Benign prostatic hyperplasia (BPH) is a common condition that affects men as they age. When symptoms such as a weak urinary stream, increased frequency, or nocturia develop, treatment typically begins with medication. Surgery is often considered only when medications become less effective. However, because BPH is a progressive condition, surgical treatment may be appropriate even when symptoms are not yet severe, depending on the underlying clinical findings.
As men get older, the prostate tends to enlarge gradually. In Korean men in their 60s, the average prostate size is reported to be in the high 20-gram range, which often already falls within the spectrum of BPH. As the prostate enlarges, it compresses the urethra, requiring the bladder to generate greater force to expel urine. Over time, this sustained pressure causes the bladder muscle to thicken. Eventually, the bladder’s storage capacity may also decrease.
A key issue is that these changes develop slowly, and many patients may not notice significant discomfort. If treatment is delayed until bladder function has already declined, surgical intervention may not fully restore normal bladder function. Therefore, if diagnostic evaluation shows declining bladder function or progression of voiding dysfunction, surgical treatment should be considered even in patients with relatively mild symptoms.
Prostate-specific antigen (PSA) levels are another important factor in determining the treatment approach. PSA is a blood marker associated with prostate conditions, and levels below 3 ng/mL are generally considered within the normal range. In patients with BPH, PSA levels may be elevated. If PSA levels continue to rise or fluctuate significantly, additional evaluation may be required to rule out prostate cancer. In some cases, removing enlarged prostate tissue through surgery can also help normalize PSA levels.
It is also important to note that symptom severity alone does not always reflect disease progression. Beyond prostate size, the shape of the prostate and the degree of urethral obstruction are critical factors. For example, if the prostate protrudes into the bladder or significantly compresses the urethra, urinary function may be impaired even when symptoms appear mild. Over time, this can lead to increased post-void residual urine and a gradual decline in urinary flow, further worsening bladder function.
In recent years, treatment options for BPH have expanded. In addition to surgical procedures such as holmium laser enucleation of the prostate (HoLEP), minimally invasive treatments—including UroLift, Rezūm, Aquablation, and iTind—have been introduced. These approaches can reduce the burden of treatment, including bleeding and hospitalization, while effectively relieving prostatic obstruction.
Clinical experts emphasize that evaluating BPH should not focus solely on how bothersome the symptoms are, but also on how far the disease has progressed. Indicators such as increasing residual urine volume, decreased urinary flow rate, intravesical prostatic protrusion, and rising PSA levels are important markers of progression and should be carefully assessed when determining the optimal timing of treatment.