Benign prostatic hyperplasia (BPH), commonly referred to as an enlarged prostate, is a highly prevalent condition affecting millions of men as they age. While it is not cancerous, its impact on daily life can be significant, causing lower urinary tract symptoms (LUTS) such as frequent urination, weak stream, urgency, or nocturia.

Over the past decade, treatment options for BPH have expanded considerably. In addition to medications and conventional surgery, there are now several minimally invasive therapies that offer effective symptom relief with reduced side effects and shorter recovery times.

What is BPH and why an enlarged prostate deserves more attention

BPH is the non-cancerous enlargement of the prostate gland, a condition that becomes increasingly common with age. As the prostate grows, it can compress the urethra and interfere with normal urine flow.

Men with BPH often experience:

• A weak or interrupted stream
• Difficulty starting urination
• Frequent urination, especially at night
• A sensation of incomplete bladder emptying

While the condition is not life-threatening, it can significantly impair quality of life. Sleep disruption, daily discomfort, and anxiety about access to bathrooms are common. Unfortunately, many men delay seeking care, either due to embarrassment or the belief that it’s just a normal part of aging.

Traditional treatments for enlarged prostate: What we’ve been using

Over the years, the management of BPH has traditionally relied on a combination of medications and surgical procedures, depending on the severity of symptoms and patient preferences. These approaches have helped many men manage their symptoms effectively, but they also come with certain limitations.

Watchful waiting: When it’s OK to wait

For men with mild symptoms that do not significantly affect quality of life, active surveillance may be appropriate. Regular monitoring without immediate intervention allows time to evaluate symptom progression and defer treatment when possible.

Medications: A first step for many men

The most common initial approach involves oral medications:

• Alpha-blockers (e.g., tamsulosin) relax the smooth muscle of the prostate and bladder neck to improve urine flow.
• 5-alpha-reductase inhibitors (e.g., finasteride) work by shrinking the prostate over time.

While medications can be effective, they may cause side effects such as dizziness, fatigue, or sexual dysfunction. Additionally, some men do not experience sufficient relief or become less responsive over time.

TURP: the surgical gold standard

Transurethral resection of the prostate (TURP) has long been considered the standard surgical treatment for BPH. It involves removing obstructing prostate tissue using an instrument inserted through the urethra.

TURP offers durable results, but it also requires anesthesia, a hospital stay, and a longer recovery period. Potential side effects include bleeding, incontinence, and retrograde ejaculation.

What’s new in treating BPH and why it matters

In recent years, minimally invasive surgical treatments (MISTs) have become more widely available. These procedures aim to provide symptom relief with less downtime, fewer side effects, and in many cases, preservation of sexual function.

Laser ablation techniques (HoLEP, PVP): modern options with deep roots

Laser therapies such as HoLEP (Holmium laser enucleation of the prostate) and PVP (photoselective vaporization) have long-standing FDA clearance, depending on the specific laser platform (e.g., GreenLight laser for PVP). These procedures have evolved significantly and are now considered key surgical options for managing BPH.

HoLEP is a laser-based enucleation technique widely endorsed by both the American Urological Association (AUA) and the European Association of Urology (EAU) as a size-independent gold-standard treatment for BPH. It provides excellent outcomes even in very large prostates, with lower bleeding risk, shorter catheterization time, and faster hospital discharge compared to traditional TURP.

PVP uses laser energy to vaporize obstructing tissue with minimal blood loss and is often preferred in patients on anticoagulation. Both procedures are typically performed under general or spinal anesthesia and require specialized surgical expertise, but offer long-term symptom relief with favorable safety profiles.

Rezūm: steam therapy that shrinks the prostate

Rezūm is an FDA-approved office-based procedure that uses water vapor to ablate excess prostate tissue. It typically takes 10–30 minutes and is performed under local anesthesia.

