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Male lower urinary tract symptoms presumed secondary to benign prostatic enlargement — MSRA MCQ

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HardLUTSMale lower urinary tract symptoms presumed secondary to benign prostatic enlargementMSRA

A 74-year-old man presents with 10 months of bothersome hesitancy, weak stream, intermittency and nocturia. His IPSS is 23. He has reduced evening fluid intake and caffeine without adequate benefit. Urine dipstick is negative for blood, leucocytes, nitrites and glucose. Digital rectal examination shows a smooth prostate estimated at 48 g. Following counselling, his PSA is 2.8 micrograms/L. Renal function is normal and there is no palpable bladder, recurrent UTI, visible haematuria or suspicion of prostate cancer. He is scheduled for elective cataract surgery in 4 weeks. He wishes to begin drug treatment now. What is the most appropriate pharmacological management?

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

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Correct answer: D — Start finasteride 5 mg once daily and review response in 3 to 6 months

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

This man has bothersome moderate-to-severe voiding LUTS with a prostate estimated at 48 g and PSA 2.8 micrograms/L. Both markers exceed NICE thresholds for a 5-alpha reductase inhibitor (5-ARI), and his age and enlarged prostate indicate a meaningful risk of progression. Finasteride is therefore appropriate, although he should be counselled that symptomatic benefit may require at least 6 months and that sexual adverse effects can occur. Tamsulosin would usually be an appropriate first-line drug for rapid symptom relief, and combination alpha-blocker/5-ARI treatment would ordinarily be reasonable in this phenotype. However, the tamsulosin SmPC states that initiating treatment in people scheduled for cataract surgery is not recommended because intraoperative floppy iris syndrome (IFIS) can increase operative complications. Informing the surgeon does not remove this prescribing concern (B). Stopping tamsulosin 1 to 2 weeks preoperatively is only anecdotally considered helpful, with no established benefit (A). Deferring all treatment (C) unnecessarily withholds an indicated disease-modifying treatment that does not create the same perioperative IFIS concern. Solifenacin (E) targets overactive-bladder storage symptoms; this stem describes predominantly voiding symptoms without urgency or urge incontinence.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Last updated 3 June 2015; last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Tamsulosin hydrochloride Zentiva 400 microgram prolonged-release hard capsules — Summary of Product Characteristics (Published 2024) — https://www.medicines.org.uk/emc/product/9245/smpc Finasteride 5 mg film-coated tablets — Summary of Product Characteristics (Published 2024) — https://www.medicines.org.uk/emc/product/9958/smpc