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Acute urinary retention secondary to likely benign prostatic enlargement — MSRA MCQ

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ModerateLUTSAcute urinary retention secondary to likely benign prostatic enlargementMSRA

A 69-year-old man presents with acute urinary retention. He has had 8 months of progressively weak stream, hesitancy and nocturia, but no dysuria, fever, visible haematuria, constipation, lower-limb weakness or saddle sensory disturbance. Bladder scan shows 920 mL and urethral catheterisation drains 1.0 L of clear urine with immediate relief. He is haemodynamically stable. Urine dipstick is negative for blood, nitrites and leucocytes. Digital rectal examination shows a smoothly enlarged prostate, estimated at 45 g. Renal function is normal. A trial without catheter is planned. What is the most appropriate pharmacological management before catheter removal?

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Correct answer: B — Start tamsulosin MR 400 micrograms once daily before the trial without catheter

This is acute urinary retention in a man with likely bladder outlet obstruction from benign prostatic enlargement: the catheter has relieved the acute episode, infection and neurological precipitants are not suggested, and a trial without catheter is planned. NICE recommends offering an alpha blocker before catheter removal in men with acute urinary retention. Tamsulosin is therefore the appropriate immediate treatment because its smooth-muscle effect can improve the chance of successful voiding at the trial without catheter. Finasteride is reasonable longer-term treatment in men with a prostate larger than 30 g who are at risk of progression, but it does not provide the prompt functional benefit needed before catheter removal. Combination treatment may later be appropriate for bothersome moderate-to-severe LUTS with an enlarged prostate, but finasteride adds no acute benefit in this sequence. Solifenacin could worsen emptying and is inappropriate following retention. Deferring treatment misses the recommended opportunity to give an alpha blocker before the catheter is removed.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Drug treatment (Last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations