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Chronic urinary retention secondary to benign prostatic enlargement — MSRA MCQ

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HardBPHChronic urinary retention secondary to benign prostatic enlargementMSRA

A 69-year-old man is assessed in a urology clinic for persistent LUTS attributed to benign prostatic enlargement. Despite 9 months of tamsulosin MR 400 micrograms once daily and finasteride 5 mg once daily, he has severe hesitancy, weak stream, straining, incomplete emptying and overflow nocturnal enuresis (IPSS 25). He is otherwise fit for an operation. Post-void residual volumes measured on two occasions 2 weeks apart are 820 mL and 790 mL. Uroflowmetry shows a low flow rate. DRE shows a smooth enlarged prostate. Serum creatinine is 82 micromol/L (eGFR 78 mL/min/1.73 m²), and renal ultrasound shows no hydronephrosis. There is no UTI, haematuria, neurological disease or suspected prostate cancer. What is the most appropriate management plan?

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

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Correct answer: C — Offer bladder-outlet surgery without prior catheterisation

Explanation lettering: E = shown as C · C = shown as D · D = shown as E

This man has chronic urinary retention with severe, bothersome voiding symptoms despite appropriate medical treatment. The key discriminator is that he has neither renal impairment nor upper-tract abnormality: renal function is preserved and ultrasound shows no hydronephrosis. NICE therefore advises that bladder-outlet surgery may be offered without prior catheterisation in men with chronic retention, bothersome LUTS and no renal or upper-tract impairment. A is appropriate for non-bothersome chronic retention when the bladder has not been drained, not for severe symptoms refractory to drug treatment. B is unnecessarily invasive in this case: catheterisation is required when chronic retention has caused renal impairment or hydronephrosis, neither of which is present. C is a reasonable alternative where markedly impaired bladder function is suspected, but the stem supports outlet obstruction and provides no evidence of detrusor failure. D reflects the acute urinary retention pathway, in which catheterisation and alpha-blockade precede catheter removal; this is chronic retention rather than acute painful retention. Therefore, definitive outlet surgery without preceding bladder drainage is the best plan.

Reference: Lower urinary tract symptoms in men: management — recommendations, section 1.7 Treating urinary retention (Last updated 3 June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations