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

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HardBPHLower urinary tract symptoms presumed secondary to benign prostatic enlargementMSRA

A 73-year-old man presents in general practice with 9 months of progressively worsening hesitancy, weak stream, intermittency and straining. During the past month, he has had three episodes of nocturnal enuresis without preceding urgency. He has no dysuria, fever, visible haematuria, flank pain or neurological symptoms. Urine dipstick and culture are negative. DRE shows a smooth enlarged prostate. PSA measured 4 months ago was 1.8 micrograms/L. He has not had renal function checked for 3 years. Which single additional investigation is most appropriate at this initial GP assessment?

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Correct answer: D — Measure serum creatinine and calculate eGFR

The correct answer is to measure serum creatinine and calculate eGFR. His obstructive voiding symptoms and smooth enlargement are consistent with bladder outlet obstruction secondary to benign prostatic enlargement. Crucially, new nocturnal enuresis raises concern for chronic retention with possible renal impairment, even without pain, infection or visible haematuria. NICE recommends renal function testing at initial assessment when renal impairment is suspected; nocturnal enuresis is specifically given as an example. Renal tract imaging, uroflowmetry with post-void residual measurement, cystoscopy and cystometry are not routine initial-assessment investigations in primary care. They may become appropriate following specialist assessment or if renal dysfunction, retention, recurrent infection, haematuria or another complication is identified. A previously unremarkable PSA neither evaluates renal consequences of obstruction nor removes the need to assess current renal function. If renal impairment attributable to lower urinary tract dysfunction is found, he requires specialist referral.

Reference: NICE CG97: Lower urinary tract symptoms in men: management, Recommendations (2010; last updated 3 June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management, Recommendations (2010; last updated 3 June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management, Recommendations (2010; last updated 3 June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations