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Male lower urinary tract symptoms complicated by recurrent urinary tract infection — MSRA MCQ

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HardLUTSMale lower urinary tract symptoms complicated by recurrent urinary tract infectionMSRA

A 69-year-old man is reviewed for bothersome lower urinary tract symptoms. For 9 months he has had hesitancy, weak stream, intermittency, nocturia and a sensation of incomplete emptying. His IPSS is 22. He has reduced caffeine intake and completed a 6-month adherent trial of tamsulosin MR 400 micrograms once daily, with only modest improvement. During the last 7 months he has had 3 episodes of dysuria and frequency, each with a midstream urine culture growing >100,000 CFU/mL Escherichia coli and each resolving with culture-directed antibiotics. He is currently asymptomatic; repeat urine culture is negative. He has no fever, loin pain, visible haematuria, weight loss or bone pain. DRE shows a smooth enlarged prostate estimated at 42 g. PSA, taken before tamsulosin, was 2.4 micrograms/L. eGFR is 76 mL/min/1.73 m² and there is no palpable bladder. What is the most appropriate next management step?

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Correct answer: C — Refer for urological specialist assessment

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

This man requires urological specialist assessment because his LUTS are complicated by recurrent culture-confirmed urinary tract infection. NICE specifically recommends specialist referral for LUTS complicated by recurrent or persistent UTI, irrespective of the absence of renal impairment or overt retention. His persistent bothersome voiding symptoms despite an adequate alpha-blocker trial provide an additional reason for referral. A is initially attractive because alpha-blockers are appropriate for moderate-to-severe LUTS, but continued primary-care review alone is insufficient once recurrent UTI complicates LUTS. B may ultimately form part of specialist investigation, particularly if chronic retention or upper-tract pathology is suspected, but imaging is not a substitute for the indicated specialist referral. D is plausible in recurrent UTI management, but recurrent UTI in a man warrants specialist advice to identify and address an underlying cause such as bladder outlet obstruction; suppressive antibiotics should not be the default next step. E is inappropriate because there is no malignant-feeling prostate, visible haematuria, systemic cancer features or concerning PSA result in the stem. The correct priority is referral for assessment of complicated LUTS, with specialist investigations guided by the findings.

Reference: NICE CG97: Lower urinary tract symptoms in men: management (2010) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management (2010) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE Quality Standard QS90: Referring adults with recurrent urinary tract infection (2023) — https://www.nice.org.uk/guidance/qs90/chapter/quality-statement-5-referring-adults-with-recurrent-urinary-tract-infection