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Benign prostatic hyperplasia, lower urinary tract symptoms and PSA
Urinary symptoms in an older man split into voiding symptoms (weak stream, hesitancy) and storage symptoms (frequency, urgency, nocturia); an alpha-blocker relieves quickly, a 5-alpha-reductase inhibitor shrinks a large prostate over months, and PSA is a shared decision, not a routine test.
Why it matters in the exam
The exam asks about the first treatment for a man with a weak stream, what to add when an alpha-blocker is not enough, how a 5-alpha-reductase inhibitor affects PSA, and when surgery is needed. Urinary retention after an anticholinergic drug and a PSA test in an asymptomatic 70-year-old also appear.
Remember the "floppy iris" phenomenon in cataract surgery in a patient taking tamsulosin — the ophthalmologist must be told.
Benign prostatic enlargement is very common after age 50, and treatment depends on how much it bothers the patient, not on prostate size alone. Ask about new medicines too, because some worsen symptoms or cause retention.
The exam also shows a man who still passes urine at night despite an alpha-blocker, and asks what to add: by prostate size a 5-alpha-reductase inhibitor, and by storage symptoms a drug that calms the bladder. Frequent nocturia also calls for asking about evening fluids, diuretics and sleep apnoea. A man who presents with acute urinary retention receives a catheter and an alpha-blocker before a trial without catheter.
Key points
- Voiding symptoms and storage symptoms — two kinds.
- Alpha-blocker — fast; 5-alpha-reductase inhibitor — 6–12 months, for a large prostate.
- Finasteride lowers PSA by about half.
- Anticholinergics and decongestants may cause retention.
- PSA at 55–69 — shared decision; raised — MRI before biopsy.
Summary table
| Treatment | Mechanism | Time to response | Effects and warnings |
|---|---|---|---|
| Alpha-blocker (tamsulosin) | Relaxes smooth muscle in the bladder neck and prostate | Days | Postural hypotension, ejaculatory disorder, "floppy iris" in cataract surgery |
| 5-alpha-reductase inhibitor (finasteride, dutasteride) | Shrinks prostate volume | 6–12 months | Lowers PSA by about 50%; reduced libido; suits a large prostate |
| Combination treatment | Both mechanisms | — | Reduces retention and need for surgery in a large prostate |
| Tadalafil | PDE5 inhibitor | Weeks | Suits a man who also has erectile dysfunction; not with nitrates |
| Antimuscarinic or beta-3 agonist | Calms the bladder muscle | Weeks | For storage symptoms; check the post-void residual first |
| Surgery (TURP and similar) | Removes obstructing tissue | — | Recurrent retention, recurrent infections, stones, haematuria, renal impairment |
Free exam questions
מה מהבאים נכון בהתייחס לאי נקיטת שתן לאחר כריתה רדיקלית של הערמונית? (the question as examined, in Hebrew)
- א. במרבית המחקרים שיעורה נמוך מ- 5% שנה לאחר הניתוח
- ב. כריתת ערמונית בעזרת רובוט הורידה באופן משמעותי את ההיארעות של אי נקיטת שתן לאחר ניתוח
- ג. בגישה רובוטית השגת השליטה על השתן טובה ומהירה יותר יחסית לגישה הלפרוסקופית
- ד. לשימור עצבי אין השפעה על שיעור אי נקיטת שתן
מה מהבאים נכון לגבי חזרת סרטן ערמונית לאחר טיפול מקומי? (the question as examined, in Hebrew)
- א. PSA= 0.1ng/ml לאחר כריתה רדיקלית היא Biochemical Recurrence הגדרת
- ב. במידה ומוצע טיפול הצלה קרינתי במטופל בסיכון גבוה, מומלץ לשלבו עם .ADT
- ג. אין מקום לבצע MRI לבירור חזרת מחלה לאחר כריתת ערמונית
- ד. טיפול הצלה בכריתת ערמונית, לאחר טיפול קרינתי, מומלץ בהיעדר גרורות ו- PSA מעל .10
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Sources
- American Urological Association, 2021 (amended 2023) — Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia
- European Association of Urology, 2024 — Guidelines on non-neurogenic male LUTS and on prostate cancer (early detection)
- US Preventive Services Task Force, 2018 — Screening for prostate cancer
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.