Benign Prostatic Hyperplasia (BPH) is a widespread condition affecting a majority of men as they age. This non-cancerous growth of the prostate gland causes lower urinary tract symptoms by squeezing the urethra, leading to issues like frequent, urgent, or weak urination. The prevalence of BPH is high, with up to 90% of men over the age of 80 showing signs of the condition. Over the past two decades, the approach to managing BPH has shifted significantly, moving away from traditional, highly invasive surgical procedures toward a modern spectrum of less invasive, often outpatient, options.
Initial Medical and Lifestyle Management
The first step in addressing an enlarged prostate is often watchful waiting combined with simple lifestyle adjustments, particularly for men with mild symptoms. Adjusting fluid intake timing is one of the most effective modifications, such as limiting consumption of alcohol and caffeine before bedtime to reduce nighttime urination. Dietary changes focusing on a low-fat diet rich in fruits, vegetables, and healthy fats can also help manage symptoms.
If symptoms become bothersome, prescription medication is typically the next line of defense. Alpha-blockers work quickly by relaxing the smooth muscles in the prostate and bladder neck, which immediately improves urine flow without shrinking the gland. The other main class is 5-alpha reductase inhibitors, which function by reducing the body’s production of dihydrotestosterone (DHT), the hormone responsible for prostate growth. These inhibitors are slow-acting, taking several months to reduce prostate volume, and are often prescribed for men with larger prostates (typically over 30cc or 40mL). While these medications effectively manage symptoms and can slow the progression of the condition, they do not offer a permanent resolution or cure for BPH.
Modern Minimally Invasive Office Procedures
For men seeking relief without the long-term commitment of daily medication or the recovery associated with major surgery, several minimally invasive procedures can be performed in an outpatient setting. Water Vapor Thermal Therapy (Rezūm) uses sterile steam to treat the excess prostate tissue. During the procedure, the steam is injected into the targeted area, and the thermal energy destroys the obstructing cells. The body gradually absorbs the treated tissue, which shrinks the prostate and opens the urethra over the next three months. This treatment is suitable for prostates between 30 and 80 cubic centimeters and aims to preserve sexual function.
The Prostatic Urethral Lift (PUL), marketed as UroLift, uses a mechanical approach where tiny, permanent implants are inserted through the urethra to physically pull the enlarged prostate lobes away from the urinary channel. This action immediately relieves compression on the urethra, resulting in rapid symptom improvement and minimal downtime. A new, non-ablative option is the Temporary Implantable Nitinol Device (iTind), where a temporary scaffold is placed in the prostatic urethra for five to seven days. Once removed, this device leaves behind a wider passage for urine flow by gently remodeling the tissue. Both PUL and iTind are frequently chosen for their ability to preserve both erectile and ejaculatory function.
Advanced Surgical and Ablative Techniques
For men with larger prostates, more severe symptoms, or those who fail to find relief from less invasive methods, advanced surgical techniques offer durable, long-term solutions. Holmium Laser Enucleation of the Prostate (HoLEP) is a highly effective procedure considered the modern standard for removing large amounts of tissue. The surgeon uses a laser to precisely peel the inner obstructing prostate tissue from the outer capsule (enucleation), before the removed tissue is chopped and suctioned out. HoLEP can be used on prostates of virtually any size, and its thorough removal of tissue makes re-treatment highly unlikely, though it carries a high risk of permanent retrograde ejaculation.
Waterjet Ablation (Aquablation)
Waterjet Ablation, or Aquablation, uses a robotically controlled, heat-free, high-pressure water jet to remove prostate tissue. This procedure is guided by real-time ultrasound imaging, allowing the surgeon to create a precise, customized surgical map to spare sensitive structures. Aquablation is highly effective for any prostate size and is associated with a lower risk of long-term sexual side effects compared to traditional surgery.
Prostate Artery Embolization (PAE)
Prostate Artery Embolization (PAE) is a non-surgical option performed by an interventional radiologist. It involves blocking the small arteries that supply blood to the prostate, causing the gland to shrink over several months. PAE is done under local anesthesia and is a viable choice for patients who are not candidates for other surgery, such as those on blood thinners or with significant comorbidities.
Factors Guiding Treatment Selection
The selection of the appropriate treatment depends on multiple anatomical and personal factors. The primary variable is prostate size, often measured in cubic centimeters (cc). Smaller glands (30cc to 80cc) are suitable for office-based procedures like Rezūm and UroLift. Conversely, HoLEP and Aquablation are often reserved for prostates exceeding 80cc, where less aggressive methods may be insufficient. Prostate Artery Embolization is often considered when the gland is at least 45cc and the patient is high-risk for anesthesia.
Symptom severity, quantified using the International Prostate Symptom Score (IPSS), helps determine if watchful waiting, medication, or a procedural intervention is necessary. Patient preference regarding sexual side effects is a major deciding factor, as the risk of retrograde ejaculation is nearly certain with HoLEP but low with UroLift, iTind, and PAE. Recovery time is also a consideration; office procedures offer the quickest return to normal activities, while HoLEP and Aquablation may require a hospital stay and a longer period of restricted activity. The best course of action is determined through a comprehensive evaluation and discussion with a urologist.