Benign Prostatic Hyperplasia (BPH) and Urinary Symptoms: Why Surgery May Be Considered Even When the Prostate Is Not Large
Benign prostatic hyperplasia (BPH) refers to a condition in which the prostate gland becomes enlarged and compresses the urethra, making it difficult for urine to pass normally and causing various urinary symptoms. BPH typically begins gradually after the age of 40. It affects approximately 60–70% of men in their 60s and nearly all men in their 70s.
Common symptoms include a weaker urine stream than before, increased urinary frequency—often more than eight times per day—and waking up at least once during the night to urinate. These urinary symptoms can significantly interfere with daily life and reduce quality of life for middle-aged men. Because of this, BPH should be actively evaluated and treated when symptoms become bothersome.
In the early stages of BPH, medication therapy is often effective. However, when symptoms become severe or do not respond to medication, surgical treatment may be considered. In general, urologists consider surgical treatment when the prostate size is approximately 35–40 grams or larger. However, there are cases in which surgery may still be necessary even when the prostate size is relatively small. The following clinical cases illustrate situations in which surgery may be considered despite a small prostate size.
Case A involved a 59-year-old man who frequently woke up three to four times per night due to nocturia. He also experienced a weak urinary stream and frequent urination. A transrectal ultrasound examination showed that his prostate size was 19.8 grams. Considering that the normal prostate size is approximately 15–20 grams, this size would not usually lead to surgical consideration. Despite this, the patient did not experience any improvement with medication therapy.
To identify the underlying cause more accurately, an additional cystourethroscopy was performed. The examination revealed that the bladder neck—the area where the bladder transitions into the urethra—was significantly narrowed, preventing urine from flowing properly. Surgical treatment was performed to correct the bladder neck obstruction. After the procedure, the patient’s peak urinary flow rate improved to 19.5 mL/sec. Considering that a normal peak urinary flow rate is above 15 mL/sec, this indicated a return to normal urinary function.
Case B presented an unusual symptom pattern. The patient reported that urination was relatively normal while standing but became difficult when sitting. The patient had already undergone medication therapy without improvement before visiting our clinic. Transrectal ultrasound examination revealed that the total prostate size was 23.4 grams, which is also generally considered too small to require surgical treatment.
However, uroflowmetry and post-void residual urine testing revealed a peak urinary flow rate of only 3.9 mL/sec and a residual urine volume of 85 mL. Given that the normal peak urinary flow rate is above 15 mL/sec, the urinary flow was significantly reduced. In addition, the residual urine volume accounted for nearly half of the total voided urine volume (153.5 mL), indicating severe urinary obstruction.
To determine the underlying cause of the severe symptoms despite the relatively small prostate size, cystourethroscopy was performed. The examination showed that part of the prostate was protruding into the urethra and also extending toward the bladder. In such cases, surgical treatment can be highly effective. Surgery was performed, and the patient’s peak urinary flow rate improved to 14.1 mL/sec with no remaining residual urine after urination.
These cases demonstrate that surgery for benign prostatic hyperplasia may be considered even when the prostate size is not particularly large. As seen in these examples, identifying the exact cause of urinary symptoms requires more than ultrasound examination alone. Additional diagnostic evaluation such as cystourethroscopy may be necessary because the location and pattern of prostate enlargement can vary significantly from one patient to another.
Because urinary symptoms can significantly affect the quality of life of middle-aged men, it is important to determine whether surgical treatment is necessary through a comprehensive evaluation. If you experience difficulty with urination or other urinary symptoms, seeking evaluation and treatment for benign prostatic hyperplasia is strongly recommended.
As men enter middle age and beyond, urologic conditions become increasingly common. By providing useful information about urinary diseases that interfere with daily life, the goal is to help individuals maintain a healthier and more comfortable quality of life.