What is the next step in managing a 77-year-old man with bothersome urinary frequency, urgency, and nocturia, on tamsulosin for 6 weeks, with hypertension, an enlarged prostate, and elevated post-void residual volume?

Management of Persistent LUTS in an Elderly Man with Enlarged Prostate

The next step in managing this 77-year-old man with persistent LUTS despite 6 weeks of tamsulosin therapy should be adding a 5-alpha reductase inhibitor (5-ARI) such as finasteride or dutasteride to the current tamsulosin regimen due to his significantly enlarged prostate (60g). 1

Assessment of Current Status

• Patient has bothersome urinary frequency, urgency, and nocturia despite 6 weeks of tamsulosin therapy 1
• Prostate is significantly enlarged at 60g (normal <30g) 1
• Post-void residual (PVR) is 100ml, which is mildly elevated but not severely obstructive 1
• Hypertension is present (145/96) and should be considered in management 1
• Urinalysis is unremarkable, ruling out infection as a cause 1

Rationale for Adding a 5-Alpha Reductase Inhibitor

• 5-ARIs are specifically indicated for men with LUTS and prostatic enlargement >30cc, making this patient an ideal candidate 1
• Combination therapy with an alpha-blocker and 5-ARI is appropriate and effective for patients with LUTS associated with demonstrable prostatic enlargement 1
• 5-ARIs reduce prostate size and have been shown to prevent disease progression, reducing the risk of acute urinary retention and need for surgery 1
• Alpha blockers like tamsulosin provide rapid symptom relief but do not address the underlying prostatic enlargement 1, 2

Treatment Algorithm

1. Continue tamsulosin for immediate symptom relief 2
2. Add a 5-ARI (finasteride or dutasteride) to address the enlarged prostate 1
3. Schedule follow-up in 3 months to assess the efficacy of combination therapy, as 5-ARIs require at least 3 months to show clinical effect 1
4. Monitor blood pressure and consider separate treatment for hypertension if needed 1

Expected Outcomes

• Improved symptom control with combination therapy 1
• Reduction in prostate volume over time (3-6 months) with 5-ARI 1
• Decreased risk of disease progression and complications 1
• Potential improvement in urinary flow rates 2

Important Considerations

• 5-ARIs reduce serum PSA by approximately 50%; this should be considered in future prostate cancer screening (multiply PSA value by 2) 1
• Common side effects of 5-ARIs include sexual adverse events (decreased ejaculation, decreased libido, erectile dysfunction) 1
• If combination therapy fails after 3-6 months, urologic referral for additional workup (urodynamics, cystoscopy) and consideration of surgical options would be warranted 1
• Patients with significant nocturia may benefit from additional assessment with a frequency-volume chart 1

Why Not Other Options?

• Anticholinergics could worsen voiding symptoms in a patient with enlarged prostate and may increase PVR 1
• Immediate surgical intervention is not indicated as the patient has not failed an adequate trial of medical therapy 1
• Watchful waiting is inappropriate given the patient's bothersome symptoms despite current therapy 1