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Bothersome moderate-to-severe male LUTS without evidence of significant prostatic enlargement — MSRA MCQ

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ModerateLUTSBothersome moderate-to-severe male LUTS without evidence of significant prostatic enlargementMSRA

A 63-year-old man presents with 8 months of bothersome lower urinary tract symptoms. He reports weak stream, hesitancy, intermittency, daytime frequency and nocturia. His International Prostate Symptom Score is 21. He has no visible haematuria, recurrent urinary tract infection, retention, palpable bladder, renal impairment or features suggesting prostate cancer. Urine dipstick is negative for blood, leucocytes, nitrites and glucose. Digital rectal examination shows a smooth prostate estimated at 28 g. Following shared decision-making, his PSA is 1.2 micrograms/L. He has tried reducing evening fluid intake and caffeine without sufficient benefit and wishes to start medication. What is the most appropriate initial drug treatment?

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Correct answer: B — Start tamsulosin modified-release 400 micrograms once daily

Tamsulosin is the most appropriate initial treatment. He has moderate-to-severe, bothersome LUTS, for which NICE recommends offering an alpha blocker. His symptoms include both voiding and storage symptoms, but there is no predominant overactive-bladder syndrome established by bladder diary, and no indication that an antimuscarinic or beta-3 agonist should be the first pharmacological choice. Finasteride is not indicated on the information given. NICE recommends a 5-alpha reductase inhibitor for men at high risk of progression with a prostate estimated at more than 30 g or PSA greater than 1.4 ng/mL. This man's prostate is estimated at 28 g and PSA is 1.2 micrograms/L, so neither surrogate marker of significant prostatic enlargement is present. Combination alpha-blocker and 5-alpha reductase inhibitor treatment is similarly inappropriate initially. Solifenacin could be considered if he had persisting overactive-bladder symptoms after treatment of the voiding component, but it does not address his prominent obstructive symptoms. Mirabegron is an alternative where antimuscarinics are unsuitable, ineffective or not tolerated for overactive bladder; that sequence has not yet arisen here.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (2010; last reviewed 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (2010; last reviewed 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (2010; updated references include 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations