Most men with LUTS/BPH who desire treatment will initially opt for medications.212 The advent and rise of BPH medication use in the 1990s has demonstrated an overall decrease in the use of surgical therapy over the subsequent decades.212-214 However, symptomatic improvement with medications can be underwhelming, especially when viewed relative to placebo effect,215 with relatively poor medication adherence especially when combination therapy is recommended.216 The effect of ubiquitous medication use can be seen in the patient population now undergoing surgery. Patients are now generally older and have more medical comorbidities at the time of procedures.217, 218 In one study, men in the oldest age group (>85 years of age) had the highest rate of undergoing BPH surgery.212 Procedural options have more pronounced improvements in symptom score outcomes but also more concerning risk profiles than medications. Improvements in the safety of many of our traditional operating room procedures, and the introduction of many office-based options, have changed the relative risk-benefit profile in the decision for procedural management of LUTS/BPH. While generally considered safe, there are effects of long-term medication use. For these reasons, men with LUTS/BPH may pursue procedural options with or without an initial trial of BPH medications. Long-standing and undertreated LUTS/BPH can progress to incomplete bladder emptying, DU/detrusor acontractility, bilateral hydroureteronephrosis, and ultimately acute and/or chronic renal insufficiency. This progressive deterioration should be avoided as it is amongst the worst outcomes for men with LUTS/BPH. While men with ongoing elevated PVRs may be considered for alpha-adrenergic blockade, surgical options should also be considered due to the significant morbidity associated either with chronic catheterization or dialysis. rUTIs and bladder calculi may also fall along this continuum of incompletely treated BPH, although these sequelae are not present in all men. In men with rUTIs, BPH-specific causes such as an elevated PVR should be considered in addition to other etiologies (e.g., renal calculi, bacterial prostatitis). BPH treatment may commence while other etiologies are investigated and excluded. Medical options for BPH may be trialed, if not previously failed. Ultimately, patients with a persistently elevated PVR and rUTI may proceed to a BPH procedure to improve bladder emptying and reduce future risk of a UTI. Bladder stones are also felt to be a result of persistently elevated PVR and may be a marker of incomplete treatment of LUTS/BPH. Medical options may be considered as initial treatment. However, surgical options may be considered as first-line treatment as a combined cystolithalopaxy and BPH procedure may be appropriate in patients to reduce the potential need for two surgeries (one for stones and another for the failure of medical therapy).219 The number and size of bladder stones may influence the surgical approach between transurethral, open, or laparoscopic. It is important to note, however, that an elevated PVR without clinical sequelae should not be used as the only indication for bladder outlet surgery. The clinician should recall that there can be intra-patient variability in PVR over time.220 A persistently elevated PVR should be evaluated for safety issues as outlined in the AUA Non-Neurogenic Chronic Urinary Retention White Paper.66 History, physical exam, and testing should include changes that involve quality of life such as urinary symptoms and more dangerous signs and symptoms such as renal insufficiency and chronic UTI. Intermittent catheterization can always be considered for these patients to improve bladder drainage without the sequelae of chronic urethral catheterization or suprapubic tube. An incidentally discovered elevated PVR should certainly trigger additional thought and workup, but these patients may be followed carefully and longitudinally with safety and quality of life assessments. While an appropriate hematuria workup should not be sacrificed, therapy for refractory hematuria due to prostatic bleeding may be of benefit to patients. Clinicians may consider initial management with a 5-ARI as this has demonstrated efficacy.221 However, 5-ARI therapy is not a requirement before surgical BPH debulking and may be performed as either a planned outpatient procedure or at the time of admission for refractory, gross hematuria.