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Benign prostatic enlargement with recurrent urinary tract infection — MSRA MCQ

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HardBPHBenign prostatic enlargement with recurrent urinary tract infectionMSRA

A 74-year-old man is reviewed after his second culture-confirmed Escherichia coli lower UTI in 5 months. Between infections he has persistent bothersome hesitancy, weak stream and incomplete emptying despite tamsulosin MR 400 micrograms once daily. His DRE shows a smooth enlarged prostate. He has no visible haematuria, loin pain, fever, palpable bladder, neurological symptoms or weight loss. His eGFR is 73 mL/min/1.73 m² and PSA, checked before starting tamsulosin 8 months ago, was 1.9 micrograms/L. He is now asymptomatic after completing culture-directed antibiotics. What is the most appropriate next management step?

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Correct answer: B — Refer for specialist urological assessment of recurrent UTI complicating lower urinary tract symptoms

This man has recurrent UTI, defined as at least 2 UTIs in 6 months, in the context of persistent LUTS attributed to benign prostatic enlargement. NICE recommends specialist referral for men with LUTS complicated by recurrent or persistent UTI. Specialist assessment can determine whether clinically significant bladder outlet obstruction, residual urine, stones or another structural cause is contributing; flow rate and post-void residual measurement are part of specialist LUTS assessment. Finasteride could subsequently be appropriate because his PSA exceeds 1.4 ng/mL and he is older, suggesting a risk of progression. However, adding it now does not address the indication for specialist assessment created by recurrent infection. Antibiotic prophylaxis should not be initiated independently in this setting: NICE advises referral or specialist advice for recurrent UTI in men. A suspected cancer pathway is not indicated solely by recurrent uncomplicated UTI without visible haematuria or another specific cancer feature. Increasing tamsulosin is inappropriate: 400 micrograms is the standard modified-release dose, and escalation would neither investigate nor address recurrent infection.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (2010; last updated 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE NG112: Urinary tract infection (recurrent): antimicrobial prescribing — Referral and seeking specialist advice (2018; amended 2024) — https://www.nice.org.uk/guidance/ng112/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Drug treatment (2010; last updated 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations