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Benign prostatic enlargement with planned cataract surgery — MSRA MCQ

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HardBPHBenign prostatic enlargement with planned cataract surgeryMSRA

A 76-year-old man has 10 months of bothersome hesitancy, weak stream, intermittency and incomplete emptying despite fluid and caffeine modification. His IPSS is 22. Urine dipstick is normal, eGFR is 76 mL/min/1.73 m², and there is no visible haematuria, recurrent UTI, retention, palpable bladder, neurological abnormality or weight loss. DRE shows a smooth enlarged prostate; ultrasound estimates prostate volume at 48 mL. PSA, measured before any BPH treatment, is 2.6 micrograms/L. He is booked for elective cataract surgery in 3 weeks. He wants pharmacological treatment now and accepts that a treatment aimed at reducing longer-term progression may not give rapid symptom relief. Which is the most appropriate pharmacological plan?

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Correct answer: D — Start finasteride 5 mg once daily and defer alpha-blocker initiation until after cataract surgery

This man has moderate-to-severe bothersome voiding LUTS with benign examination findings and an enlarged prostate (48 mL) with PSA above 1.4 micrograms/L. He is therefore an appropriate candidate for a 5-alpha-reductase inhibitor, particularly as his age and prostate size indicate a higher risk of progression. Finasteride can be started now, with counselling about sexual adverse effects and the need to interpret future PSA results in the context of treatment. However, tamsulosin should not be initiated when cataract surgery is scheduled because of the association with intraoperative floppy iris syndrome (IFIS), which can increase operative complications. Stopping tamsulosin 1–2 weeks pre-operatively is not a reliable solution: the SmPC states that any benefit from withdrawal is unproven, and IFIS has occurred after previous exposure. Alfuzosin is not a safe workaround because other alpha-1 blockers may also carry a class effect. Combination therapy would consequently introduce the same avoidable peri-operative risk. Deferring every treatment is less appropriate because finasteride is indicated and does not create the alpha-blocker-associated cataract risk.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (2010; page current when checked 16 August 2026) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Tamsulosin hydrochloride Zentiva 400 microgram prolonged-release hard capsules — Summary of Product Characteristics (2024; checked 16 August 2026) — https://www.medicines.org.uk/emc/product/9245/smpc Finasteride 5 mg Tablets — Summary of Product Characteristics (Updated July 2026; checked 16 August 2026) — https://www.medicines.org.uk/emc/product/547/smpc