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Benign prostatic enlargement treated with finasteride — MSRA MCQ

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HardBPHBenign prostatic enlargement treated with finasterideMSRA

A 66-year-old man is reviewed in general practice 9 months after starting tamsulosin MR 400 micrograms once daily and finasteride 5 mg once daily for bothersome moderate-to-severe LUTS attributed to benign prostatic enlargement. Before treatment, his prostate was estimated at 46 g, DRE was smooth, and PSA was 3.4 micrograms/L. His voiding symptoms have improved substantially. He has no dysuria, fever, perineal pain, visible haematuria, recent urinary instrumentation or urinary tract infection. DRE remains smooth. He reports full adherence to both medicines and wishes to pursue investigation if clinically indicated. PSA measured today is 2.4 micrograms/L. What is the most appropriate next management step?

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Correct answer: E — Arrange a suspected cancer pathway referral for prostate cancer while continuing current treatment

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

After at least 6 months of finasteride, the measured PSA should be doubled when comparing it with reference ranges for untreated men. His PSA of 2.4 micrograms/L therefore equates to approximately 4.8 micrograms/L. In a symptomatic man aged 60–69 years, this exceeds the NICE age-specific PSA threshold of 4.5 micrograms/L at which a suspected cancer pathway referral should be considered. His preference to investigate and absence of major competing comorbidity support referral. A is unsafe because the apparent PSA reduction is misleading: 2.4 micrograms/L is not reassuring without adjustment for finasteride. B is inappropriate because stopping finasteride delays assessment and is not required to interpret PSA after 6 months of treatment. C would be reasonable only if there were evidence suggesting UTI or prostatitis as a transient cause of PSA elevation; none is present. D under-prioritises the possibility of prostate cancer once the appropriately adjusted PSA exceeds the relevant threshold. Finasteride can be continued while referral proceeds; a sustained PSA rise during finasteride treatment also warrants evaluation.

Reference: Finasteride 5 mg film-coated tablets - Summary of Product Characteristics (Published 2025) — https://www.medicines.org.uk/emc/product/13543/smpc Suspected cancer: recognition and referral (NG12), recommendations organised by site of cancer (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer