Many men take medication to manage benign prostatic hyperplasia (BPH). A common question patients ask is: how long do these medications need to be taken? Because BPH is a condition that progresses with aging, many patients continue medication for many years, often for life. However, surgical treatment can eliminate the need for long-term medication. In some cases, when a patient is highly likely to require surgery in the future, considering surgical treatment earlier may be a better option. Nevertheless, many patients prefer to delay surgery because their symptoms do not feel severe or because they are afraid of undergoing a procedure. For this reason, it is helpful to review real clinical cases that illustrate when earlier surgical treatment may be appropriate.
Consider the case of a 70-year-old male patient. He reported that his urinary symptoms improved when he took medication. A transrectal ultrasound examination showed that his prostate size was 40.2 grams. Since the average prostate size for Korean men in their 60s is typically in the high-20-gram range, this finding indicated benign prostatic hyperplasia. A uroflowmetry test showed a peak urinary flow rate of 16.4 mL/sec. In general, a peak flow rate above 15 mL/sec is considered relatively normal, meaning his symptoms were not extremely severe. However, the time required to complete urination was approximately one minute, suggesting that bladder outlet obstruction was present.
To determine whether surgery would be appropriate, cystoscopy (urethro-cystoscopy) was performed. Normally, the bladder lining should appear smooth, similar to the lining of the inside of the mouth. In this patient, however, the bladder mucosa appeared very irregular and uneven. This finding indicated bladder trabeculation, meaning the bladder muscle layer had become thickened.
When benign prostatic hyperplasia progresses, the bladder must generate significant pressure to push urine through the obstructed urethra. Just as muscles enlarge with repeated exercise, the bladder muscle also thickens under sustained pressure, leading to trabeculation. Over time, the bladder wall can become even thicker and the bladder’s storage capacity may decrease. In situations like this, earlier surgical treatment is often recommended. After discussing the findings, the patient underwent holmium laser enucleation of the prostate (HoLEP). Following surgery, his peak urinary flow rate improved to 25.9 mL/sec, returning to a normal range. This case demonstrates that when bladder function begins to deteriorate, earlier surgical treatment may be beneficial.
Surgical treatment may also be considered when prostate-specific antigen (PSA) levels are elevated, even if urinary symptoms are not severe. If PSA levels are high and continue to rise each year, prostate cancer must be considered, and additional tests such as MRI scans or prostate biopsy may be required. However, elevated PSA levels can also occur because of benign prostatic hyperplasia, and PSA levels often decrease after surgical treatment for BPH.
A second case involved a 56-year-old male patient. His PSA levels changed significantly over several years: 14.08 ng/mL in 2017, 7.52 ng/mL in 2019, and 33.39 ng/mL in 2020. Considering that PSA levels are generally expected to remain below approximately 3 ng/mL, these values were highly concerning. In such situations, repeated prostate biopsies or MRI examinations may be necessary to rule out prostate cancer. This patient underwent three prostate biopsies over three years, but none showed evidence of cancer. Prostate biopsy can be a difficult and uncomfortable procedure for patients because approximately twelve tissue samples are taken through the rectum using a needle.
In this patient’s case, transrectal ultrasound measured his prostate size at 71 grams. Given that a normal prostate is typically about 15–20 grams, this represented significant enlargement. Interestingly, the patient reported that his urinary symptoms were not particularly severe. However, from a specialist’s perspective, the combination of significantly elevated PSA levels, large prostate size, and fluctuating PSA values raised concern. For this reason, surgical treatment was recommended.
The patient ultimately underwent HoLEP surgery. After the procedure, the urethra was fully opened, and uroflowmetry results normalized. Most importantly, his PSA level dropped to 0.39 ng/mL, returning to a normal range and eliminating concerns about possible prostate cancer.
These cases demonstrate that even when patients believe their condition is manageable, objective medical evaluation may reveal underlying problems that require treatment. Fortunately, modern surgical techniques have advanced significantly. Many procedures are now less painful and require less operating time than in the past. For this reason, patients experiencing urinary symptoms should consult a urology specialist to receive a thorough evaluation and develop an appropriate treatment plan.
As men reach middle age and older, urologic conditions become increasingly common. By providing reliable information about urinary health conditions that affect everyday life, the goal is to help individuals maintain a healthier and more comfortable quality of life.