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Benign prostatic enlargement causing moderate-to-severe voiding LUTS — MSRA MCQ

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HardBPHBenign prostatic enlargement causing moderate-to-severe voiding LUTSMSRA

A 78-year-old man presents with bothersome lower urinary tract symptoms. His IPSS is 24, predominantly due to hesitancy, weak stream, intermittency and incomplete emptying. Urine dipstick is negative, eGFR is 74 mL/min/1.73 m², and there is no palpable bladder, recurrent urinary infection, haematuria or neurological disease. DRE shows a smooth enlarged prostate; PSA is 3.1 ng/mL and ultrasound estimates prostate volume at 52 mL. Two years ago, doxazosin prescribed for hypertension was stopped after recurrent presyncope and a syncopal fall. Formal assessment documented orthostatic hypotension. He remains symptomatic on lifestyle measures and wants drug treatment. What is the most appropriate pharmacological management?

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, explaining that benefit may require at least 6 months before assessment

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

This man has moderate-to-severe, predominantly voiding LUTS with benign examination findings and a clearly enlarged prostate (52 mL; PSA also exceeds 1.4 ng/mL). At his age, this indicates a substantial risk of BPH progression, so a 5-alpha-reductase inhibitor is appropriate. Finasteride is licensed to reduce prostate size, improve urinary flow and reduce acute retention and surgery risk; however, meaningful benefit may require at least 6 months, so expectation-setting and review are essential. ([nice.org.uk](https://www.nice.org.uk/guidance/cg97/chapter/recommendations?utm_source=openai)) Tamsulosin would usually be a suitable first-line option for rapid relief of moderate-to-severe LUTS, and combination therapy is often considered for men with enlarged prostates and troublesome symptoms. In this case, however, tamsulosin is contraindicated because he has a history of orthostatic hypotension; his previous alpha-blocker-associated syncope makes this clinically important. Therefore, both B and C are inappropriate. ([nice.org.uk](https://www.nice.org.uk/guidance/cg97/chapter/recommendations?utm_source=openai)) Tadalafil should not be prescribed solely to treat LUTS outside a randomised trial under NICE CG97. Solifenacin treats overactive-bladder storage symptoms, whereas this man's symptom pattern is predominantly obstructive/voiding and there is no urgency syndrome to target. ([nice.org.uk](https://www.nice.org.uk/guidance/cg97/chapter/recommendations?utm_source=openai))

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Published 23 May 2010; last updated 3 June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations TAMFREX XL 400 microgram capsules — Summary of Product Characteristics (Last updated on emc 5 August 2026) — https://www.medicines.org.uk/emc/product/5218/smpc Finasteride 5 mg Tablets — Summary of Product Characteristics (Last updated on emc 8 March 2024) — https://www.medicines.org.uk/emc/product/3493/smpc