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Chronic urinary retention secondary to bladder outlet obstruction — MSRA MCQ

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HardLUTSChronic urinary retention secondary to bladder outlet obstructionMSRA

A 73-year-old man is assessed in a community urology service for 9 months of bothersome LUTS. He has frequency, nocturia, weak stream, hesitancy and a persistent sensation of incomplete emptying despite 6 months of tamsulosin and finasteride. He has had no acute urinary retention, recurrent UTI, haematuria or loin pain. Digital rectal examination shows a smoothly enlarged prostate. Urine culture is negative. PSA has remained stable at 2.8 micrograms/L and he would accept definitive treatment. Uroflowmetry shows a low maximum flow rate. Post-void residual volume is 1.15 L on two separate measurements. Serum creatinine is 96 micromol/L (eGFR 71 mL/min/1.73 m²), unchanged from baseline, and renal ultrasound shows no hydronephrosis or upper-tract abnormality. He is independently able to perform clean intermittent self-catheterisation if needed. What is the most appropriate management plan now?

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

Reveal the answer and explanation

Correct answer: D — Offer bladder outlet surgery without prior catheterisation

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

This man has chronic urinary retention, demonstrated by a residual volume greater than 1 L on repeated measurement. However, he has bothersome LUTS refractory to appropriate medical treatment, stable renal function and no hydronephrosis or other upper-tract abnormality. NICE specifically advises that bladder outlet surgery can be considered without prior catheterisation in men with chronic retention and bothersome LUTS when there is no renal impairment or upper-tract abnormality. Therefore D is the best plan. A is inappropriate because he has persistent troublesome symptoms despite adequate alpha-blocker and 5-alpha-reductase inhibitor treatment, and the residual is substantial. B is plausible because intermittent catheterisation is often considered before surgery in chronic retention, particularly where bladder function may be markedly impaired; it is not required before surgery in this specified low-risk upper-tract/renal context. C is less appropriate because there is no renal impairment or hydronephrosis requiring decompression, and an indwelling catheter adds infection and quality-of-life burdens. E is intended for men with non-bothersome chronic retention who have not undergone drainage, not for this symptomatic man seeking definitive treatment.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — treating urinary retention (2010; checked 15 August 2026) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations