Can Lexapro (escitalopram) cause frequent urination in a patient?

Can Lexapro Cause Frequent Urination?

Lexapro (escitalopram) does not typically cause frequent urination, but it can paradoxically cause urinary retention (difficulty emptying the bladder), particularly in elderly men with benign prostatic hyperplasia, which may lead to compensatory frequent voiding attempts or overflow incontinence.

Understanding the Urinary Effects of Escitalopram

Primary Urinary Effect: Retention, Not Frequency

• Escitalopram is associated with acute urinary retention (AUR), not increased urinary frequency 1, 2.
• The mechanism involves serotonergic effects on bladder function, though the exact pathway remains incompletely understood 1.
• Urinary retention occurred in approximately 0.025% of patients on selective serotonin reuptake inhibitors (SSRIs) in systematic analysis 3.

High-Risk Populations

• Elderly men with known or latent benign prostatic hyperplasia are at particular risk for escitalopram-associated urinary retention 2.
• Three documented cases showed AUR development after starting standard-dose escitalopram in men with prostatic issues, with two cases resolving after discontinuation and one requiring emergent prostatectomy 2.
• Medical causes of urinary retention should be ruled out, but escitalopram may be overlooked as a cause due to underreporting 1.

Why Patients May Report "Frequent Urination"

Retention Masquerading as Frequency

• When urinary retention develops, patients may experience frequent small voids or overflow incontinence, which they describe as "urinating often" 4.
• Symptoms include straining, intermittency, post-void dribbling, weak stream, and incomplete bladder emptying—all of which may prompt frequent bathroom trips 5.
• The bladder never fully empties, creating a sensation of needing to void frequently 5.

Antidepressants and Incontinence

• Antidepressants as a drug class have been proposed to induce urinary incontinence, though evidence for SSRIs specifically is limited 4.
• One case report documented urinary incontinence induced by the antidepressant mirtazapine (not an SSRI), which resolved completely after discontinuation 6.
• Antidepressants affect adrenergic and dopaminergic regulatory mechanisms in the central nervous system, potentially affecting lower urinary tract function 6.

Clinical Evaluation Approach

Essential Diagnostic Steps

• Measure post-void residual urine volume using portable ultrasound to identify retention 5.
• Peak urinary flow rate assessment should be considered in patients with lower urinary tract symptoms 5.
• Complete urinalysis and culture are essential to exclude bacterial cystitis, as SSRIs do not increase infection risk but symptoms may overlap 5.

Key History Elements

• Ask specifically about incomplete bladder emptying, weak stream, hesitancy, and straining—not just frequency 5.
• Determine the timing of symptom onset relative to escitalopram initiation (typically develops shortly after starting) 1, 2.
• In elderly men, assess for known or suspected prostatic enlargement 2.

Management Strategy

If Urinary Retention is Confirmed

• Discontinue escitalopram immediately—normal micturition typically resumes within days without further catheterization 1.
• In documented cases, urinary retention receded after escitalopram discontinuation in 2 of 3 patients 2.
• Consider whether compromised urinary outflow should be a contraindication for escitalopram treatment in elderly men 2.

Alternative Antidepressant Considerations

• Duloxetine (a serotonin-norepinephrine reuptake inhibitor) showed no urinary retention in 1,139 patients studied, though it has different indications 3.
• Tricyclic antidepressants have higher urinary retention rates (17.6% with imipramine) and should be avoided 3.

Critical Pitfalls to Avoid

• Do not assume frequent urination means increased urine production—always check for retention first 5, 1.
• Escitalopram-induced urinary retention is often overlooked because of reporting paucity and the misconception that SSRIs don't affect the bladder 1.
• Do not attribute symptoms solely to age-related prostatic changes without considering medication effects 2.
• Physicians must closely monitor patients for urinary symptoms after new SSRI prescriptions or dosage changes 4.