My Clinical Approach to BPH
BPH is one of the most common conditions I treat at my urology practice in Rhodes. Many men endure significant urinary symptoms for years before seeking help — wrongly assuming that nocturia and a weak stream are simply “part of ageing.” They are not inevitable, and virtually always treatable.
My approach starts with accurate symptom quantification (IPSS Score + 3-day voiding diary), cancer exclusion (PSA + DRE), and post-void residual urine (PVR) measurement. I follow the EAU 2026 stepwise approach — progressing from watchful waiting to medication to minimally invasive procedures or surgery, guided by the balance of efficacy, side-effects and durability.
- IPSS Score + post-void residual + PSA as the foundation of every evaluation.
- Cancer exclusion before attributing symptoms to BPH.
- Individualised treatment — medical, minimally invasive, or surgical.
- Quality-of-life focus — restoring normal voiding is the goal.
What is Benign Prostatic Hyperplasia
The prostate is a walnut-sized gland located below the bladder, surrounding the urethra. Over time, the prostate naturally enlarges (hyperplasia) and may compress the urethra, obstructing urine flow. This non-cancerous enlargement is called BPH.
BPH affects an estimated 5–6% of men aged 40–64 and 29–33% of men aged ≥65. The prostate continues to grow throughout life — but the rate and impact vary considerably between individuals.
BPH, LUTS & BPO — Modern EAU Terminology
The EAU 2026 uses three distinct terms: BPH (histological diagnosis — confirmed only microscopically), LUTS (the patient’s clinical symptoms), and BPO (Benign Prostatic Obstruction — the urodynamically confirmed obstruction that is actually treated).
BPH ≠ Prostate cancer. BPH does not develop into prostate cancer. However, they can coexist — which is why PSA testing and DRE remain important for every patient presenting with LUTS.
Causes & Risk Factors
BPH results from hormonal changes associated with ageing:
Age
The single most important risk factor. BPH is rare before 40 — incidence rises dramatically after 60.
Hormonal Changes
Shifts in testosterone/oestrogen ratios with age, and accumulation of dihydrotestosterone (DHT) within prostate tissue, drive glandular proliferation.
Family History
Men with a father or brother with BPH tend to develop the condition earlier and with greater enlargement.
Metabolic Syndrome / Obesity
Diabetes, hypertension, and elevated BMI are associated with higher risk of symptomatic BPH.
Symptoms & Clinical Presentation
BPH causes lower urinary tract symptoms (LUTS), classified as:
Storage Symptoms
Urinary frequency (>8 times/day), nocturia (≥2 times/night), urgency (sudden strong urge to void), sensation of incomplete bladder emptying.
Voiding Symptoms
Weak or intermittent urine stream, hesitancy (difficulty starting), prolonged voiding, terminal dribbling.
Post-Voiding Symptoms
Feeling of incomplete emptying, post-micturition dribble.
BPH or Prostate Cancer? — The Symptoms Can Be Identical
The urinary symptoms of BPH are the same as those that can appear in advanced prostate cancer. The key difference: prostate cancer in its early, curable stage is asymptomatic. This is why proper assessment is mandatory:
- PSA blood test for every new patient presenting with LUTS.
- Digital rectal examination (DRE) to assess prostate texture.
- Never attribute urinary symptoms to BPH without a proper urological evaluation.
IPSS Score — Symptom Severity
The International Prostate Symptom Score (IPSS) is the standardised questionnaire for assessing LUTS severity. It comprises 7 questions (0–5 points each) + 1 quality-of-life question:
IPSS 0–7
Mild SymptomsWatchful WaitingRegular monitoring without immediate treatment. Lifestyle modifications (reduce caffeine/alcohol, limit evening fluids, double voiding technique).
IPSS 8–19
Moderate SymptomsMedical TherapyAlpha-blockers ± 5-alpha reductase inhibitors ± tadalafil 5 mg/day. Reassess in 4-6 weeks.
IPSS 20–35
Severe SymptomsSurgical AssessmentEvaluation for TURP, HoLEP, or minimally invasive procedures. Urgent treatment if complications present.
Diagnostic Evaluation
Standard evaluation for a man presenting with LUTS:
History & IPSS Score
Detailed symptom history, current medications, voiding diary. IPSS questionnaire completion.
PSA & Digital Rectal Examination
Cancer exclusion. PSA density (PSA/prostate volume) for risk assessment. DRE to assess prostate size and consistency.
Ultrasound of the Urinary Tract
Prostate volume measurement. Post-void residual urine (PVR) quantification. Kidney assessment for hydronephrosis.
Urodynamic Studies (selected cases)
When there is uncertainty about the degree of obstruction versus a weak detrusor muscle — before deciding between medical and surgical management.
Treatment Options
Treatment is chosen based on symptom severity, prostate size, and presence of complications:
Watchful Waiting & Lifestyle Changes
For IPSS 0-7 without complications. Reduce caffeine/alcohol, limit evening fluids, double voiding technique, regular moderate exercise. Annual review.
Medical Therapy
Alpha-blockers (tamsulosin, silodosin) for rapid flow improvement. 5-alpha reductase inhibitors (finasteride, dutasteride) to shrink prostate >40 mL — 3-6 months for effect. Combination therapy ± tadalafil 5 mg/day for LUTS + erectile dysfunction.
Minimally Invasive Procedures (MiSTs)
UroLift (PUL): mechanical tissue lift — no heat, preserves ejaculation, day-case. Rezūm (water vapour): targeted steam ablation of prostate tissue. iTIND: temporary nitinol device remodelling the urethra. Prostatic Artery Embolisation (PAE): for selected patients. Best for prostates 30–80 mL without a large median lobe. Rapid recovery.
Surgical Treatment — TURP / HoLEP / Aquablation
TURP (bipolar): gold standard for 30–80 mL prostates. HoLEP (holmium laser enucleation): for all sizes including >100 mL — durable results >15 years, minimal bleeding. Aquablation (robotic waterjet): novel technology preserving ejaculation in high proportion of patients. Open/robotic simple prostatectomy (RASP) for very large glands (>100–150 mL).
Complications & When to See a Urologist
If BPH is left untreated, complications can develop:
- Acute urinary retention — complete inability to urinate, requiring emergency catheterisation.
- Recurrent urinary tract infections (UTIs).
- Bladder stones (from urinary stasis).
- Kidney damage from chronic urinary retention (hydronephrosis).
- Haematuria (blood in urine) — requires urological investigation.
See a Urologist Urgently if:
- You cannot urinate at all (medical emergency).
- You notice blood in your urine.
- You develop a fever alongside urinary symptoms (possible infection/abscess).
- Your symptoms suddenly worsen significantly.
Follow-up & Prognosis
BPH is a chronic condition requiring regular monitoring:
- Annual urological review: IPSS Score + post-void residual + PSA.
- Assessment of medical therapy effectiveness at 4-6 weeks.
- On watchful waiting: reassessment every 6-12 months.
- After surgery: check at 4-6 weeks, then annually.
Prognosis
With appropriate treatment, the vast majority of men achieve satisfactory voiding quality. After TURP/HoLEP, >85% experience significant IPSS improvement. Medical therapy controls symptoms in most mild-to-moderate cases, though it does not reverse the anatomical enlargement.
Frequently Asked Questions (FAQ)
Is benign prostatic hyperplasia the same as prostate cancer?
No. BPH is a non-cancerous enlargement of the prostate. It does not develop into prostate cancer. However, they can coexist and share similar urinary symptoms — which is why PSA testing and proper clinical evaluation are necessary for every man with LUTS.
Does a larger prostate always cause worse symptoms?
Not necessarily. Symptom severity depends on where the enlarged tissue presses on the urethra, not just prostate volume. A moderately enlarged prostate in a strategic position can cause worse obstruction than a very large one. The IPSS Score and post-void residual urine measurement are more reliable indicators than size alone.
What is the difference between alpha-blockers and 5-alpha reductase inhibitors?
Alpha-blockers (e.g. tamsulosin, silodosin) relax the smooth muscle of the bladder neck and urethra — they provide fast relief within 1-2 weeks but do not shrink the prostate. 5-alpha reductase inhibitors (finasteride, dutasteride) actually reduce prostate size by blocking DHT production — but take 3-6 months for full effect and work best for prostates >40 mL. They are often combined.
Can BPH surgery be done as a day case?
Often yes. UroLift and Rezūm are typically performed as outpatient procedures under local anaesthesia. TURP and HoLEP require a short hospital stay (1-2 days) but offer more durable results. The right procedure depends on prostate size, anatomy, and patient health.
Will I need a catheter or experience incontinence after surgery?
After TURP or HoLEP, a urinary catheter is placed for 1-2 days post-operatively. Temporary urinary urgency or leakage is common but usually resolves within weeks. Minimally invasive options (UroLift/Rezūm) have faster recovery and minimal incontinence risk.
Does BPH affect erectile function?
BPH itself does not cause erectile dysfunction. However, certain medications (finasteride rarely) and surgical procedures (TURP/HoLEP) are associated with retrograde ejaculation in 60-90% of cases. Minimally invasive techniques generally preserve antegrade ejaculation. Tadalafil 5 mg/day treats both LUTS and erectile dysfunction simultaneously.
Can I delay treatment for BPH?
Yes, if symptoms are mild (IPSS 0-7) and no complications are present. Watchful waiting with lifestyle modifications is safe. However, if complications develop — urinary retention, recurrent infections, bladder stones, or kidney damage — treatment becomes urgent.
What lifestyle changes help with BPH symptoms?
Reducing caffeine and alcohol (especially in the evening), limiting fluid intake after 6 pm, practising double voiding (trying to urinate twice in succession), avoiding medications that worsen urinary retention (certain antihistamines, cold remedies), and regular moderate exercise all help reduce LUTS severity.
Related Topics
Book Your Appointment in Rhodes
Urinary symptoms affecting your sleep or daily life? Specialised urological assessment with IPSS scoring, ultrasound, and PSA at our practice in Rhodes.
References – Sources
- EAU Guidelines on Non-neurogenic Male LUTS 2026 — uroweb.org
- AUA Guideline on Benign Prostatic Hyperplasia 2024 — auanet.org
- Sakalis V, et al. EAU Guidelines on Management of Non-Neurogenic Male LUTS. Eur Urol 2025;87:doi:10.1016/j.eururo.2025.04.025
- McVary KT, et al. Update on AUA Guideline on the Management of BPH. J Urol 2011;185:1793–803.
- NIDDK: Prostate Enlargement (Benign Prostatic Hyperplasia) — niddk.nih.gov
Medical Review
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas runs a private urology practice in Rhodes specialising in the assessment and management of benign prostatic hyperplasia, applying the EAU 2026 stepwise approach with an individualised plan for each patient.
View full profile
