A careful work-up is essential before choosing between medication, laser surgery and the various non-laser options. The aim is to quantify the obstruction, measure the prostate, rule out prostate cancer and check that the bladder is still working well.
The consultation begins with a structured history: symptom pattern and duration, episodes of retention or haematuria, medications (including alpha-blockers, 5-alpha-reductase inhibitors, anticholinergics, diuretics, blood thinners), previous prostate surgery, sexual function, and relevant comorbidities. The IPSS questionnaire is completed to quantify the burden of symptoms.
A focused abdominal examination looks for a palpable bladder suggestive of chronic retention. A digital rectal examination (DRE) estimates prostate size and detects firm areas that might indicate cancer. DRE findings always need to be correlated with PSA and imaging.
PSA (prostate-specific antigen) is measured to screen for prostate cancer before any prostate surgery. The result is always interpreted alongside age, prostate size, DRE and (where appropriate) MRI findings. A mildly elevated PSA in an enlarged prostate is often explained by the BPH itself, but significant elevations usually warrant further imaging and sometimes targeted biopsies.
A flow study is a simple non-invasive test in which the patient voids into a calibrated funnel. The peak flow rate (Qmax), average flow rate and pattern of the curve are recorded. Typical findings in outflow obstruction are a low Qmax (often under 10 mL/s) with a "plateau" curve. A flow study is usually repeated after surgery.
An ultrasound scan measures the volume of urine left in the bladder immediately after passing urine. A significantly elevated residual volume (often over 100 mL) suggests incomplete emptying and can influence the decision to operate.
An ultrasound scan performed via the rectum measures prostate volume accurately. This is particularly important before HoLEP, as gland size helps predict operating time and is sometimes used to determine whether very large glands need a staged approach.
Multiparametric MRI of the prostate is used where there is a suspicion of prostate cancer on DRE or PSA, or in men with a previous biopsy. It can also be helpful before HoLEP of a very large gland to visualise the adenoma and identify any anatomical variants.
A short day-procedure in which a flexible telescope is passed along the urethra to inspect the urethra, prostate and bladder. Indicated if there is blood in the urine, a suspicion of a urethral stricture or bladder-neck narrowing, or previous prostate surgery.
A specialised pressure-flow study, reserved for patients with a complex history (known neurological disease, previous prostate or bladder surgery, suspected detrusor underactivity) where it is important to distinguish between outflow obstruction and bladder muscle weakness before proceeding to surgery.
You can ask for a second opinion on your symptoms, flow studies and prostate size before deciding between medication, HoLEP, GreenLight, TURP, UroLift, Rezum or iTind.