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Benign prostatic enlargement with a new malignant-feeling prostate on examination — MSRA MCQ

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HardBPHBenign prostatic enlargement with a new malignant-feeling prostate on examinationMSRA

A 69-year-old man is reviewed in general practice. He has had 10 months of bothersome hesitancy, weak stream and incomplete emptying attributed to benign prostatic enlargement. Six months ago, before treatment, his DRE was smooth and enlarged, PSA was 2.0 micrograms/L, and prostate volume was estimated at 44 mL. He was started on tamsulosin MR 400 micrograms once daily and finasteride 5 mg once daily, with substantial symptomatic improvement. He has no dysuria, fever, visible haematuria, perineal pain, recent urinary instrumentation or urinary tract infection. Today, DRE identifies a firm irregular nodule in the left peripheral zone. PSA is 1.1 micrograms/L. He is otherwise well and wishes to understand the significance of this finding. What is the most appropriate next management step?

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

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Correct answer: A — Make an urgent suspected cancer pathway referral for prostate cancer, documenting the finasteride exposure and PSA history

Explanation lettering: E = shown as C · C = shown as E

The firm irregular peripheral-zone nodule is a malignant-feeling prostate on DRE. NICE NG12 recommends suspected cancer pathway referral on this finding; referral is not contingent on a raised PSA. The current PSA should not reassure: finasteride commonly reduces PSA by about 50% after 6 months, so 1.1 micrograms/L broadly corresponds to an untreated value of approximately 2.2 micrograms/L. However, PSA adjustment does not override an abnormal DRE, and finasteride-related PSA suppression does not exclude concomitant prostate cancer. B is inappropriate because stopping finasteride and repeating PSA delays referral prompted by a malignant-feeling DRE. C correctly recognises the approximate PSA adjustment but wrongly uses an adjusted PSA below the age-specific threshold to overrule the examination finding. D also delays the required referral; PSA may be repeated or further assessed within the specialist pathway. E mistakes improvement in LUTS for diagnostic reassurance: symptomatic BPH and prostate cancer can coexist, and the new DRE abnormality changes the priority from routine BPH follow-up to urgent cancer assessment.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer, prostate cancer recommendation 1.6.1 (Updated January 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer Finasteride 5 mg film-coated tablets — Summary of Product Characteristics, section 4.4 (Updated 2025) — https://www.medicines.org.uk/emc/product/13543/smpc