skip to main content

Benign prostatic enlargement with coexisting erectile dysfunction and nitrate therapy — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardBPHBenign prostatic enlargement with coexisting erectile dysfunction and nitrate therapyMSRA

A 72-year-old man has 12 months of bothersome hesitancy, weak stream, intermittency and incomplete emptying despite reducing caffeine and evening fluid intake. His IPSS is 24. Urine dipstick is normal, eGFR is 72 mL/min/1.73 m², and there is no visible haematuria, recurrent UTI, urinary retention, palpable bladder, neurological abnormality or suspicion of prostate cancer. DRE shows a smooth enlarged prostate; ultrasound estimates prostate volume at 46 mL. PSA, measured before treatment, is 2.1 micrograms/L. He also has erectile dysfunction. He has stable exertional angina and carries sublingual glyceryl trinitrate, which he uses approximately twice monthly. His other medicine is atorvastatin. Seated and standing blood pressures are 134/78 mmHg and 128/76 mmHg respectively, without postural symptoms. He asks whether one medicine can treat both his urinary and erectile symptoms. Which is the most appropriate pharmacological plan?

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

Reveal the answer and explanation

Correct answer: D — Start tamsulosin MR 400 micrograms once daily with finasteride 5 mg once daily, and do not prescribe tadalafil

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

This man has severe, bothersome voiding LUTS (IPSS 24) with a prostate larger than 30 g and PSA above 1.4 ng/mL. NICE recommends an alpha blocker for moderate-to-severe LUTS and supports combination alpha-blocker/5-alpha-reductase-inhibitor treatment in men with bothersome moderate-to-severe LUTS plus prostate enlargement or raised PSA. Tamsulosin provides relatively prompt symptom relief, while finasteride addresses longer-term progression risk. Tadalafil 5 mg daily is licensed for BPH with or without erectile dysfunction, so options A-C are initially attractive. However, tadalafil is contraindicated with any organic nitrate because it potentiates nitrate-induced hypotension. This applies even though he uses sublingual glyceryl trinitrate intermittently. Stopping prescribed nitrate treatment simply to facilitate tadalafil is inappropriate without a cardiovascular review and would not address his established anti-anginal indication. Tamsulosin can cause postural hypotension, but his postural observations are stable and he has no history of symptomatic orthostasis; it is not contraindicated by nitrate availability. He should nevertheless receive counselling about dizziness and be reviewed for treatment effect and adverse effects. Erectile dysfunction should be managed with non-PDE5 options or following cardiology-led reconsideration of his anti-anginal regimen if clinically appropriate.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (2010; page checked August 2026) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Tadalafil 5 mg film-coated tablets — Summary of Product Characteristics (2024; page checked August 2026) — https://www.medicines.org.uk/emc/product/10231/smpc Tamsulosin hydrochloride 400 micrograms prolonged-release hard capsules — Summary of Product Characteristics (2025; page checked August 2026) — https://www.medicines.org.uk/emc/product/2508/smpc