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Bothersome voiding LUTS secondary to benign prostatic enlargement — MSRA MCQ

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ModerateBPHBothersome voiding LUTS secondary to benign prostatic enlargementMSRA

A 67-year-old man has had 8 months of bothersome lower urinary tract symptoms. He reports hesitancy, weak stream, intermittency, straining and a sensation of incomplete emptying. His IPSS is 24. Urine dipstick and culture are negative. There is no haematuria, recurrent UTI, palpable bladder, neurological abnormality or renal impairment. DRE shows a smooth enlarged prostate, and ultrasound estimates prostate volume at 44 g. PSA, measured before treatment, is 2.1 micrograms/L. He has tried fluid timing and reducing caffeine without worthwhile benefit. He wants drug treatment and is willing to take long-term medication to reduce his risk of symptom progression. Which pharmacological regimen is most appropriate to start now?

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Correct answer: E — Start an alpha blocker together with a 5-alpha reductase inhibitor

This man has bothersome severe LUTS (IPSS 24), predominantly voiding symptoms, with benign prostatic enlargement demonstrated by a 44 g prostate and PSA above 1.4 micrograms/L. NICE recommends considering combined treatment with an alpha blocker and a 5-alpha reductase inhibitor for men with bothersome moderate-to-severe LUTS and a prostate larger than 30 g or PSA greater than 1.4 ng/mL. The alpha blocker provides relatively prompt symptom relief, while the 5-alpha reductase inhibitor reduces prostate volume and the longer-term risk of progression. An alpha blocker alone would be reasonable for moderate-to-severe LUTS without evidence of significant enlargement or where rapid symptom relief is the sole priority, but it does not address progression risk as effectively in this case. A 5-alpha reductase inhibitor alone is plausible because his prostate is enlarged, but symptom improvement is slower and combination treatment is preferred here because symptoms are severe and bothersome. Anticholinergic and beta-3-adrenoceptor agonist therapy target overactive-bladder storage symptoms; neither matches this predominantly obstructive presentation. There are no complications requiring urgent catheterisation or specialist referral before initiating drug treatment.

Reference: NICE CG97: Lower urinary tract symptoms in men: management, recommendations (Last updated June 2015; last reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations