Lower urinary tract symptoms: poor flow, hesitancy, incomplete emptying, frequency, urgency and nocturia, are common as men age. When benign enlargement of the prostate (BPH) is genuinely responsible, treatment may include lifestyle measures, medication, minimally invasive procedures or surgery. Prostate artery embolisation (PAE) is one option that may be considered for appropriately assessed patients.

PAE is not simply a “smaller TURP”. It works differently, is performed by an experienced interventional radiologist, and has a different balance of benefits, limitations and risks. The most important question is not whether the prostate looks large, but whether prostatic obstruction is actually causing the patient’s symptoms.

What is prostate artery embolisation?

PAE is a minimally invasive, image-guided procedure. A small catheter is introduced through an artery, usually at the wrist or groin, and guided into the arteries supplying the prostate. Tiny permanent particles or, in selected expert practice, a liquid embolic agent are delivered to reduce blood flow to the hyperplastic prostate tissue. This causes controlled ischaemia, gradual shrinkage of the transition zone and reduced compression of the urethra.

The procedure can often be performed without a general anaesthetic and does not require instruments to pass through the urethra. Improvement, when it occurs, is usually progressive rather than immediate and may take several weeks or months. Results vary, and some men obtain little benefit or require another treatment.

Regulatory note for Australian readers: The TGA regulates therapeutic goods, including medicines and medical devices; it does not “approve” or endorse a medical procedure or an individual health service. References to PAE in this article should not be interpreted as TGA endorsement. Any embolic agent, catheter or other medical device used must be lawfully supplied in Australia and used in accordance with its applicable regulatory status, intended purpose and clinical governance requirements.

Important Wesley Hospital research

Associate Professor Nicholas Brown, an interventional radiologist affiliated with The University of Queensland and I-MED Radiology at The Wesley Hospital, led the following Australian studies of PAE.

The P-EASY ADVANCE randomised controlled trial, published in BJU International in 2024, compared PAE with combined tamsulosin and dutasteride therapy in 39 treatment-naïve men with enlarged prostates, moderate-to-severe symptoms and obstructed or equivocal urodynamic studies. At follow-up, 63% of men treated with PAE were urodynamically unobstructed, compared with 28% receiving medication. Within this study population and follow-up period, the PAE group had greater improvements in prostate volume, urinary flow, incomplete emptying, overall symptom score and quality of life. The trial was small, the estimates should not be generalised to every patient, and larger comparative trials with longer follow-up are required.

The follow-up P-EASY PLUS study, published in BJU International in 2025, assessed 105 men at a mean of 18 months. Mean prostate volume fell by 30.6%, total symptom scores improved by 55%, quality-of-life scores improved by 65.9%, and maximum urinary flow increased by 5 mL/second. Among the 57 men who completed paired urodynamic testing, the proportion classified as obstructed fell from 66.7% to 29.8%. No major procedural complication or new urinary incontinence was reported in this cohort; new retrograde ejaculation occurred in 2%. These are group-level study outcomes and do not guarantee an individual result. The authors noted that longer-term comparative research is required.

The P-EASY ADVANCE publication received the BJUI Global Prize for 2026. This statement describes the publication award only; it is not a patient-outcome claim, regulatory endorsement or guarantee of treatment effectiveness.

Author disclosure: I, Dr Joseph Schoeman, was a co-author of both Wesley Hospital studies. I performed some of the urodynamic studies for this article. Readers should take this relationship into account when considering the discussion. The results are reported with their limitations and placed alongside independent guidelines, randomised trials and systematic reviews. No patient testimonial or individual outcome has been used in this article.

Who may be a good candidate?

