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Benign prostatic enlargement with severe refractory voiding LUTS and a small prostate — MSRA MCQ

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HardBPHBenign prostatic enlargement with severe refractory voiding LUTS and a small prostateMSRA

A 68-year-old man is reviewed by urology for severe voiding LUTS attributed to benign prostatic enlargement. He has persistent hesitancy, weak stream, straining and incomplete emptying despite fluid modification and 6 months of tamsulosin MR 400 micrograms once daily. His IPSS is 24. Urine culture is negative, eGFR is 78 mL/min/1.73 m², and there is no visible haematuria, recurrent UTI, urinary retention, neurological disease or suspicion of prostate cancer. DRE is benign. Specialist assessment shows a maximum flow rate of 7 mL/second, post-void residual volume of 110 mL, and prostate volume of 27 g; PSA is 0.9 micrograms/L. He wishes to proceed with operative management after counselling. Which is the most appropriate management plan?

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

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Correct answer: A — Offer transurethral incision of the prostate as an alternative to TURP, TUVP or HoLEP

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

D is correct. He has severe, predominantly voiding LUTS with objective evidence of obstruction and persistent symptoms despite appropriate conservative treatment and an alpha blocker; surgery is therefore reasonable. His prostate is estimated at 27 g. NICE specifically recommends transurethral incision of the prostate (TUIP) as an alternative to TURP, TUVP or HoLEP when the prostate is smaller than 30 g. A is inappropriate because a 5-alpha reductase inhibitor is recommended for men at higher risk of progression with a prostate larger than 30 g or PSA above 1.4 ng/mL; neither criterion is met. It would also delay a definitive option after failed alpha-blocker treatment. B is inappropriate because open prostatectomy is reserved as an alternative for prostates larger than 80 g. C is not indicated: catheterisation before surgery is considered in chronic retention, particularly where renal impairment, upper-tract abnormality or markedly impaired bladder function is suspected; this man has none of these. E is inappropriate because NICE advises intraprostatic botulinum toxin only within a randomised controlled trial.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Published 2010; last updated June 2015; last reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Drug treatment (Published 2010; last updated June 2015; last reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations