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Bothersome moderate-to-severe LUTS due to benign prostatic enlargement — MSRA MCQ

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ModerateLUTSBothersome moderate-to-severe LUTS due to benign prostatic enlargementMSRA

A 70-year-old man has 10 months of bothersome LUTS despite reducing evening fluid intake and moderating caffeine intake. His International Prostate Symptom Score is 22. He reports weak stream, hesitancy, intermittency, frequency and nocturia. He has no recurrent UTI, visible haematuria, retention, palpable bladder, renal impairment or features suggesting prostate cancer. Urine dipstick is negative. Digital rectal examination shows a smoothly enlarged prostate, estimated at 52 g. Following counselling, PSA is 3.0 micrograms/L. He has no postural symptoms and wishes to start drug treatment. What is the most appropriate initial drug management?

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

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Correct answer: C — Begin combined tamsulosin MR and finasteride therapy

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

Combined tamsulosin MR and finasteride is the best initial treatment. He has bothersome moderate-to-severe symptoms (IPSS 22) and clear markers of a larger prostate and progression risk: estimated prostate size is 52 g and PSA is 3.0 micrograms/L. NICE recommends considering an alpha blocker plus a 5-alpha reductase inhibitor in men with bothersome moderate-to-severe LUTS and a prostate larger than 30 g or PSA above 1.4 ng/mL. A is plausible because alpha blockers are recommended for moderate-to-severe LUTS and improve symptoms, but monotherapy does not address his substantial risk of progression as well as combination treatment. B is plausible because finasteride is indicated with an enlarged prostate, but does not provide the symptom-directed alpha-blocker component recommended for this presentation. D is inappropriate because he has neither complications requiring specialist intervention nor failure of drug treatment. E would be reasonable for non-bothersome symptoms, but he remains significantly troubled despite appropriate lifestyle measures.

Reference: NICE CG97: Lower urinary tract symptoms in men: management, recommendations 1.4.3, 1.4.6 and 1.4.7 (Published 2010; last updated 3 June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations