Can Atarax (hydroxyzine) cause urinary retention?

Can Atarax (Hydroxyzine) Cause Urinary Retention?

Yes, Atarax (hydroxyzine) can cause urinary retention due to its anticholinergic properties, and it should be avoided or used with extreme caution in patients at risk for urinary retention, particularly elderly patients and those with benign prostatic hyperplasia.

Mechanism and Risk Profile

Hydroxyzine is an antihistamine with significant anticholinergic activity that can impair bladder contractility and increase urinary retention risk 1, 2. The anticholinergic effects include:

• Impaired detrusor muscle contraction, preventing effective bladder emptying 2, 3
• Increased bladder outlet resistance through effects on the bladder neck and urethra 2
• Dose-dependent anticholinergic burden that accumulates with other medications 1

High-Risk Populations

Elderly patients (≥65 years) are at substantially elevated risk because 1:

• Pre-existing bladder dysfunction and reduced detrusor contractility
• Concurrent benign prostatic hyperplasia in men 2, 3
• Polypharmacy with other anticholinergic medications 1
• Impaired drug metabolism and clearance 1

Men with prostatic enlargement face the highest risk, as anticholinergic effects compound existing bladder outlet obstruction 1, 2, 3.

Clinical Evidence and Guidelines

Multiple authoritative sources classify hydroxyzine and similar anticholinergic antihistamines as potentially inappropriate medications:

• The American Geriatrics Society Beers Criteria identifies anticholinergic drugs like diphenhydramine (structurally similar to hydroxyzine) as associated with increased postoperative delirium and urinary retention 1
• European Society of Cardiology guidelines list anticholinergic medications among drugs causing urinary retention as an adverse effect 1
• Research demonstrates that up to 10% of urinary retention episodes may be attributable to concomitant anticholinergic medication use 2

Specific Anticholinergic Effects

Hydroxyzine causes the classic anticholinergic adverse effect profile 1:

• Dry mouth and constipation
• Urinary retention (particularly problematic)
• Cognitive impairment and confusion in elderly patients 1
• Increased fall risk due to sedation and dizziness 1

Management Recommendations

If urinary retention develops 1, 4, 2:

1. Immediately discontinue hydroxyzine or reduce the dose 2, 3
2. Perform bladder decompression via urethral catheterization if acute retention occurs 4
3. Remove Foley catheters as soon as medically possible, ideally within 24-48 hours 1, 4
4. Avoid medications that cause urinary retention, including anticholinergics, in persons >65 years 1

Prevention strategies 1, 2:

• Screen for pre-existing lower urinary tract symptoms before prescribing 5
• Assess for concurrent medications with anticholinergic properties 1, 2
• Consider alternative non-anticholinergic antihistamines (e.g., cetirizine, loratadine) in high-risk patients
• Monitor elderly patients closely for urinary symptoms 1

Critical Caveats

Do not prescribe hydroxyzine in patients with 1, 2:

• History of urinary retention
• Benign prostatic hyperplasia with obstructive symptoms
• Neurogenic bladder dysfunction 5
• Concurrent use of other anticholinergic medications 1, 2

Combination with other anticholinergics dramatically increases retention risk, as anticholinergic effects are additive 1, 2, 6. This includes medications like oxybutynin, tolterodine, tricyclic antidepressants, and antipsychotics 7, 8, 6.

The risk-benefit ratio for hydroxyzine is particularly unfavorable in elderly patients, where safer alternatives exist for most indications 1.