiting falls on the kidneys or the bladder.

• Urine stops more than once, or will not restart after a catheter comes out.
• Kidney function has dropped, or the kidneys are swollen.
• Bladder stones have formed because the bladder never empties.
• Urine infections keep coming back.
• Bleeding from the prostate that tablets do not control.

Beyond these, surgery is offered when symptoms stay troublesome on full treatment, or the side effects are not worth it.

The Operations

• TURP: The long-established standard. A telescope passes along the urine pipe and removes the blocking tissue. No cut on the body. One to two nights, catheter out in a day or two, normal activity in two to four weeks. Suits glands up to about 80 g.
• Bipolar TURP: The same operation with a safer irrigation fluid, which allows longer working time.
• HoLEP and similar: Laser removal of the whole blocking portion. For large glands where TURP would take too long.
• Open or keyhole prostatectomy: For very large glands, or when bladder stones need dealing with at the same time.

Afterwards

• Semen goes backwards into the bladder in most men after TURP or HoLEP. It does not affect erection or sensation, but it does affect fertility. Raise it beforehand if that matters to you.
• Blood in the urine for a few weeks is normal. It often increases briefly around day ten to fourteen as the scab separates. Drink more, avoid straining, and ring if it is heavy.
• Burning and urgency can last several weeks while the raw surface heals. This is the commonest cause of disappointment after surgery, and it passes.
• Urgency may not go completely. A bladder that has pushed against a blockage for years does not always settle once the blockage is gone. Surgery fixes the outflow, not the years of change behind it — which is an argument for not leaving it too long.
• No heavy lifting for about four weeks.

The Long View

Prostate enlargement keeps progressing. Gland size, PSA level, symptoms and residual urine all help predict who will need more done in time. Regular review matters more than any one decision. A man comfortable on tablets today should still have his flow, residual urine and creatinine checked from time to time — because blockage can worsen quietly, long before the symptoms make it obvious.

Read More

• Full guide: prostate and urinary symptoms
• BPH: when to see a urologist
• What is TURP? · Can it damage the kidneys?

This page provides general information only. It is not a substitute for medical advice, diagnosis or treatment. Consult a qualified urologist for assessment appropriate to your situation.