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Male lower urinary tract symptoms with nocturnal enuresis — MSRA MCQ

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ModerateLUTSMale lower urinary tract symptoms with nocturnal enuresisMSRA

A 73-year-old man presents with 9 months of hesitancy, weak stream, intermittency and nocturia. Over the past 6 weeks he has also had two episodes of nocturnal enuresis. His IPSS is 18. Urine dipstick is negative for blood, leucocytes, nitrites and glucose. Digital rectal examination shows a smooth, moderately enlarged prostate. He has no visible haematuria, recurrent urinary tract infection, renal stone history, loin pain or palpable bladder. Following discussion, he does not currently wish to have PSA testing. Which additional investigation is most appropriate at this initial assessment to assess for a complication of lower urinary tract dysfunction?

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Correct answer: C — Arrange serum creatinine measurement with eGFR calculation

Nocturnal enuresis in a man with voiding LUTS is a feature that should raise concern about possible renal impairment related to lower urinary tract dysfunction. NICE therefore advises serum creatinine measurement with eGFR calculation at initial assessment when renal impairment is suspected; examples include nocturnal enuresis, a palpable bladder, recurrent UTI or renal stones. Renal and bladder ultrasonography is not routinely required at initial assessment in the absence of established chronic retention or another specific indication. Uroflowmetry and post-void residual measurement are part of specialist assessment rather than routine initial primary-care assessment. Cystoscopy is not indicated without features such as haematuria, recurrent infection, sterile pyuria, pain or profound symptoms. Multiparametric prostate MRI is not an investigation for assessing obstructive LUTS-related renal complications and would be considered only within an appropriate prostate-cancer diagnostic pathway. The key discriminator is not the overall IPSS severity or benign rectal examination, but the new nocturnal enuresis accompanying voiding symptoms: this changes the initial investigation threshold for renal-function testing.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (2010) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations