I have an enlarged prostate with urinary frequency and severe urgency. About every hour I feel a strong need to urinate.
Several urologists have given me different opinions. Some recommend surgery while others advise me not to have surgery.
I have taken tamsulosin 0.4 mg and Proscar (finasteride) 5 mg without much improvement.
Should I continue medicines or consider surgery? Are there herbal medicines that can reduce the prostate and improve frequency and urgency?
Quick Answer
Severe urinary urgency and frequency despite BPH medication do not automatically mean that you need surgery, but they do justify a careful reassessment.
At age 75, symptoms such as urinating every hour can result from prostate obstruction, but they can also come from an overactive bladder, urinary tract infection, incomplete emptying, bladder muscle changes, stones, excess fluid or caffeine, medications, or other urinary conditions.
Before deciding between medicines and surgery, I would want to know your prostate size, urinary flow rate, post-void residual urine, urinalysis, kidney function, PSA when appropriate, and how severe the symptoms are on a standard symptom score.
Surgery becomes more compelling when medication has failed and symptoms remain very troublesome, or when BPH causes complications such as recurrent urinary retention, recurrent infection, bladder stones, persistent bleeding, or kidney and upper urinary tract problems.
Herbal treatments should not be relied on to shrink a significantly enlarged prostate or replace indicated medical or surgical treatment. Evidence for saw palmetto is inconsistent, and evidence for Pygeum and similar products remains limited. :contentReference[oaicite:1]{index=1}
Why Can BPH Cause Frequency and Urgency?
Benign prostatic hyperplasia can narrow the outlet from the bladder and make urination more difficult.
Over time, the bladder may need to contract more strongly to overcome this resistance. In some men, the bladder becomes more sensitive or overactive, leading to what doctors call storage symptoms.
These can include:
- frequent urination;
- sudden urgency;
- urgency incontinence;
- and waking repeatedly at night to urinate.
Current EAU guidance recognizes that urgency and frequency are important male lower urinary tract symptoms and that treatment sometimes needs to address the bladder itself rather than the prostate alone. :contentReference[oaicite:2]{index=2}
Why Might Tamsulosin Not Be Enough?
Tamsulosin is an alpha-blocker. It relaxes smooth muscle around the prostate and bladder outlet and can improve urinary flow and symptoms relatively quickly.
However, it does not substantially shrink the prostate and it does not prevent BPH progression, urinary retention or the eventual need for surgery. :contentReference[oaicite:3]{index=3}
If urgency is being driven mainly by an overactive bladder rather than outlet resistance, tamsulosin alone may provide limited relief.
You can read more about how alpha-blockers differ from other BPH medications .
What About Finasteride 5 mg?
Finasteride is a 5-alpha-reductase inhibitor. Unlike tamsulosin, it can gradually reduce prostate volume in appropriately selected men.
It is most useful when the prostate is sufficiently enlarged and the patient has a meaningful risk of BPH progression.
Its effect develops slowly, often over months rather than days or weeks.
If you have taken finasteride adequately but continue to have severe symptoms, your urologist should ask whether:
- the prostate remains obstructive;
- the bladder has developed overactivity;
- the bladder muscle has become weak;
- post-void residual urine is elevated;
- or another diagnosis is contributing.
Burning During Urination Is Not Typical BPH Alone
Burning or painful urination deserves special attention because it is not a classic symptom that should simply be attributed to benign prostate enlargement.
Possible explanations include:
- urinary tract infection;
- prostatitis;
- urethral irritation or inflammation;
- bladder stones;
- urinary retention with secondary irritation;
- or another urinary tract disorder.
Urinalysis and, when infection is suspected, urine culture can help determine whether bacteria are present. Antibiotics should not be taken automatically; they are appropriate when a bacterial infection is actually suspected or confirmed.
What Does Lower Abdominal Pain Mean?
Lower abdominal discomfort may have several causes.
In a man with urinary problems, one important possibility is a bladder that is not emptying properly.
A markedly full bladder can cause pressure or discomfort above the pubic bone. But lower abdominal pain can also arise from infection, stones, bowel problems, musculoskeletal causes or other abdominal conditions.
This is why a proper prostate and urinary evaluation is more useful than assuming every symptom comes from the enlarged prostate.
What Tests Help Decide Whether Surgery Is Needed?
When two urologists give different recommendations, I would want the decision based on objective findings rather than age alone.
| Assessment | Why It Matters |
|---|---|
| Symptom score (IPSS) | Shows how severe the urinary symptoms are and how much they affect quality of life. |
| Urinalysis / urine culture | Helps detect infection, blood or other urinary abnormalities. |
| Post-void residual (PVR) | Measures how much urine remains in the bladder after urination. |
| Uroflowmetry | Measures urinary-flow rate and may suggest obstruction or weak bladder contraction. |
| Prostate size | Helps determine whether finasteride is appropriate and influences which procedure may be suitable. |
| Kidney function | Important when significant obstruction or chronic retention is suspected. |
| Ultrasound or other imaging | Can assess bladder, kidneys, residual urine, stones and prostate size when indicated. |
| PSA | May be used when prostate-cancer risk assessment would influence management. |
When Is Surgery Usually Recommended?
Surgery is not recommended simply because a prostate is enlarged.
Current EAU guidance says surgery is usually required when BPH causes significant complications such as:
- recurrent or refractory urinary retention;
- overflow incontinence;
- recurrent urinary tract infections;
- bladder stones or diverticula;
- persistent visible bleeding due to BPH;
- upper urinary tract dilation caused by obstruction;
- or associated kidney impairment.
Surgery may also be reasonable when symptoms remain substantially bothersome despite appropriately chosen conservative and medical treatment. :contentReference[oaicite:4]{index=4}
The decision depends more on overall health, heart and lung status, medications, prostate anatomy, severity of obstruction, bladder function, procedure type and how much the symptoms are affecting daily life.
Why Might Different Urologists Give Different Advice?
This can happen because there is not always one objectively correct treatment for men who fall between mild disease and an absolute surgical indication.
One urologist may prioritize avoiding procedural risk, while another may place more weight on the severity of symptoms and failure of medication.
The disagreement becomes easier to resolve when you know:
- your exact prostate volume;
- your IPSS symptom score;
- your maximum urinary-flow rate;
- your post-void residual;
- whether there is bladder damage or stone formation;
- whether your kidneys are affected;
- and whether urgency comes mainly from obstruction or overactive bladder.
Could the Bladder Be Causing the Urgency?
Yes.
Men can have both BPH and overactive bladder.
If urgency and daytime frequency are the dominant symptoms and post-void residual is reasonably low, the treating clinician may sometimes consider an overactive-bladder medication in addition to or instead of modifying BPH treatment.
Current EAU guidance states that antimuscarinic drugs can improve urgency, urgency incontinence and daytime frequency in men whose predominant symptoms are bladder-storage symptoms. However, these drugs require caution when residual urine is elevated; the guideline advises against their use when PVR is greater than 150 mL. :contentReference[oaicite:5]{index=5}
This is exactly why measuring residual urine before simply escalating medication can be useful.
Could a Beta-3 Agonist Be Considered?
Another class of medicines used for overactive bladder is the beta-3 adrenergic agonist class.
These medicines work on the bladder rather than shrinking the prostate. They may be considered in selected men with troublesome storage symptoms, depending on blood pressure, other conditions and the overall urinary assessment.
This is a discussion to have with your treating physician rather than a reason to add medication yourself.
Can Herbal Medicine Reduce the Prostate?
I would be cautious with that expectation.
Several supplements have been promoted for BPH, including saw palmetto, Pygeum, stinging nettle and pumpkin-derived products.
The evidence is much weaker and less consistent than the evidence supporting established BPH medication and procedural treatment.
Saw palmetto
Large controlled trials and systematic reviews have found that saw palmetto often performs no better than placebo for BPH urinary symptoms, although some studies of specific preparations have reported modest benefit. NCCIH therefore describes the evidence as mixed rather than establishing saw palmetto as a reliable treatment. :contentReference[oaicite:6]{index=6}
Pygeum
Pygeum africanum has limited older evidence suggesting possible short-term symptom improvement, but the trials were small, short and used varying preparations. It has not been established as a dependable way to shrink a large prostate or prevent urinary retention. :contentReference[oaicite:7]{index=7}
For a full evidence review, see: natural remedies for enlarged prostate .
If testing shows recurrent retention, high residual urine, bladder damage, recurrent infection, stones, kidney consequences or severe obstruction, supplements are not an evidence-based substitute for appropriate urological treatment.
Can Lifestyle Changes Help Urgency and Frequency?
They may help, especially when symptoms have a significant bladder-storage component.
Useful measures may include:
- avoiding excessive fluid intake;
- reducing evening fluids if nighttime urination is troublesome;
- limiting caffeine if it worsens urgency;
- limiting alcohol if it increases frequency;
- avoiding constipation;
- reviewing diuretics and other medicines with your doctor;
- timed voiding or bladder training when appropriate;
- and avoiding unnecessary repeated trips to the toilet “just in case.”
Lifestyle treatment is part of BPH management , but severe persistent symptoms still deserve medical evaluation.
Dr. Albana’s Perspective
For Haroon, I would not recommend choosing surgery or herbs from the symptom description alone.
The key fact is that you are urinating roughly every hour despite having tried tamsulosin and finasteride. That tells me the current strategy has not controlled the problem adequately, but it does not tell me why.
I would want to separate three questions:
- Is the enlarged prostate significantly obstructing urine flow?
- Is the bladder itself overactive or weakened?
- Is another condition, such as infection or stones, contributing to the burning and lower abdominal discomfort?
If testing shows substantial obstruction or a BPH complication, surgery may offer more benefit than continuing ineffective medication.
If obstruction is modest and urgency is mainly coming from an overactive bladder, a bladder-directed treatment may be more appropriate than prostate surgery.
That distinction can explain why different urologists have given you different recommendations.
— Dr. Albana Greca, MD, MMedSc
Family Physician / General Practitioner
If Surgery Is Recommended, Which Procedure?
There is no single best BPH operation for every man.
Procedure selection depends heavily on prostate size and anatomy, as well as bleeding risk, medications, anesthesia considerations, surgeon expertise and whether preserving ejaculation is important to the patient.
Options may include:
- transurethral resection of the prostate (TURP);
- laser enucleation procedures such as HoLEP;
- other laser or ablative procedures;
- selected minimally invasive approaches;
- or simple prostatectomy for particularly large glands when appropriate.
See my complete BPH surgery guide for the differences between procedures.
What Should You Ask the Urologist Before Agreeing to Surgery?
- What is my exact prostate size?
- What is my maximum urinary-flow rate?
- What is my post-void residual urine?
- Do I have definite bladder outlet obstruction?
- Could my urgency be caused partly by overactive bladder?
- Why have tamsulosin and finasteride not helped enough?
- Do I have any absolute indication for surgery?
- What happens if I choose not to have surgery now?
- Which procedure are you recommending and why?
- What is the expected chance that urgency and frequency will improve?
- Could urgency remain even after prostate surgery?
- What are the risks of bleeding, infection, incontinence and sexual side effects?
Prostate surgery can relieve obstruction very effectively, but bladder overactivity may sometimes persist afterward, particularly when storage symptoms have been present for a long time. This is important when deciding whether surgery is likely to solve the symptom that bothers you most.
When to Seek Urgent Medical Care
Seek prompt medical attention if you develop:
- complete inability to urinate;
- severe lower abdominal pain with a full or swollen bladder;
- fever or chills with burning urination;
- visible blood in the urine that is heavy or persistent;
- vomiting, weakness or confusion associated with urinary symptoms;
- or significant flank/back pain with urinary problems.
Acute urinary retention and serious urinary infection require prompt assessment rather than self-treatment with herbs or leftover medication.
Frequently Asked Questions
Does severe urinary urgency mean I need BPH surgery?
Not automatically. Urgency can result from bladder outlet obstruction, overactive bladder, infection and other causes. Surgery is more appropriate when objective obstruction or BPH complications are present, or when bothersome symptoms remain inadequately controlled despite appropriate treatment.
Why am I urinating every hour despite tamsulosin?
Tamsulosin may not fully relieve obstruction, and urgency may be caused partly by bladder overactivity rather than the prostate alone. Post-void residual, urinary-flow testing and assessment for infection or other bladder problems can help clarify the cause.
Does finasteride work immediately?
No. Finasteride acts gradually and its benefits usually develop over several months. It is most useful in appropriately selected men with an enlarged prostate and a risk of BPH progression.
Can burning urination be caused by BPH?
BPH can coexist with burning, but painful or burning urination is not a specific BPH symptom. Urinary infection, prostatitis, urethral irritation, stones and other conditions should be considered.
Can saw palmetto replace tamsulosin or surgery?
Not reliably. Evidence for saw palmetto is inconsistent, and high-quality studies have often found no better symptom improvement than placebo. It should not replace necessary BPH treatment when obstruction or complications are present.
Can BPH surgery cure urinary urgency?
Surgery can relieve obstruction, which may improve urgency and frequency. However, some men continue to have overactive-bladder symptoms even after the obstruction has been treated, so the likely cause of urgency should be discussed before surgery.
Is age 75 too old for BPH surgery?
Not necessarily. Chronological age alone does not determine suitability. Overall health, anesthesia risk, medications, prostate anatomy, severity of obstruction and the expected benefit of the procedure are more important.
Related Guides
Medical References
-
European Association of Urology.
EAU Guidelines on the Management of Non-neurogenic Male Lower Urinary
Tract Symptoms — Disease Management.
EAU Male LUTS Guideline -
European Association of Urology.
EAU Guidelines on Non-neurogenic Male LUTS — 2026 Update.
EAU 2026 Guideline Update -
National Center for Complementary and Integrative Health.
Benign Prostatic Hyperplasia and Complementary and Integrative
Approaches.
NCCIH -
National Center for Complementary and Integrative Health.
Saw Palmetto.
NCCIH Saw Palmetto Review
Medical information notice: This article provides general patient education. Whether BPH surgery is appropriate depends on the severity and cause of urinary symptoms, prostate size, residual urine, urinary-flow testing, complications, bladder function, overall health and the patient’s preferences. Do not stop prescribed BPH medication or substitute herbal products without discussing the change with the treating clinician.
Written & medically reviewed by Dr. Albana Greca, MD, MMedSc • Family Physician / General Practitioner • Last medically reviewed: August 2026