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Benign prostatic hyperplasia with bothersome moderate-to-severe LUTS — MSRA MCQ

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HardBPHBenign prostatic hyperplasia with bothersome moderate-to-severe LUTSMSRA

A 72-year-old man requests drug treatment for bothersome lower urinary tract symptoms despite fluid and caffeine modification. His IPSS is 20, predominantly due to hesitancy, poor stream and incomplete emptying. Urine dipstick is negative, DRE shows a smooth enlarged prostate, creatinine is normal and post-void residual volume is 90 mL. PSA is 2.4 ng/mL and ultrasound estimates prostate volume at 46 mL. He is scheduled for cataract surgery in 12 days, with surgery on the other eye 5 weeks later. He has no postural symptoms and is not taking antihypertensives. What is the most appropriate pharmacological management now?

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

Reveal the answer and explanation

Correct answer: E — Start finasteride 5 mg once daily and defer tamsulosin until both cataract operations have been completed

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

This man has bothersome moderate-to-severe voiding LUTS associated with benign prostatic enlargement. His prostate volume is greater than 30 g and PSA exceeds 1.4 ng/mL; as an older man, he is at increased risk of progression. NICE therefore supports offering a 5-alpha-reductase inhibitor, and finasteride is licensed for BPH in men with an enlarged prostate. He should be counselled that a meaningful symptomatic response may require at least 6 months. An alpha blocker would usually be offered for faster symptom improvement, and combination treatment would ordinarily be reasonable in this phenotype. However, tamsulosin is associated with intraoperative floppy iris syndrome (IFIS) during cataract surgery. Its SmPC states that initiating tamsulosin is not recommended in patients for whom cataract surgery is scheduled. This is especially relevant because surgery is imminent and the second procedure remains pending. A and E are attractive because alpha blockers, alone or combined with finasteride, are standard treatments for moderate-to-severe LUTS; informing the ophthalmic team is appropriate for existing or previous exposure but does not override the recommendation against new initiation. B is incorrect because stopping tamsulosin shortly before surgery has unproven benefit, and IFIS has occurred after longer discontinuation. C avoids tamsulosin exposure but unnecessarily withholds finasteride, which addresses his progression risk while cataract surgery is completed.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (2010) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Tamsulosin hydrochloride SUN Pharma 400 micrograms prolonged-release hard capsules — Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/2508/smpc Finasteride 5mg Tablets — Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/547/smpc