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Benign prostatic enlargement with persistent storage LUTS/overactive bladder symptoms — MSRA MCQ

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HardBPHBenign prostatic enlargement with persistent storage LUTS/overactive bladder symptomsMSRA

A 76-year-old man with benign prostatic enlargement takes tamsulosin MR 400 micrograms daily. His previous hesitancy and weak stream have improved, and post-void residual volume is 45 mL. He now has persistent urinary urgency, frequency and urge incontinence despite bladder training, caffeine reduction and fluid-timing advice. Urine culture is negative, eGFR is 68 mL/min/1.73 m², and a frequency-volume chart does not show nocturnal polyuria. He has chronic narrow-angle glaucoma. At this review, repeated blood pressure measurements are 184/112 mmHg and 182/110 mmHg; he has no symptoms or signs of acute target-organ damage, and same-day hypertension management has been arranged. Which is the most appropriate pharmacological treatment for his persistent urinary symptoms while continuing tamsulosin?

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Correct answer: A — Add vibegron 75 mg once daily

This is persistent storage LUTS consistent with overactive bladder: urgency and urge incontinence persist despite improved voiding symptoms on tamsulosin, low residual urine and appropriate conservative measures. NICE directs clinicians to beta-3-adrenoceptor agonist technology appraisals when antimuscarinics are unsuitable. Solifenacin would usually be a plausible add-on to an alpha blocker for persistent storage symptoms, but it is contraindicated in narrow-angle glaucoma. Mirabegron is also a plausible non-antimuscarinic alternative, but its SmPC contraindicates use in severe uncontrolled hypertension, defined as systolic blood pressure of at least 180 mmHg and/or diastolic pressure of at least 110 mmHg. This patient meets both thresholds on repeat measurement. Vibegron is NICE-recommended for adult overactive bladder when antimuscarinics are unsuitable. It is therefore the best pharmacological option while his hypertension is addressed. Because he has bladder outlet obstruction from BPH, he should be advised about retention symptoms and reviewed for this risk. Finasteride may reduce progression risk in men with an enlarged prostate but does not specifically address his current storage-predominant syndrome. Desmopressin is for nocturnal polyuria, which the frequency-volume chart excludes.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Drug treatment (2015; last reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE TA999: Vibegron for treating symptoms of overactive bladder syndrome — Recommendations (September 2024) — https://www.nice.org.uk/guidance/TA999/chapter/1-Recommendations Mirabegron Astellas 50 mg prolonged-release tablets — Summary of Product Characteristics (Updated 2026) — https://www.medicines.org.uk/emc/product/7540/smpc