The role of MRI in BPH: clearing the waters

Abstract Background: Benign Prostatic Hyperplasia (BPH) is common in ageing men. Traditional assessment involves a clinical history, flow studies, Digital Rectal Examinations (DRE), Prostate Specific Antigen (PSA) levels, International Prostate Symptom Score (IPSS), ultrasound (U,S), and histopathologic analysis (to exclude prostatic neoplasia). Magnetic resonance imaging (MRI), initially used to enhance neoplastic detection, is now emerging as a valuable tool in BPH classification and management. Objective: This review aims to elucidate the role of MRI in diagnosing, classifying, and managing BPH and highlights its advantages over conventional imaging modalities. Methods: A narrative review was conducted using current literature on prostate anatomy, BPH pathophysiology, and various imaging techniques, focusing on the evolving use of MRI. Findings: While transabdominal ultrasound remains a key initial tool for assessing bladder wall thickness, post-void residual volume, and general prostatic anatomy, MRI offers superior imaging resolution. It provides detailed visualisation of prostate architecture and accurate prostate volume estimation, therefore informing targeted biopsies and guiding treatment decisions. Wasserman's MRI-based classification system for BPH – PIRADS – notably correlates with symptom severity and IPSS. MRI also shows promise in preoperative planning; for instance, improved outcomes in holmium laser enucleation have been associated with preoperative peripheral zone thickness on MRI once malignancy is excluded. Conclusion: MRI is becoming increasingly valuable for diagnosing, classifying, and managing BPH. It enhances phenotypic characterization and guides therapeutic strategies with greater precision. Despite these benefits, MRI's cost and limited accessibility continue to hinder its routine use in managing BPH and remain a barrier to its widespread clinical adoption.