What are the treatment options for overactive bladder (OAB) in males?

Treatment of Overactive Bladder in Males

Begin immediately with behavioral therapies for all male patients with OAB, then add beta-3 agonist mirabegron (25-50 mg daily) as the preferred pharmacologic agent over antimuscarinics due to lower cognitive risk, with special attention to excluding benign prostatic obstruction which may require alpha-blocker therapy first. 1, 2

Initial Evaluation: What to Look For

Before treating OAB in men, you must distinguish primary OAB from bladder outlet obstruction (BOO) caused by benign prostatic enlargement (BPE), as the treatment algorithms differ significantly. 3

• Obtain International Prostate Symptom Score (IPSS) to quantify symptom severity and assess for voiding symptoms suggesting BOO. 3
• Perform urinalysis (dipstick or microscopic) to exclude infection and microhematuria; obtain urine culture if positive. 1, 2
• Measure post-void residual (PVR) in men with emptying symptoms, history of urinary retention, enlarged prostate, neurologic disorders, prior prostate surgery, or long-standing diabetes—this is mandatory before starting antimuscarinics. 1, 2
• Assess prostate size via digital rectal exam or ultrasound; prostates >30 cc suggest BPE requiring consideration of 5-alpha reductase inhibitor (5ARI) in addition to alpha-blocker. 3
• Check urine flow rate (Qmax) if available; Qmax <10 mL/second suggests significant obstruction requiring interventional therapy consideration. 3

Critical distinction: If storage symptoms (urgency, frequency, nocturia) predominate without evidence of BOO, treat as primary OAB. If voiding symptoms and/or enlarged prostate are present, start with alpha-blocker therapy before or concurrent with OAB treatment. 3

First-Line Treatment: Behavioral Therapies (Start Immediately)

These interventions have zero drug interaction risk and equal effectiveness to antimuscarinics in many patients. 1, 2

• Timed voiding and urgency suppression: Teach patients to practice postponing urination when urgency occurs—stop, sit down, perform pelvic floor contractions, use distraction techniques, wait for urgency to pass, then walk calmly to bathroom. 1, 2
• Bladder training: Gradually extend intervals between voids to retrain bladder capacity. 1, 2
• Fluid management: Reduce total daily fluid intake by 25%, with particular attention to evening fluid restriction to reduce nocturia. 1, 4
• Eliminate bladder irritants: Advise complete avoidance of caffeine and alcohol, which directly irritate the bladder. 1, 2
• Weight loss: Even 8% reduction in obese men reduces urgency incontinence episodes by 42%. 1
• Pelvic floor muscle training: Strengthening exercises improve urge suppression and bladder control. 1, 2

Second-Line Treatment: Pharmacologic Options

Preferred Agent: Beta-3 Agonist

Mirabegron 25-50 mg daily is the preferred pharmacologic option due to significantly lower cognitive impairment risk compared to antimuscarinics—a critical consideration in aging male populations. 1, 2, 5

• Start at 25 mg daily and titrate to 50 mg if needed after 4-8 weeks. 1
• Terminal half-life is approximately 50 hours, allowing once-daily dosing. 5
• Safe in mild-to-moderate renal impairment (dose adjustment not required for eGFR ≥30 mL/min). 5
• Avoid in severe renal impairment (eGFR 15-29 mL/min) where exposure increases 92-118%. 5

Alternative: Antimuscarinic Agents

Use antimuscarinics only when beta-3 agonists fail, are contraindicated, or patient preference dictates. No single antimuscarinic shows superior efficacy over others. 1, 2

Options include: darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium. 1, 2

Absolute contraindications and critical precautions: 1, 2

• Do not prescribe in narrow-angle glaucoma, impaired gastric emptying, or history of urinary retention
• Exercise extreme caution with PVR >250-300 mL (retention risk increases significantly)
• Avoid in cognitive impairment—antimuscarinics cross blood-brain barrier and worsen dementia risk
• Check PVR before prescribing in all high-risk patients (see Initial Evaluation section)

Combination Therapy for Men with Coexisting BPH/BOO

When storage symptoms (OAB) coexist with voiding symptoms (BOO), combination therapy is often required. 3

• Alpha-blocker (e.g., tamsulosin, alfuzosin) + antimuscarinic or beta-3 agonist shows increasing evidence of safety and efficacy in men with both OAB and BOO. 3, 6
• Alpha-blocker + 5ARI (e.g., finasteride, dutasteride) for prostates >30 cc or PSA >1.5 ng/mL shows highest efficacy for long-term symptom control. 3
• Phosphodiesterase-5 inhibitors (e.g., tadalafil 5 mg daily) can be considered as initial therapy in men with both OAB and erectile dysfunction. 3, 6

Treatment Monitoring and Adjustments

• Allow 8-12 weeks to assess efficacy before changing therapies—this is critical as premature switching leads to treatment failure. 1, 2
• If inadequate symptom control or intolerable side effects occur: 1, 2
  • Modify dose (increase or decrease)
  • Switch to a different antimuscarinic
  • Switch from antimuscarinic to beta-3 agonist
  • Add behavioral therapies if not already implemented
• Combination of behavioral + pharmacologic therapy yields superior outcomes compared to either alone—initiate simultaneously for best results. 1, 2
• Manage antimuscarinic side effects actively (dry mouth with sugar-free gum/lozenges, constipation with fiber/fluids) to improve continuation rates. 2

Third-Line Treatment: Minimally Invasive Therapies

Reserve for men who fail behavioral and pharmacologic interventions after adequate trials. 1, 2

• Intradetrusor onabotulinumtoxinA (100-200 units): Effective but requires patient willingness to perform clean intermittent self-catheterization if urinary retention develops (6-8% risk). 1, 2, 6
• Sacral neuromodulation (SNS): Implantable device with test stimulation period before permanent implant. 1, 2, 6
• Peripheral tibial nerve stimulation (PTNS): Requires frequent office visits (weekly for 12 weeks, then monthly maintenance). 1, 2

Fourth-Line Treatment: Surgical Options

Extremely rare in male OAB; reserved for refractory cases unresponsive to all other therapies. 2

• Augmentation cystoplasty or urinary diversion—discuss risks/benefits extensively before proceeding. 3, 2

Critical Pitfalls to Avoid in Male OAB Management

• Do not prescribe antimuscarinics without checking PVR in men with enlarged prostate, neurologic disorders, diabetes, or prior prostate surgery—retention risk is unacceptably high. 1, 2
• Do not use antimuscarinics in men with cognitive impairment—always choose beta-3 agonists instead. 1, 2
• Do not treat OAB symptoms in men without first excluding BOO—treating primary OAB when obstruction exists leads to treatment failure and potential acute urinary retention. 3
• Do not abandon behavioral therapies when starting medications—combination therapy is superior to monotherapy. 1, 2
• Do not continue ineffective antimuscarinic monotherapy beyond 8-12 weeks—switch agents or add combination therapy. 1, 2
• Do not refer for surgical intervention without adequate trials of behavioral, pharmacologic, and minimally invasive therapies first. 3, 2

When to Refer to Urology

• Failure of conservative management (behavioral + pharmacologic therapy) after adequate trials 3, 7
• Hematuria on urinalysis requiring cystoscopy 2
• Elevated PVR (>250-300 mL) suggesting significant retention 1, 2
• Qmax <10 mL/second suggesting significant BOO requiring interventional therapy 3
• Consideration of third-line therapies (botulinum toxin, neuromodulation) 1, 2
• Recurrent urinary tract infections or complicated medical history 8

Incontinence Management Strategies

While treating underlying OAB, provide symptom management tools to maintain quality of life. 1, 2

• Absorbent products: Pads, liners, absorbent underwear for managing leakage episodes. 1, 2
• Barrier creams: Prevent urine dermatitis from chronic exposure. 1, 2
• External collection devices: Condom catheters for men with severe urgency incontinence. 1

Emphasize to patients: These products manage symptoms but do not treat the underlying condition—use alongside, not instead of, active treatment. 1