<p>Lower urinary tract symptoms (LUTS) significantly impair quality of life, yet the role of education level and health literacy in treatment decision-making remains unclear. This study aimed to evaluate the impact of education level and health literacy on treatment choice and satisfaction in men with LUTS. In this prospective study, 93 men aged ≥ 40 years with moderate-to-severe LUTS (IPSS 8–35) were enrolled. After standardized, neutral counselling, patients independently chose medical or surgical treatment. Demographic characteristics, education level, health literacy (Newest Vital Sign), clinical parameters, and treatment satisfaction were recorded. Logistic regression analysis was used to identify independent predictors of surgical treatment. Surgical treatment was selected by 50.5% of patients and was associated with older age and higher International Prostate Symptom Score (IPSS). Higher education level was associated with a preference for medical treatment in univariate analysis (<i>p</i> = 0.009), but this association was not sustained after adjustment. Health literacy correlated strongly with education level (r²=0.574, <i>p</i> &lt; 0.001) but did not independently influence treatment choice. In multivariate analysis, IPSS was the only independent predictor of surgical treatment (OR 1.663, 95% CI 1.345–2.056, <i>p</i> &lt; 0.001). Treatment satisfaction was higher among surgically treated patients but tended to decline with increasing education level. Symptom severity, rather than education level or health literacy, is the primary determinant of treatment choice in men with LUTS. These findings highlight the dominant role of symptom burden in real-world decision-making and underscore the importance of patient-centered counselling strategies.</p>