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Bothersome moderate-to-severe male LUTS associated with benign prostatic enlargement — MSRA MCQ

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ModerateLUTSBothersome moderate-to-severe male LUTS associated with benign prostatic enlargementMSRA

A 68-year-old man is reviewed 6 weeks after starting tamsulosin MR 400 micrograms once daily for bothersome lower urinary tract symptoms. Before treatment, his International Prostate Symptom Score was 20. He reports a modest improvement in hesitancy and weak stream but continues to be significantly troubled by nocturia and poor flow. He has no urgency urinary incontinence, dysuria, visible haematuria, recurrent urinary tract infection, palpable bladder or symptoms of retention. Digital rectal examination shows a smoothly enlarged prostate, estimated at 45 g. PSA, measured before starting treatment after appropriate counselling, was 2.0 micrograms/L. Renal function is normal and urine dipstick is negative. What is the most appropriate management now?

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

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Correct answer: B — Add finasteride to tamsulosin and arrange review in 3 to 6 months

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

This man has persistent, bothersome moderate-to-severe LUTS despite an adequate initial alpha-blocker trial. His estimated prostate size is greater than 30 g and his baseline PSA is greater than 1.4 ng/mL (micrograms/L), both markers of a larger prostate and increased risk of progression. NICE recommends considering combination treatment with an alpha blocker and a 5-alpha reductase inhibitor in men with bothersome moderate-to-severe LUTS meeting either of these size criteria. Finasteride should therefore be added while tamsulosin is continued; review is appropriate after 3 to 6 months because benefit from 5-alpha reductase inhibition develops gradually. A is inappropriate because he remains significantly symptomatic and has features supporting progression-directed treatment. B is less appropriate because replacing tamsulosin removes the comparatively rapid symptomatic benefit of alpha blockade while waiting for finasteride to act. C is intended for persistent storage symptoms after alpha-blocker treatment; his predominant residual symptoms are voiding symptoms, without urgency or urge incontinence. E is not indicated: there is no retention, recurrent infection, renal impairment, haematuria or suspected malignancy requiring referral.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Last updated 3 June 2015; checked 15 August 2026) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Review (Last updated 3 June 2015; checked 15 August 2026) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations