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decision pointShould I have surgery or take medication to treat benign prostatic hyperplasia (BPH)?

If your benign prostatic hyperplasia (BPH) is causing lower urinary tract symptoms, options include watchful waiting, medicine, and surgery. Generally, watchful waiting or medicines are considered first, and then surgery. This Decision Point focuses on deciding between medicines and surgery.

Consider the following when making your decision:

  • If you have acute urinary retention (AUR, a blockage of the urethra that makes urination impossible) that comes back, urinary tract infections that happen again, kidney problems, bladder stones, or blood in your urine, surgery may be your best choice.
  • The American Urological Association (AUA) symptom index is used to help men determine the severity of their urinary symptoms and can also be used to measure the effectiveness of treatment. But the most important factor in deciding whether to get treatment is not your AUA rating, but how much the symptoms bother you and affect your quality of life.
  • Your BPH symptoms may come and go, stabilize, or get better over time. About 4 out of 10 men improve without treatment.1
  • You may find the side effects of medicine or surgery more bothersome than the BPH symptoms.
  • Medicines may decrease the risk for acute urinary retention and future surgery.2
  • There is no research directly comparing surgical treatment and medicine.

What is benign prostatic hyperplasia?

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland that occurs in almost all men as they age. The enlargement is usually harmless, but it often results in problems urinating. About half of all men older than 75 have some symptoms.3

What are the risks of BPH?

BPH can be inconvenient and may affect your quality of life, but it is usually not a serious problem.

In a small number of cases, BPH may cause bladder outlet obstruction (BOO), making it impossible or extremely difficult to urinate. This may result in backed-up urine (urinary retention), leading to bladder infections or bladder stones or kidney damage.

BPH may also irritate the bladder muscles as they enlarge to compensate for the increased force needed to empty the bladder.

BPH does not cause prostate cancer and does not affect a man's ability to father children. And it doesn't usually result in erection problems. But there is some association between severe symptoms of BPH and an increased risk of erection problems.

If you need more information, see the topic Benign Prostatic Hyperplasia (BPH).

Your choices are:

  • Use prescription medicines to relieve your symptoms. These include:
    • Alpha-blockers, such as doxazosin (Cardura) and terazosin (Hytrin).
    • 5-alpha reductase inhibitors, such as dutasteride (Avodart) or finasteride (Proscar).
  • Have surgery to relieve your symptoms. The most frequently performed surgeries are:
    • Transurethral resection of the prostate (TURP), where an instrument is inserted up the urethra to remove the section of prostate tissue that is blocking urine flow.
    • Transurethral incision of the prostate (TUIP), where an instrument is inserted up the urethra and an electric current or a laser beam is used to make incisions in the prostate where the prostate meets the bladder. This relaxes the opening to the bladder, decreasing resistance to the flow of urine out of the bladder. No tissue is removed.

The decision about whether to use medicines or surgery for BPH takes into account your personal feelings and the medical facts.

The American Urological Association (AUA) symptom index is used to help men determine the severity of their urinary symptoms and can also be used to measure the effectiveness of treatment. But the most important factor in deciding whether to get treatment is not your AUA rating, but how much the symptoms bother you and affect your quality of life.

Deciding about surgery or medicine for BPH
General reasons to have surgery General reasons to not have surgery and to use medicine
  • You cannot urinate.
  • You have a partial blockage in your urethra that is causing repeated urinary tract infections, bladder stones or infections, or bladder damage.
  • You have kidney damage.
  • You have moderate to severe symptoms that bother you.
  • Surgery provides quick relief of symptoms, as opposed to 2 or 3 weeks to 6 months with medicines.
  • Surgery gives a higher degree of symptom relief than medicine (see below).
  • Surgery gives more men symptom relief than medicine does (see below).

Are there other reasons you might want to have surgery?

  • You have mild or moderate symptoms.
  • Symptoms of BPH may come and go, stabilize, or get better over time.
  • Medicines relieve symptoms and may prevent complications (see below).
  • Surgery carries a risk of complications (see below).
  • You have other medical conditions that may affect the success of surgery.
  • Medicines don't require a hospital stay.

Are there other reasons you might not want to have surgery but instead might want to use medicines?

Comparison of treatments

The wide range of numbers in the following table is because few studies have been done and the studies have conflicting results.

How BPH treatments compare
Outcome from treatment

TURP (transurethral resection of the prostate)

TUIP (transurethral incision of the prostate)

Medicines (alpha-blockers or 5-alpha reductase inhibitors)

Chance that symptoms will improve

70%–96%4

78%–83%4

60%–85% for alpha-blockers5

50%–70% for finasteride5

Amount of symptom improvement

85%4

73%4

15%–44% with alpha-blockers5

25%–30% with finasteride5

Ejaculation problems, such as retrograde ejaculation in surgeries (semen enters the bladder instead of going out of the penis) or less semen ejaculated (smaller ejaculatory volume)

25%–99%4

6%–55%4

1%–10%6

Erection problems

3%–35%4

4%–25%4

2%–4% (finasteride)6

Chance of needing a second operation

2 or 3 men out of 100 after 3 years4

About 10 men out of 100 after 15 years4

None

Incontinence

70–140 men out of 10,0004

6–11 men out of 10,0004

None

Other

Often used for larger prostates

Very large prostates may require an open prostatectomy.

  • Less blood loss than TURP
  • Done more quickly than TURP
  • Often used for smaller prostates or if a man wants to reduce the chance of retrograde ejaculation

5-alpha reductase inhibitors: Other side effects include decreased sex drive and reduced ejaculatory volume.

Alpha-blockers: Other side effects include weakness or fatigue; lightheadedness, dizziness, or fainting when standing; a slight decrease in blood pressure; and headaches and nasal congestion.

See information on medicines for benign prostatic hyperplasia.

Those with very large prostates may consider an open prostatectomy.

Other surgical options include laser therapy, transurethral microwave therapy (TUMT), and transurethral needle ablation (TUNA). There are some other surgeries that are used in rare cases. Talk to your doctor about these options.

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about surgery or medicines to treat your BPH. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I have a lot of trouble urinating. Yes No Unsure
I have repeated urinary infections or bladder stones. Yes No Unsure
I have bladder or kidney damage. Yes No Unsure
I have moderate to severe symptoms that bother me. Yes No Unsure
I understand that symptoms may come and go or get better. Yes No Unsure
Surgery scares me. Yes No Unsure
I worry about the complications of surgery. Yes No Unsure
I have tried watchful waiting and medicines, and my symptoms still bother me. Yes No NA*
I have another medical condition that may affect having surgery. Yes No NA

*NA = Not applicable

Use the following space to list any other important concerns you have about this decision.

 

 

 

 

 

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason for making your choice.

Check the box below that represents your overall impression about your decision.

Leaning toward medicines

 

Leaning toward surgery

         

Citations

  1. Roehrborn CG, McConnell JD (2007). Benign prostatic hyperplasia: Etiology, pathophysiology, epidemiology, and natural history. In AJ Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 3, pp. 2727–2765. Philadelphia: Saunders Elsevier.

  2. Webber R (2006). Benign prostatic hyperplasia, search date May 2005. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

  3. Presti JC, et al. (2008). Benign prostatic hyperplasia (BPH) section of Neoplasms of the prostate gland. In EA Tanagho, JW McAninch, eds., Smith’s General Urology, 17th ed., pp. 348–370. New York: McGraw-Hill.

  4. Fitzpatrick JM (2007). Minimally invasive and endoscopic management of benign prostatic hyperplasia. In AJ Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 3. pp. 2803–2844. Philadelphia: Saunders Elsevier.

  5. Paterson R, Goldenberg L (2001). Benign prostatic hyperplasia. In J Teichman, ed., 20 Common Problems in Urology, part 2, pp. 185–198. New York: McGraw-Hill.

  6. Kirby R, Lepor H (2007). Evaluation and nonsurgical management of benign prostatic hyperplasia. In AJ Wein, ed., Campbell-Walsh Urology, 9th ed., vol. 3, pp. 2766–2802. Philadelphia: Saunders Elsevier.

Author Monica Rhodes
Editor Kathleen M. Ariss, MS
Associate Editor Pat Truman, MATC
Primary Medical Reviewer E. Gregory Thompson, MD - Internal Medicine
Specialist Medical Reviewer Christopher G. Wood, MD, FACS - Urology/Oncology
Last Updated March 24, 2008

WebMD Medical Reference from Healthwise

Last Updated: March 24, 2008
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.

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