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Benign prostatic hyperplasia with moderate-to-severe LUTS and symptomatic orthostatic hypotension — MSRA MCQ

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HardBPHBenign prostatic hyperplasia with moderate-to-severe LUTS and symptomatic orthostatic hypotensionMSRA

A 78-year-old man has 11 months of bothersome hesitancy, weak stream, intermittency and incomplete emptying despite reducing evening fluids and caffeine. His IPSS is 24. Urine dipstick is normal, eGFR is 71 mL/min/1.73 m², and there is no recurrent UTI, visible haematuria, retention, palpable bladder, nocturnal enuresis or neurological abnormality. DRE shows a smooth enlarged prostate; ultrasound estimates prostate volume at 54 g. PSA, measured before treatment, is 2.3 micrograms/L. He has a documented history of orthostatic hypotension, with two previous falls associated with postural dizziness. Current postural blood pressures are 146/80 mmHg supine and 112/66 mmHg after 3 minutes standing, with reproduced light-headedness. He wishes to try drug treatment and understands that some treatments have a delayed effect. Which is the most appropriate pharmacological plan?

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Correct answer: E — Start finasteride 5 mg once daily and assess response after at least 6 months

This man has moderate-to-severe, bothersome voiding LUTS consistent with benign prostatic enlargement, without features requiring urgent catheterisation or specialist assessment for retention, renal impairment, recurrent infection, haematuria or suspected cancer. His prostate volume exceeds 30 g and PSA exceeds 1.4 ng/mL, making him an appropriate candidate for a 5-alpha reductase inhibitor; his age also indicates a higher risk of progression. Finasteride is therefore suitable and may reduce prostate size, acute retention and future need for surgery. He must be counselled that meaningful assessment of benefit may require at least 6 months. Alpha blockers would normally provide quicker symptom improvement, and combination treatment is often considered for severe symptoms with an enlarged prostate. However, tamsulosin, doxazosin and alfuzosin are inappropriate here because he has symptomatic, documented orthostatic hypotension with falls. This is a contraindication in the relevant SmPCs and the clinical risk is particularly important in an older person already experiencing a substantial postural blood-pressure fall. Combination therapy retains the same unacceptable alpha-blocker risk.

Reference: Lower urinary tract symptoms in men: management — Recommendations (2010; last updated 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Finasteride 5 mg film-coated tablets — Summary of Product Characteristics (2024) — https://www.medicines.org.uk/emc/product/9958/smpc Tabphyn MR 400 microgram modified-release capsules — Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/5277/smpc