skip to main content

Male LUTS with recurrent UTI and suspected chronic incomplete bladder emptying — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardLUTSMale LUTS with recurrent UTI and suspected chronic incomplete bladder emptyingMSRA

A 71-year-old man is reviewed after 10 weeks of tamsulosin MR 400 micrograms once daily for bothersome mixed LUTS. His nocturia and weak stream have improved slightly, but he still has marked urgency, frequency and urge urinary incontinence. He also describes hesitancy and an incomplete-emptying sensation. He has had two culture-confirmed Escherichia coli lower UTIs in the past 3 months, each resolving with culture-directed antibiotics. He is currently afebrile and urine dipstick is negative for nitrites, leucocytes and blood. Digital rectal examination shows a smoothly enlarged prostate. PSA before starting treatment was 2.1 micrograms/L and estimated prostate size is 45 g. A bladder scan, performed because of the recurrent infections and incomplete emptying symptoms, shows a post-void residual volume of 380 mL. eGFR is stable at 68 mL/min/1.73 m². He has no palpable bladder, loin pain or symptoms of acute retention. What is the most appropriate next management step?

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

Reveal the answer and explanation

Correct answer: C — Refer for specialist urological assessment now while continuing tamsulosin

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

This man requires specialist urological assessment now. He has recurrent culture-confirmed UTI and significant incomplete bladder emptying in the context of mixed LUTS. NICE recommends specialist referral for men whose LUTS are complicated by recurrent or persistent UTI, retention, or renal impairment suspected to result from lower urinary tract dysfunction. Specialist assessment should include flow rate and post-void residual measurement, with cystoscopy and upper-tract imaging considered where recurrent infection or chronic retention is present. A is initially attractive because NICE permits addition of an anticholinergic when storage symptoms persist despite an alpha blocker. However, solifenacin should be avoided in clinically significant bladder outlet obstruction where urinary retention is a risk; this patient already has a substantial residual volume and voiding symptoms. B does not address the likely outlet/emptying problem, and beta-3 agonists can also be associated with urinary retention in bladder outlet obstruction. C may ultimately be appropriate because his prostate is enlarged and PSA exceeds 1.4 micrograms/L, but it does not replace investigation of recurrent infection and possible chronic retention. D may be needed after specialist evaluation, but immediate primary-care initiation is not the recommended first step in a stable man without renal impairment, hydronephrosis or acute retention.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Published 2010; last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Specialist assessment (Published 2010; last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing — Referral and seeking specialist advice (2018; amended 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations