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Benign prostatic enlargement causing moderate-to-severe lower urinary tract symptoms — MSRA MCQ

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ModerateUrologyBenign prostatic enlargement causing moderate-to-severe lower urinary tract symptomsMSRA

A 70-year-old man presents with 18 months of worsening hesitancy, weak stream, intermittency and a sensation of incomplete bladder emptying. His International Prostate Symptom Score is 22/35 and symptoms interfere with travel and sleep. He has tried reducing evening fluids and caffeine for 8 weeks without benefit. He has no urgency incontinence, dysuria, visible haematuria, recurrent UTI, retention, loin pain or weight loss. Urine dipstick is negative for blood, nitrites and leucocytes. Digital rectal examination shows a smooth, symmetrically enlarged prostate estimated at 40 g. PSA, measured after discussion of its limitations, is 2.1 ng/mL. eGFR is 76 mL/min/1.73 m². What is the most appropriate pharmacological management?

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Correct answer: B — Offer combined tamsulosin and finasteride therapy

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

This man has bothersome, moderate-to-severe voiding LUTS consistent with benign prostatic enlargement: he has an IPSS of 22, a smooth enlarged prostate, negative urine testing and no features requiring urgent specialist assessment. Conservative measures have not helped, so drug treatment is appropriate. An alpha blocker such as tamsulosin is recommended for moderate-to-severe LUTS. However, he also has markers of increased risk of progression: prostate size exceeds 30 g and PSA exceeds 1.4 ng/mL. NICE therefore recommends considering combination treatment with an alpha blocker plus a 5-alpha reductase inhibitor in men with bothersome moderate-to-severe LUTS and either of these features. Tamsulosin provides relatively prompt symptom improvement, while finasteride reduces prostate volume and progression risk over time. A is plausible because alpha-blocker monotherapy is appropriate for moderate-to-severe LUTS, but it does not address his identified progression risk as well as combination treatment. B may be used where a 5-alpha reductase inhibitor is indicated, but does not provide the quicker symptomatic benefit of an alpha blocker. D is unnecessary because there is no retention, recurrent infection, renal impairment or suspected cancer. E is directed mainly at storage LUTS suggestive of overactive bladder, rather than this predominantly voiding presentation.

Reference: Lower urinary tract symptoms in men: management — Recommendations (Published 2010; last updated June 2015; reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Lower urinary tract symptoms in men: management — Recommendations (Published 2010; last updated June 2015; reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations