Can Lexapro (Escitalopram) Cause Urinary Retention?
Yes, Lexapro (escitalopram) can cause urinary retention, though this is a rare adverse effect that occurs most commonly in elderly men with known or latent benign prostatic hyperplasia (BPH).
Evidence from FDA Labeling
The FDA-approved prescribing information for escitalopram explicitly lists "difficult urination" as a reported side effect in children and adolescents, confirming that urinary difficulties are a recognized adverse effect of this medication 1.
Clinical Evidence and Risk Factors
Documented Cases and Incidence
- Case reports and case series have documented acute urinary retention (AUR) developing after escitalopram initiation at standard doses 2, 3.
- The systematic review examining antidepressants and urinary retention found that selective serotonin reuptake inhibitors (SSRIs) as a class were associated with urinary retention in approximately 0.025% of patients, making this a rare but real complication 4.
- Escitalopram-induced urinary retention is often overlooked because of the paucity of reporting and because SSRIs are not typically suspected as causes of AUR 2.
High-Risk Populations
Elderly men with BPH represent the highest-risk group for escitalopram-induced urinary retention 3. Specific risk factors include:
- Men with previously diagnosed benign prostatic hyperplasia 3
- Men with unknown or latent, non-symptomatic BPH 3
- Elderly patients (age >65 years) due to existing co-morbidities and polypharmacy 5
- Patients taking 7 or more concomitant medications 6
Mechanism and Clinical Course
- Drug-induced urinary retention occurs through complex interactions with the micturition pathway, though the exact mechanism for SSRIs remains incompletely understood 5.
- In documented cases, urinary retention typically resolved after escitalopram discontinuation, though one case required emergent prostatectomy 3.
- The temporal relationship is clear: symptoms develop after drug initiation and resolve after discontinuation 2, 3.
Clinical Management Approach
When Urinary Retention Develops
If a patient on escitalopram develops urinary retention, the evaluation should include 7:
- Review all concomitant medications for anticholinergic agents, alpha-agonists, antimuscarinics, or opioids
- Assessment for benign prostatic hyperplasia in men or anatomical causes in all patients
- Measurement of post-void residual volume to confirm retention
- Consideration of neurological causes if applicable
Treatment Strategy
- Drug-induced urinary retention is generally treated by urinary catheterization (especially if acute) in combination with discontinuation or dose reduction of the causal drug 5.
- In the documented escitalopram cases, normal micturition resumed only after stopping the medication without further need for catheterization 2.
Prevention and Prescribing Considerations
Pre-Treatment Evaluation
Before prescribing escitalopram to elderly men, evaluate for obstructive urinary symptoms and consider the presence of BPH 8. Men with moderate to severe symptomatic BPH may benefit from:
- Urological optimization with alpha-blockers (tamsulosin, doxazosin) before starting escitalopram 8
- Consideration of alternative antidepressant options 8
Monitoring During Treatment
Patients at high risk (elderly, BPH, polypharmacy) should be evaluated for obstructive urinary symptoms at treatment initiation and during ongoing therapy 8.
Important Clinical Caveats
- Urinary retention from escitalopram may persist for several days even after discontinuing other suspected medications (such as anticholinergics), so escitalopram itself must be considered and stopped 2.
- The rarity of this adverse effect means it is frequently overlooked in clinical practice, leading to delayed recognition 2.
- Some case series suggest that compromised or marginal urinary outflow should potentially be considered a relative contraindication for escitalopram treatment, particularly in elderly men 3.