## Clinical Context This patient has benign prostatic hyperplasia (BPH) with LUTS and objective evidence of outlet obstruction (elevated post-void residual). PSA is normal, and DRE shows no suspicious features (smooth, symmetrical, no nodules). ## Rationale for Alpha-Blocker **Key Point:** Alpha-1 adrenergic antagonists (tamsulosin, doxazosin, alfuzosin) are first-line pharmacotherapy for symptomatic BPH with LUTS. **High-Yield:** The mechanism is relaxation of smooth muscle in the prostatic urethra and bladder neck, improving urinary flow without reducing prostate size. **Clinical Pearl:** In uncomplicated BPH without cancer suspicion (normal PSA, benign DRE), empirical medical management is standard before considering invasive procedures. ## Why Reassessment at 4–6 Weeks? - Allows time to assess symptom response and tolerability. - If inadequate response, 5-alpha reductase inhibitors (finasteride, dutasteride) can be added for long-term prostate volume reduction. - TURP is reserved for refractory cases or complications (recurrent UTI, retention, haematuria). ## Management Algorithm for BPH ```mermaid flowchart TD A[LUTS + Enlarged prostate]:::outcome --> B{PSA elevated?<br/>DRE nodular?}:::decision B -->|Yes| C[TRUS + Biopsy]:::action B -->|No| D[Assess symptom severity]:::decision D -->|Mild| E[Watchful waiting]:::action D -->|Moderate-Severe| F[Alpha-blocker trial]:::action F --> G{Response at 4-6 wks?}:::decision G -->|Good| H[Continue; add 5-ARI if needed]:::action G -->|Poor| I[Add 5-ARI or consider TURP]:::action ``` [cite:Harrison 21e Ch 305]
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