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Lower urinary tract symptoms with suspected benign prostatic enlargement — MSRA MCQ

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HardBPHLower urinary tract symptoms with suspected benign prostatic enlargementMSRA

A 68-year-old man presents with 5 months of bothersome lower urinary tract symptoms, including hesitancy, weak stream, intermittency and nocturia. His IPSS is 22. Urine dipstick and midstream urine culture are negative. He has had no urinary infection, catheterisation, cystoscopy, ejaculation or vigorous cycling in the preceding 48 hours. Digital rectal examination shows a smooth, symmetrically enlarged prostate with no nodules. eGFR is 76 mL/min/1.73 m². PSA, measured before any drug treatment, is 5.2 µg/L. He is fit for investigation and treatment if needed, and asks to start medication promptly for presumed benign prostatic enlargement. Which management step has priority?

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

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Correct answer: E — Arrange a suspected cancer pathway referral for prostate cancer

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

This man has LUTS compatible with benign prostatic enlargement and a benign-feeling prostate, but these findings do not exclude prostate cancer. NICE recommends considering a PSA test and DRE in men with LUTS, and considering a suspected cancer pathway referral when PSA exceeds the age-specific threshold. For men aged 60–69 years, this threshold is greater than 4.5 µg/L; his PSA of 5.2 µg/L therefore meets the referral criterion. The history excludes several common transient causes of PSA elevation, strengthening the need to act on this result. Finasteride would otherwise be plausible in an older man at risk of BPH progression, but prostate cancer assessment takes priority. It also lowers PSA by about 50% after treatment is established, complicating subsequent interpretation. Tamsulosin may eventually be used for symptom relief, but options C and D wrongly substitute drug treatment and delayed reassessment for indicated cancer-pathway referral. Routine referral in A is insufficiently urgent. Repeating PSA in E would be reasonable if there were a reversible explanation for elevation, such as recent infection or instrumentation, but none is present.

Reference: Suspected cancer: recognition and referral (NG12) – Recommendations organised by site of cancer (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer Finasteride 5 mg film-coated tablets – Summary of Product Characteristics (Revised 10 September 2025) — https://www.medicines.org.uk/emc/product/13543/smpc Lower urinary tract symptoms in men: management (CG97) – Recommendations (2010, current NICE guidance page checked) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations