Lexapro (Escitalopram) Can Cause Urinary Retention in Elderly Men with BPH
Yes, escitalopram can cause urinary retention in elderly men with benign prostatic hyperplasia, and this is a documented adverse effect that warrants serious clinical consideration, particularly in this vulnerable population. While the incidence may be uncommon, the clinical consequences can be severe, including acute urinary retention requiring emergent intervention.
Evidence for Escitalopram-Induced Urinary Retention
Case series data demonstrate that escitalopram at standard doses has precipitated acute urinary retention in elderly men with both known and previously undiagnosed/latent BPH. 1 In one published series, three male patients developed acute urinary retention after starting escitalopram, with one case requiring emergent prostatectomy. Importantly, urinary retention resolved after escitalopram discontinuation in two of these cases, establishing a clear temporal relationship. 1
Additional case reports confirm this association, describing new-onset acute urinary retention following escitalopram initiation that resolved only after drug discontinuation, not after stopping other potentially causative medications. 2 This suggests escitalopram was the primary causative agent rather than a contributing factor.
Why This Matters Clinically
The key issue is that elderly men with BPH already have compromised urinary outflow, and adding a medication that can further impair bladder emptying may tip them into acute retention. 1 This is particularly concerning because:
Muscarinic receptor antagonists (which have anticholinergic properties similar to some effects of SSRIs) are known to cause voiding difficulties and increased post-void residual volumes in men with LUTS, though acute urinary retention is rare in men with low baseline post-void residual (<150 mL). 3
The 2023 European Association of Urology guidelines explicitly warn that anticholinergic medications should be prescribed with caution in men with LUTS, requiring regular re-evaluation of symptoms and post-void residual, with discontinuation advised if worsening voiding symptoms occur. 3
The 2023 ASCO cancer pain guidelines specifically identify urinary retention as occurring in 25% of postoperative patients on opioids, with higher prevalence in elderly men due to BPH or polypharmacy. 3
Clinical Context and Risk Stratification
The risk is highest in elderly men with:
- Known prostatic enlargement 1
- Latent/asymptomatic BPH that hasn't been previously diagnosed 1
- Baseline elevated post-void residual volumes 3
- Concurrent use of other medications affecting bladder function 3
Practical Management Approach
Before prescribing escitalopram to elderly men, assess for:
- History of urinary symptoms (weak stream, hesitancy, frequency, nocturia) 3
- Digital rectal examination to evaluate prostate size 3
- Measurement of post-void residual volume if BPH is suspected 3
If escitalopram is necessary in a man with known BPH:
- Consider prophylactic alpha-blocker therapy (tamsulosin 0.4 mg daily) to reduce urinary retention risk 3, 4
- Educate the patient about urinary retention symptoms and when to seek immediate care 3
- Monitor closely during the first weeks of therapy when risk may be highest 1, 2
If acute urinary retention develops:
- Discontinue escitalopram immediately 1, 2
- Perform bladder decompression via catheterization 4
- Initiate alpha-blocker therapy if not already prescribed 4
- Consider alternative antidepressant with lower urinary retention risk
Common Pitfall to Avoid
Do not dismiss urinary retention as "too rare" to consider when prescribing escitalopram to elderly men with BPH. The published literature specifically highlights that this adverse effect "may often be overlooked possibly because of the paucity of reporting," 2 meaning the true incidence may be underestimated. The consequences—including catheterization, emergency surgery, and significant quality of life impact—are too severe to ignore this risk. 5