Introduction: Benign prostatic hyperplasia (BPH) and prostate cancer (PCa) are prevalent in elderly men, yet differentiation using two-dimensional transrectal ultrasound (TRUS) remains challenging.

Objective: To compare grayscale TRUS features, color Doppler flow imaging (CDFI), and hemodynamic parameters between BPH and PCa in older men.

Methods: A total of 228 patients (132 BPH, 96 PCa) underwent TRUS from January 2022 to December 2023 at the Department of Urology at the Affiliated Hospital of Yanbian University. Two-dimensional characteristics, CDFI flow distribution, and hemodynamic parameters—including systolic blood flow velocity (Vs), diastolic blood flow velocity (Vd), and resistive index (RI)—were recorded and compared. Receiver operating characteristic (ROC) curves assessed diagnostic performance.

Results: BPH nodules were typically round/oval and located in the transition zone, whereas PCa lesions were predominantly irregular and situated in the peripheral zone. Echogenicity types differed significantly (p = 0.013), with hypoechoic nodules more frequent in PCa (43.8% vs. 3.7%). Pulsed Doppler measurements showed higher Vs, Vd, and RI values in the PCa group than in the BPH group (all p < 0.01). ROC analysis yielded areas under the curves of 0.914, 0.835, and 0.792 for Vs, Vd, and RI, respectively. PCa vessels were thicker, more tortuous, and branched, mainly in the peripheral zone, whereas BPH vessels were thinner and straighter, predominantly in the transition zone.

Conclusion: TRUS with CDFI and hemodynamic assessment may provide useful supplementary information for differentiating BPH from PCa. However, histopathological confirmation via prostate biopsy remains the definitive standard.