PAE may be considered when a man has:

• bothersome moderate-to-severe urinary symptoms attributable to benign prostatic obstruction;
• an enlarged prostate, particularly a moderately large or very large gland;
• inadequate relief, unacceptable adverse effects or a preference not to take long-term medication;
• a wish to avoid transurethral or more invasive surgery;
• increased anaesthetic or surgical risk;
• a preference for an option with lower reported rates of ejaculatory dysfunction or urinary incontinence in some studies, while recognising that these complications can still occur;
• catheter-dependent urinary retention where obstruction from BPH is considered reversible and bladder contractility is adequate; or
• recurrent or refractory bleeding shown to arise from the prostate in selected circumstances.

Current European Association of Urology guidance recommends offering PAE to men with moderate-to-severe LUTS due to benign prostatic obstruction who want a minimally invasive option and accept that outcomes may be less optimal than TURP. The American Urological Association also permits PAE as a treatment option when performed by appropriately trained clinicians, but grades the evidence as conditional.

What assessment is needed before PAE?

A large prostate does not prove obstruction, and urinary symptoms are not always caused by the prostate. Appropriate assessment may include:

• symptom and quality-of-life scoring;
• urinalysis and urine culture when indicated;
• PSA assessment and prostate-cancer evaluation appropriate to age and risk;
• digital rectal examination;
• urinary flow rate and post-void residual measurement;
• ultrasound or MRI assessment of prostate size and anatomy;
• cystoscopy where haematuria, urethral stricture, bladder-neck pathology, stones or bladder disease is suspected;
• urodynamic studies when the diagnosis is uncertain, symptoms are mixed, bladder contractility may be poor, or prior pelvic treatment has complicated the picture; and
• CT or MR angiographic assessment of pelvic arterial anatomy, renal function and contrast risk when requested by the interventional radiologist.

The best decisions are generally made jointly by a urologist and an experienced PAE interventional radiologist.

Potential advantages of PAE

Potential advantages include:

• no prostate tissue resection and usually no general anaesthetic;
• day-stay or short hospital admission in many patients;
• lower reported rates of major bleeding and transfusion than some operative procedures in comparative studies;
• low reported, but not zero, rates of urinary incontinence;
• a lower reported likelihood of retrograde ejaculation than with TURP or enucleation procedures in available studies;
• usefulness in some very large prostates and medically complex patients; and
• preservation of later surgical options if symptoms persist or recur.

Caveats: what PAE may not do as well

Compared with TURP or endoscopic enucleation, PAE generally produces a less immediate and less pronounced improvement in urinary flow and objective relief of obstruction. A Cochrane review found that short-term symptom improvement may be similar to TURP, but the certainty of evidence was low and retreatment may be more likely after PAE. Meta-analyses and longer-term randomised data generally show stronger objective improvement after TURP. Comparisons across studies must be interpreted cautiously because patient selection, technique, follow-up and outcome definitions differ.

PAE also does not provide prostate tissue for histology. Prostate cancer must therefore be considered and investigated before treatment rather than assumed to be excluded by a fall in prostate size or PSA afterward.

Technical success depends heavily on operator experience. Prostatic arteries are tiny, variable and sometimes severely atherosclerotic. Embolic material can rarely reach non-target vessels supplying the bladder, rectum or penis. Pre-procedure vascular imaging and cone-beam CT can reduce this risk but add iodinated contrast exposure and ionising radiation.

Side effects and complications

Common short-term effects form part of a post-embolisation syndrome and may include pelvic or perineal discomfort, urinary frequency and urgency, dysuria, fatigue, nausea, low-grade fever or a small amount of blood in the urine or semen. Temporary difficulty passing urine and the need for a catheter can occur.

Less common complications include urinary infection, access-site bruising or haematoma, contrast reaction, kidney injury, arterial injury, prostate infection or abscess, and passage of necrotic prostate tissue. Rare but important complications of non-target embolisation include ischaemic injury to the bladder, rectum or penis. Severe skin injury from fluoroscopic radiation is also rare but is a recognised procedural concern, particularly during prolonged or technically difficult cases.

