skip to main content

Persistent storage LUTS/overactive bladder in a man treated for bladder outlet obstruction — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

ModerateLUTSPersistent storage LUTS/overactive bladder in a man treated for bladder outlet obstructionMSRA

A 71-year-old man is reviewed 7 weeks after starting tamsulosin MR 400 micrograms once daily for moderate-to-severe LUTS. His weak stream, hesitancy and intermittency have improved substantially. However, he continues to have urinary urgency, daytime frequency and occasional urge urinary incontinence. A 3-day frequency-volume chart shows frequent small-volume voids without nocturnal polyuria. Urine culture is negative. Uroflowmetry shows a maximum flow rate of 17 mL/second and post-void residual volume is 55 mL. His prostate is smooth and estimated at 27 g; PSA before treatment was 1.0 micrograms/L. He has untreated narrow-angle glaucoma. Blood pressure is 132/78 mmHg and eGFR is 68 mL/min/1.73 m². What is the most appropriate next pharmacological management?

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

Reveal the answer and explanation

Correct answer: B — Add mirabegron 50 mg once daily while continuing tamsulosin

This man has residual storage symptoms consistent with overactive bladder after his voiding symptoms have responded to tamsulosin. His low post-void residual volume and satisfactory flow rate make clinically significant residual obstruction or retention unlikely. An antimuscarinic would ordinarily be considered as add-on treatment for persistent storage LUTS, but solifenacin is contraindicated in narrow-angle glaucoma. Mirabegron is a NICE-recommended option for overactive bladder when antimuscarinics are contraindicated, and his blood pressure is well below the severe uncontrolled hypertension threshold at which mirabegron is contraindicated. Solifenacin is therefore inappropriate despite being a plausible add-on for persistent urgency. Finasteride is not indicated: his prostate is below 30 g and PSA is below 1.4 micrograms/L, so he does not meet NICE criteria suggesting increased risk of progression. Increasing tamsulosin would not specifically treat detrusor overactivity and his voiding symptoms are already controlled. Tadalafil should not be used solely to treat LUTS in men; there is no concurrent erectile dysfunction indication in this stem.

Reference: Lower urinary tract symptoms in men: management — Recommendations (Last updated 3 June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Mirabegron for treating symptoms of overactive bladder — Recommendations (26 June 2013) — https://www.nice.org.uk/guidance/ta290/chapter/1-Recommendations Mirabegron Astellas 25 mg prolonged-release tablets — Summary of Product Characteristics (Updated 2025) — https://www.medicines.org.uk/emc/product/2977/smpc