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Bothersome moderate-to-severe male LUTS associated with benign prostatic enlargement and alpha-blocker-induced

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HardLUTSBothersome moderate-to-severe male LUTS associated with benign prostatic enlargement and alpha-blocker-induced orthostatic hypotensionMSRA

A 77-year-old man is reviewed 5 weeks after starting tamsulosin MR 400 micrograms once daily for bothersome voiding LUTS. Before treatment, he had hesitancy, weak stream, intermittency and nocturia; IPSS was 24. DRE showed a smooth prostate estimated at 46 g and, following counselling, PSA was 2.6 micrograms/L. Urine dipstick was negative and renal function was normal. He had no palpable bladder, recurrent UTI, visible haematuria or features suggesting prostate cancer. His stream has improved, but he has had two episodes of near-syncope when rising from bed, including one fall. His seated blood pressure is 126/74 mmHg and his standing blood pressure after 3 minutes is 88/56 mmHg with light-headedness. He takes no other antihypertensive medication. He has no urgency, urge incontinence or constipation. What is the most appropriate next pharmacological management?

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

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Correct answer: E — Stop tamsulosin and start finasteride 5 mg once daily

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

This man has objectively symptomatic orthostatic hypotension with near-syncope and a fall temporally associated with tamsulosin. Tamsulosin should therefore be stopped rather than continued as combination treatment. He has severe, bothersome voiding LUTS and both markers of likely benign prostatic enlargement and progression risk: a prostate estimated at 46 g and PSA of 2.6 micrograms/L. As an older man with a prostate over 30 g and PSA over 1.4 ng/mL, he meets NICE criteria for a 5-alpha reductase inhibitor. Finasteride 5 mg daily is licensed as monotherapy for BPH with an enlarged prostate, although benefit may require at least 6 months to assess. B would ordinarily be a reasonable option for moderate-to-severe LUTS with an enlarged prostate, but continuing the causative alpha blocker is inappropriate here. C is initially attractive because alfuzosin is another licensed alpha blocker, but it does not address this patient’s demonstrated clinically important alpha-blocker-related postural hypotension. D treats overactive-bladder storage symptoms, which are absent. E is unsuitable because NICE advises against phosphodiesterase-5 inhibitors solely to treat male LUTS outside a randomised controlled trial.

Reference: Lower urinary tract symptoms in men: management – Recommendations (Last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Finasteride 5 mg film-coated tablets – Summary of Product Characteristics (17 September 2025) — https://www.medicines.org.uk/emc/product/13543/smpc