A 78-year-old man presents to the office with urinary hesitancy, straining to void his bladder,...

This elderly man has classic lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) : hesitancy, straining, and incomplete emptying (obstructive symptoms). MCCQE objectives emphasize recognizing obstructive voiding symptoms in older men as most commonly due to prostatic enlargement causing bladder outlet obstruction.

First-line pharmacologic therapy for symptomatic BPH is an alpha-1 adrenergic receptor blocker (e.g., tamsulosin), which relaxes smooth muscle in the prostate and bladder neck, thereby improving urinary flow and reducing obstruction. Tamsulosin works relatively quickly and is appropriate for symptomatic relief.

Nitrofurantoin treats urinary tract infections, which are not suggested here. Fesoterodine is an antimuscarinic used for overactive bladder and could worsen urinary retention in obstructive BPH. Empagliflozin (an SGLT2 inhibitor) increases urinary glucose excretion and may worsen urinary frequency. Hydrochlorothiazide increases urine output and would not relieve obstructive symptoms.

Therefore, tamsulosin is the most appropriate medication to improve this patient’s symptoms.