• Preserves erectile function
• Minimal recovery time
• Ideal for men with mild to moderate prostate enlargement

UroLift: a mechanical lift without cutting

The UroLift is also FDA-approved and involves the placement of tiny implants to lift and hold open the obstructed prostate lobes.

• No tissue is removed
• Often performed without a catheter
• Designed to preserve ejaculation and erectile function

Aquablation: robotic waterjet precision

Aquablation therapy received FDA approval in 2017. It uses robotic-guided, high-pressure water jets to remove excess prostate tissue, typically in an operating room setting.

• Heat-free, image-guided precision
• Effective also for larger prostates
• May preserve ejaculation in many patients

Prostatic artery embolization (PAE): a radiologic approach for select patients

Prostatic artery embolization (PAE) is a minimally invasive procedure performed by interventional radiologists to treat benign prostatic hyperplasia (BPH). It works by embolizing (blocking) the arteries supplying blood to the prostate, leading to gradual shrinkage of the gland and relief of urinary symptoms.

• Performed under local anesthesia, typically on an outpatient basis
• No instrumentation of the urethra, reducing the risk of sexual or urinary side effects
• Shorter recovery time compared to traditional surgical procedures
• Particularly suitable for patients with large prostates, multiple comorbidities, or those who wish to avoid surgery
• Symptom improvement typically seen within weeks to a few months

PAE offers an alternative for patients who are poor surgical candidates or wish to avoid more invasive procedures like TURP or laser therapies. However, thorough evaluation and imaging are essential to determine anatomical suitability and procedural success.

Choosing the right treatment: What really matters

Prostate size, symptoms, and patient goals

Treatment selection depends on factors such as:

• Prostate volume
• Severity of symptoms
• Patient age and health status
• Impact on sexual function

Some therapies are better suited for larger prostates, while others aim to preserve ejaculation or offer same-day recovery.

What matters most to men: recovery, function, and lifestyle

Men often prioritize preservation of sexual function, short recovery time, and avoiding long-term medication. Having a thorough discussion with a urologist can help match treatment to expectations.

What you should ask your doctor

To make an informed decision, patients should consider asking:

• Am I a candidate for a minimally invasive procedure?
• What are the potential side effects and benefits of each option?
• How will this treatment affect my sexual health?
• What is the recovery time?
• What happens if I choose to delay treatment?

Open communication leads to more personalized care and better long-term satisfaction.

Final thoughts: You have options—use them

An enlarged prostate may be common, but that doesn’t mean you have to live with the symptoms indefinitely. New treatment options make it possible to reduce discomfort, improve urinary function, and protect quality of life, with less downtime than ever before.

If you’re experiencing urinary symptoms, it’s worth asking about the latest options. Treatment is no longer one-size-fits-all, and the right choice starts with the right conversation.

Martina Ambardjieva is a dedicated urologist and medical educator with extensive experience in both clinical practice and academic instruction. She earned her MD from the University “Sv. Kiril i Metódij” in Skopje and is a PhD candidate in urological oncology, with a focus on bladder carcinoma. Her scholarly work includes numerous publications in oncologic urology, urinary calculosis, and men’s health.

Dr. Ambardjieva currently serves as a urologist at the PHI University Surgical Clinic “Naum Ohridski” and completed her residency training at the University Urology Clinic in Skopje. Earlier in her career, she practiced as a general medical doctor at Sante Plus General Hospital and completed a medical internship at the University of Ljubljana.

In addition to her clinical responsibilities, Dr. Ambardjieva is a teaching assistant at the Medical Faculty in Skopje. She works additionally as a collaborator for Dr. Telx. She has held leadership positions in the European Medical Students’ Association and actively participates in international medical education and policy. She has attended numerous congresses and workshops in France, Italy, Canada, and Turkey, and serves as a delegate for the European Association of Urology (EAU), contributing to cross-border initiatives in urology. Certified in laparoscopic surgery, she continues to integrate patient care, research, and education in her professional work.