Contraindications and reasons to pause

PAE is generally unsuitable, or requires correction and specialist review first, when there is:

• an active urinary tract or systemic infection;
• suspected or untreated prostate or bladder cancer requiring diagnostic clarification;
• symptoms predominantly caused by urethral stricture, bladder-neck contracture, bladder stone, neurogenic dysfunction, overactive bladder or another non-BPH condition;
• a poorly contractile or decompensated bladder unlikely to empty even if outlet resistance is reduced;
• severe pelvic arterial atherosclerosis, occlusion, tortuosity or anatomy that prevents safe selective catheterisation;
• an uncorrectable bleeding disorder;
• a severe iodinated-contrast allergy that cannot be safely managed;
• significant renal impairment where contrast risk is unacceptable; or
• inability to tolerate arterial access, fluoroscopy or the required aftercare.

Small prostate size is not an absolute prohibition, but it makes careful confirmation of the cause of obstruction particularly important and may reduce the likelihood of benefit. A prominent obstructing median lobe is not automatically a contraindication in experienced hands, although prostate anatomy should be considered alongside all alternative treatments.

Can PAE be performed after prostate radiotherapy?

Potentially yes, but prior pelvic or prostate radiotherapy is not a routine indication, and the decision must be individualised. It is neither sensible to call radiotherapy an automatic absolute contraindication nor appropriate to assume that PAE will relieve every post-radiation urinary symptom.

After radiotherapy, poor flow, urgency, frequency, pain, retention or bleeding may result from:

• persistent benign prostatic obstruction;
• radiation cystitis and reduced bladder capacity;
• detrusor overactivity or poor bladder contractility;
• urethral stricture or bladder-neck stenosis;
• prostate-cancer recurrence or progression;
• infection, stones or clot retention; or
• a combination of these problems.

PAE is most likely to help only when a meaningful component of the problem is supplied by vascular, enlarged prostate tissue or confirmed prostatic obstruction. It will not correct a urethral stricture, a scarred bladder neck, radiation cystitis, a small fibrotic low-capacity bladder or detrusor failure.

Evidence specifically studying PAE for BPH-type obstruction after completed radiotherapy is sparse. Most major BPH trials did not establish a dedicated post-radiotherapy evidence base. Radiotherapy can also alter pelvic tissues and small blood vessels, making angiographic anatomy and tissue response less predictable. For that reason, these patients should be assessed in a multidisciplinary setting and often benefit from cystoscopy, flow and residual testing, imaging and formal urodynamics before treatment.

PAE has been studied in men with prostate cancer and is being investigated before radiotherapy to reduce gland size and urinary symptoms. Embolisation has also been used for refractory bleeding of prostatic origin, including bleeding associated with malignancy or radiation. However, embolisation for life-threatening radiation-related haematuria may target vesical or other pelvic arteries and is a different clinical problem from PAE for benign outlet obstruction. These two indications should not be confused.

In a post-radiotherapy patient, PAE may therefore be reasonable when:

1. recurrent cancer, infection and urethral or bladder-neck stenosis have been excluded or appropriately managed;
2. investigations demonstrate an enlarged, vascular prostate with genuine outlet obstruction;
3. bladder function is adequate enough to benefit from reducing resistance;
4. pelvic arterial anatomy permits safe selective embolisation; and
5. the patient understands that outcome data are limited and that further treatment may still be required.

How does PAE compare with surgery?

There is no universally “best” procedure. TURP, GreenLight laser, HoLEP or other enucleation procedures usually provide faster and more complete mechanical relief of obstruction. PAE is less invasive and some comparative studies report fewer ejaculatory or perioperative adverse effects; however, symptom relief can be slower, objective improvement may be smaller and retreatment may be more likely.

The right option depends on prostate size and configuration, the severity and cause of symptoms, bladder function, cancer risk, medical fitness, sexual priorities, arterial anatomy, previous pelvic treatment and the patient’s tolerance for the possibility of later retreatment.

