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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 73-year-old man is reviewed in urology for longstanding lower urinary tract symptoms. Despite 6 months of tamsulosin and lifestyle measures, he has an IPSS of 26, with marked hesitancy, weak stream, straining and incomplete emptying. He finds the symptoms substantially limiting and wishes to pursue definitive treatment. Specialist assessment shows a smooth 26 g prostate on ultrasound, maximum flow rate 7 mL/second and a post-void residual volume of 1.15 L on two occasions. Serum creatinine is 82 micromol/L (eGFR 81 mL/min/1.73 m²), and renal ultrasound shows no hydronephrosis. PSA is 1.1 micrograms/L, DRE is benign, urine culture is negative, and there are no neurological features. What is the most appropriate management approach?

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

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Correct answer: E — Offer transurethral incision of the prostate without prior catheterisation

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

This man has chronic urinary retention, demonstrated by repeated residual volumes greater than 1 L. His renal function and upper tracts have appropriately been assessed and are normal. He has severe, bothersome voiding symptoms despite medical treatment, so bladder outlet surgery is appropriate. In chronic retention without renal impairment or upper tract abnormality, NICE advises that bladder outlet surgery can be considered without preceding catheterisation. His prostate is 26 g; for prostates smaller than 30 g, transurethral incision of the prostate (TUIP) is the recommended surgical alternative to TURP, TUVP or HoLEP. A is appropriate for non-bothersome chronic retention in a man whose bladder has not been drained, but not for severe symptoms refractory to treatment. B is reasonable where markedly impaired detrusor function is suspected, but this is not established here and he has obstructive symptoms with a small prostate suitable for TUIP. C would be appropriate if renal impairment or hydronephrosis required catheterisation, but neither is present; TURP is also not the preferred size-specific procedure. E is reserved for prostates larger than 80 g.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Treating urinary retention (Published 23 May 2010; updated 3 June 2015; last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Surgery for voiding symptoms (Published 23 May 2010; updated 3 June 2015; last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations