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Chronic urinary retention secondary to benign prostatic enlargement — MSRA MCQ

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HardBPHChronic urinary retention secondary to benign prostatic enlargementMSRA

A 79-year-old man reports 6 months of a reduced urinary stream and incomplete emptying, which he has not found particularly troublesome. Over the past 2 weeks, he has developed nocturnal enuresis and intermittent leakage without urgency. He has no dysuria, fever, haematuria, back pain, constipation or limb neurological symptoms. Examination reveals a painless, palpable bladder and a smooth, symmetrically enlarged prostate. Urine dipstick is negative. Bladder scanning immediately after voiding shows a residual volume of 1.3 litres. His creatinine is 196 micromol/L, compared with 88 micromol/L one year ago. Ultrasonography demonstrates bilateral hydronephrosis. He is haemodynamically stable and systemically well. Which is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Arrange prompt bladder catheterisation and specialist urology assessment

Explanation lettering: E = shown as B · B = shown as C · C = shown as D · D = shown as E

This is chronic urinary retention rather than uncomplicated benign prostatic enlargement. The painless palpable bladder, overflow-type leakage and nocturnal enuresis indicate longstanding incomplete emptying; the residual volume exceeds 1 litre. The rise in creatinine and bilateral hydronephrosis demonstrate upper urinary tract consequences. NICE recommends catheterisation when impaired renal function or hydronephrosis is secondary to chronic urinary retention, together with specialist referral for LUTS complicated by retention or associated renal impairment. A is inadequate because an alpha-blocker must not delay drainage of high-pressure chronic retention with renal compromise. C may reduce future progression in an older man with an enlarged prostate, but its delayed effect does not address established obstruction and hydronephrosis. D is a genuine exception: bladder outlet surgery without prior catheterisation may be considered for bothersome chronic retention when renal function and the upper tracts are normal; neither condition applies here. E is appropriate only for selected men with non-bothersome chronic retention whose bladder has not been drained and who can safely undergo active surveillance. The documented renal impairment and hydronephrosis instead mandate drainage.

Reference: Lower urinary tract symptoms in men: management — Recommendations (Published 23 May 2010; last updated 3 June 2015; last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations