What medications are recommended for treating overactive bladder in males?

Medications for Overactive Bladder in Males

For males with overactive bladder, the recommended pharmacologic approach is to start with an antimuscarinic medication (such as solifenacin or tolterodine) or a β3-adrenoceptor agonist (mirabegron), with combination therapy reserved for patients who fail to respond to monotherapy. 1, 2

First-Line Pharmacologic Options

Antimuscarinic Medications

• Antimuscarinic medications are effective for treating overactive bladder symptoms in males and include darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, and trospium 2, 3
• These medications work by inhibiting the binding of acetylcholine at muscarinic receptors M2 and M3 on detrusor smooth muscle cells 3
• Common side effects include dry mouth, constipation, dry eyes, blurred vision, and cognitive effects, which may limit long-term adherence 3, 4
• Tolterodine demonstrates better bladder selectivity in clinical studies, resulting in fewer side effects (particularly dry mouth) compared to oxybutynin while maintaining similar efficacy 4, 5
• Extended-release formulations (e.g., tolterodine ER 4mg once daily) are associated with fewer side effects than immediate-release formulations 5, 6

β3-Adrenoceptor Agonist

• Mirabegron is indicated for the treatment of OAB in adult patients with symptoms of urge urinary incontinence, urgency, and urinary frequency 7
• Starting dose is 25mg once daily, which can be increased to 50mg once daily after 4-8 weeks if needed 7
• Mirabegron has a different side effect profile than antimuscarinics, with lower incidence of dry mouth and constipation 1
• Dose adjustments are required for patients with renal or hepatic impairment 7

Combination Therapy

• For patients who fail to respond to monotherapy, combination therapy with an antimuscarinic and a β3-adrenoceptor agonist may be considered 1
• The strongest evidence supports combining solifenacin (5mg) with mirabegron (25mg or 50mg) 1
• Combination therapy has demonstrated improved efficacy without significant increases in adverse events compared to monotherapy 1

Special Considerations for Males with BPH

• In men with overactive bladder symptoms and benign prostatic hyperplasia (BPH), lower urinary tract symptoms may be caused by both bladder and prostate issues 1
• Alpha blockers are recommended as initial therapy for men with BPH, with antimuscarinic medications or β3-adrenoceptor agonists added for persistent storage symptoms 1
• For men with prostate size >30cc, consider addition of a 5-alpha reductase inhibitor (5ARI) 1

Dosing and Administration

• For antimuscarinics, start with the lowest effective dose and titrate based on response and tolerability 2
• For mirabegron, start with 25mg once daily and increase to 50mg if needed after 4-8 weeks 7
• Dose adjustments are required for patients with renal impairment (eGFR <30 mL/min/1.73m²) or moderate hepatic impairment 7

Common Pitfalls to Avoid

• Failing to try behavioral therapies before medication (bladder training, pelvic floor exercises, fluid management) 2
• Not checking post-void residual in men with BPH before starting antimuscarinic therapy 1, 2
• Overlooking contraindications for antimuscarinics (narrow-angle glaucoma, urinary retention) 2
• Not considering drug interactions, particularly with CYP3A4 inhibitors when using tolterodine 4
• Setting unrealistic expectations - most patients experience significant symptom reduction but not complete relief 2

Follow-up and Monitoring

• Patients should be evaluated 4-12 weeks after initiating treatment to assess response and side effects 1
• Reassessment should include symptom scores (e.g., International Prostate Symptom Score) 1
• Consider checking post-void residual in men at higher risk of urinary retention 1, 2
• If initial therapy is ineffective or poorly tolerated, consider dose modification, alternate medication, or combination therapy 1