The take-home message

PAE is an available treatment option for selected men with symptomatic benign prostatic obstruction. The Wesley Hospital P-EASY studies contribute Australian randomised and urodynamic data on symptoms, quality of life and obstruction, but their findings should be considered with the study designs, sample sizes, follow-up and declared author relationships.

It remains essential to diagnose the cause of symptoms before treating the scan. PAE is not a cure for every urinary problem and does not replace cancer assessment, cystoscopy or urodynamics when these are clinically indicated. After radiotherapy, PAE may be technically and clinically possible, but the evidence is limited and patient selection must be particularly rigorous.

References and further reading

1. Brown N, et al. P-EASY ADVANCE: a randomised controlled trial of prostate embolisation versus medication for BPH. BJU International. 2024. doi: 10.1111/bju.16479.
2. Brown N, et al. P-EASY PLUS: preliminary and follow-up urodynamic studies. BJU International. 2025. doi: 10.1111/bju.16808.
3. Mark P, Brown NI, Ormiston WEL. Current considerations in prostate artery embolisation. CVIR Endovascular. 2026;9:45. doi: 10.1186/s42155-026-00689-5.
4. European Association of Urology. Guidelines on the Management of Non-neurogenic Male LUTS: Disease Management. Current online edition accessed September 2026.
5. Sandhu JS, et al. Management of Lower Urinary Tract Symptoms Attributed to BPH: AUA Guideline Amendment 2023. Journal of Urology. 2024;211:11–19. doi: 10.1097/JU.0000000000003698.
6. Jung JH, et al. Prostatic arterial embolisation for the treatment of lower urinary tract symptoms in men with BPH. Cochrane Database of Systematic Reviews. 2022. Cochrane evidence summary.
7. Müllhaupt G, et al. Prostatic artery embolisation versus TURP for benign prostatic obstruction: long-term outcomes of a randomised trial. European Urology. 2024. PubMed record.
8. Zumstein V, et al. Prostatic artery embolization versus standard surgical treatment for LUTS secondary to BPH: systematic review and meta-analysis. European Urology Focus. 2019;5:1091–1100. doi: 10.1016/j.euf.2018.09.005.
9. Parikh N, et al. Prostate artery embolization in the setting of prostate cancer. Seminars in Interventional Radiology. 2025. Full text.
10. Kably I, et al. Prostatic artery embolization in refractory haematuria of prostatic origin. Techniques in Vascular and Interventional Radiology. 2020. PubMed record.
11. Therapeutic Goods Administration. Advertising health services that involve therapeutic goods. Updated 18 June 2026.
12. Therapeutic Goods Administration. General requirements for advertising therapeutic goods to the public. Updated 11 March 2025.
13. Australian Health Practitioner Regulation Agency. Advertising guidelines and other guidance. Accessed 22 September 2026.

Australian publication and advertising statement

This article is intended as balanced disease and treatment education. It does not advertise a named embolic product, catheter, medicine or device; offer an inducement; use testimonials; promise a cure; or claim that PAE is safe, risk-free, superior or effective in every case. Mention of the TGA, Ahpra, professional guidelines, a hospital, a journal or an award does not imply endorsement of this article, the author or the treatment.

Clinical claims are linked to identified publications and should be reviewed when the article is updated. Any future addition of brand names, booking prompts, prices, before-and-after images, patient stories, sponsored links or manufacturer-supplied material may change the regulatory character of the page and should undergo a fresh compliance review.

This article provides general information current at the stated review date and is not personal medical advice. It does not establish a doctor–patient relationship. Benefits and risks differ between individuals. Suitability for PAE should be decided after assessment by appropriately qualified clinicians, commonly including a urologist and an interventional radiologist. Patients should seek urgent medical care for inability to pass urine, fever or sepsis symptoms, severe pain, heavy bleeding or clot retention.

PAE BJU article