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Benign prostatic enlargement with persistent storage LUTS after response of voiding LUTS to an alpha blocker —

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ModerateBPHBenign prostatic enlargement with persistent storage LUTS after response of voiding LUTS to an alpha blockerMSRA

A 66-year-old man is reviewed 6 weeks after starting tamsulosin MR 400 micrograms once daily for bothersome LUTS attributed to benign prostatic enlargement. Before treatment, he had hesitancy, weak stream, urgency and frequency (IPSS 21). DRE was benign; estimated prostate volume was 28 mL and PSA was 1.0 micrograms/L. His hesitancy and weak stream have resolved and he has no postural symptoms. However, he continues to have marked urgency, daytime frequency and urge urinary incontinence several times each week. A 3-day frequency-volume chart does not demonstrate nocturnal polyuria. Urine dipstick and culture are negative, eGFR is 72 mL/min/1.73 m², and post-void residual volume is 40 mL. He has no narrow-angle glaucoma, myasthenia gravis, troublesome constipation or cognitive impairment. His only other medication is ramipril. What is the most appropriate pharmacological plan?

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

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Correct answer: C — Continue tamsulosin and add solifenacin 5 mg once daily

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

This man has had a satisfactory response of his voiding symptoms to tamsulosin but has persistent storage symptoms: urgency, frequency and urge urinary incontinence. Infection, substantial residual urine and nocturnal polyuria have been excluded. NICE advises considering an anticholinergic in addition to an alpha blocker when storage symptoms persist after alpha-blocker treatment. Solifenacin 5 mg once daily is an appropriate licensed anticholinergic starting dose for overactive-bladder symptoms. His low residual volume and absence of relevant contraindications make this reasonable, although symptoms and adverse effects should be reviewed. A is inappropriate because finasteride is principally used to reduce progression risk in men with a prostate larger than 30 g or PSA greater than 1.4 ng/mL; neither criterion is present, and it would not directly address urgency in the short term. C unnecessarily withdraws a successful alpha blocker, risking recurrence of voiding symptoms. D is for nocturnal polyuria after other causes and treatments have been addressed; his frequency-volume chart excludes this. E is not indicated without red flags such as recurrent infection, haematuria, sterile pyuria, profound symptoms or suspicion of another structural diagnosis.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Published 2010; last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Solifenacin 5 mg film-coated tablets — Summary of Product Characteristics (Last updated 30 June 2026) — https://www.medicines.org.uk/emc/product/10429/smpc