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Male lower urinary tract symptoms — MSRA MCQ

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ModeratePSAMale lower urinary tract symptomsMSRA

A 59-year-old man presents with 7 months of bothersome nocturia, hesitancy and reduced urinary stream. His International Prostate Symptom Score is 18. Conservative measures have not helped and he would like treatment. Urinalysis and midstream urine culture are negative. He has no dysuria, fever, pelvic pain, visible haematuria, retention, recent catheterisation or urinary instrumentation. He has avoided ejaculation, cycling and vigorous exercise for 48 hours before testing. Digital rectal examination shows a smooth, symmetrically enlarged prostate. PSA is 3.5 micrograms/L. He has no family history of prostate cancer, is otherwise fit and would accept investigation if it became indicated. What is the most appropriate next management plan?

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

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Correct answer: A — Offer an alpha blocker for moderate-to-severe lower urinary tract symptoms, with review and safety-netting, without a suspected cancer pathway referral at present

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

This man has moderate-to-severe uncomplicated voiding LUTS, a benign digital rectal examination and a PSA of 3.5 micrograms/L. For symptomatic men aged 50 to 59 years, NICE advises considering a suspected cancer pathway referral when PSA is more than 3.5 micrograms/L. His value is exactly 3.5 micrograms/L, so it does not meet this threshold. There are also no PSA confounders, infection features, retention or malignant DRE findings. An alpha blocker is appropriate treatment for moderate-to-severe LUTS, with review of symptomatic response and adverse effects. Safety-netting remains important, including review if symptoms progress or new features such as haematuria, bone pain, retention or an abnormal examination develop. B incorrectly interprets the threshold as greater than or equal to 3.5 micrograms/L. C would be more appropriate where a transient PSA elevation is possible, such as after urinary infection, instrumentation or ejaculation, but these have been excluded. D is inappropriate without evidence of urinary infection or prostatitis. E may be appropriate for complicated LUTS or persistent diagnostic concern, but neither is present here.

Reference: Suspected cancer: recognition and referral (NG12), prostate cancer recommendations (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer Lower urinary tract symptoms in men: management (CG97), drug treatment (Last updated 3 June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations