How to manage post void dribbling caused by tamsulosin (alpha-blocker) in patients with Benign Prostatic Hyperplasia (BPH)?

Management of Post Void Dribbling from Tamsulosin

For patients experiencing post void dribbling due to tamsulosin, pelvic floor exercises (Kegel exercises) combined with urethral milking technique are the most effective management strategies while continuing the medication for BPH treatment. 1

Understanding the Problem

Post void dribbling is a common side effect of tamsulosin and other alpha blockers used to treat BPH. This occurs because:

• Alpha blockers relax the smooth muscle in the prostate and bladder neck
• This relaxation can extend to the urethra, leading to incomplete emptying
• Small amounts of urine may remain in the urethra after voiding
• This urine then dribbles out after the patient has finished urinating

Management Strategies

First-line Approaches (Continue Tamsulosin)

1. Urethral Milking Technique:

   • After urination, press firmly behind the scrotum and milk forward along the urethra
   • This manually expels remaining urine in the urethra
   • Repeat 2-3 times to ensure complete emptying

2. Pelvic Floor Exercises (Kegel):

   • Identify pelvic floor muscles by stopping urination midstream
   • Contract these muscles for 3-5 seconds, then relax for 3-5 seconds
   • Perform 10-15 repetitions, 3 times daily
   • Strengthens muscles that help control urine flow

3. Behavioral Modifications:

   • Take time to fully empty the bladder when urinating
   • Double-void technique: urinate, wait 30 seconds, then try again
   • Reduce evening fluid intake, especially caffeine and alcohol 2
   • Rise slowly from sitting/lying positions to minimize orthostatic effects

Medication Adjustments (If First-line Approaches Fail)

1. Dose Adjustment:

   • Consider reducing tamsulosin dose if symptoms are severe and first-line approaches fail
   • Balance between BPH symptom control and post void dribbling

2. Alternative Alpha Blockers:

   • Consider switching to alfuzosin, which may have different side effect profile 1
   • Note that all alpha blockers have similar efficacy but slightly different side effect profiles

3. Alternative BPH Treatments:

   • 5-alpha reductase inhibitors (finasteride, dutasteride) for men with enlarged prostates (>30cc) 2
   • These medications do not cause post void dribbling but take 3-6 months for full effect
   • Consider combination therapy (alpha blocker + 5-ARI) for men with larger prostates and moderate-to-severe symptoms 2

Follow-up and Monitoring

• Evaluate patients 4-12 weeks after initiating treatment 1
• Assessment should include:
  • IPSS (International Prostate Symptom Score)
  • Post-void residual volume measurement
  • Effectiveness of management strategies for post void dribbling
  • Medication adherence and side effects

Important Considerations

• Post void dribbling alone is not an indication to discontinue tamsulosin if it's effectively treating BPH symptoms
• Management techniques often need to be performed consistently for optimal results
• Patients should be reassured that this is a common side effect and not a sign of worsening disease
• If post void dribbling is accompanied by other significant urinary symptoms, further evaluation may be needed

When to Consider Surgical Options

Consider surgical intervention if:

• Medical therapy fails to control BPH symptoms
• Patient experiences recurrent urinary retention
• Post void dribbling significantly impacts quality of life despite management strategies
• Patient develops complications such as recurrent UTIs, renal insufficiency, or bladder stones 2

Surgical options include transurethral resection of the prostate (TURP), minimally invasive procedures, and newer laser technologies 2.