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Benign Prostatic Hyperplasia (BPH) — UKMLA MCQ

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MediumUrologyBenign Prostatic Hyperplasia (BPH)UKMLAMRCGP AKTPARAPSA

A 67-year-old man with known benign prostatic hyperplasia (BPH) treated with tamsulosin presents with increasing lower urinary tract symptoms (LUTS), including poor stream, hesitancy, and nocturia. His IPSS score is 18 (moderate). Digital rectal examination reveals a moderately enlarged, smooth prostate. PSA is 2.5 ng/mL. Post-void residual volume on bladder scan is 80 mL. According to NICE guidelines, what is the most appropriate next step in pharmacological management?

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Correct answer: E — Add finasteride

NICE CG97 recommends managing bothersome moderate-to-severe LUTS with an alpha-blocker (like tamsulosin). If symptoms persist or worsen despite alpha-blocker therapy, and the prostate is enlarged (clinically or >30g on imaging) or PSA is >1.4 ng/mL (suggesting significant prostatic enlargement), consider adding a 5-alpha reductase inhibitor (5-ARI) such as finasteride or dutasteride. This combination therapy can improve symptoms and reduce the risk of progression (acute retention, need for surgery). Switching alpha-blockers is unlikely to help significantly. Oxybutynin is for overactive bladder symptoms (urgency, frequency), not typically obstructive symptoms. Surgery is considered if medical therapy fails or complications arise. Monitoring alone is insufficient given worsening moderate symptoms.

Reference: NICE CG97: Lower urinary tract symptoms in men