What are the best medications for treating urinary incontinence in adult men, particularly those with benign prostatic hyperplasia (BPH)?

Best Medications for Urinary Incontinence in Men

For men with urinary incontinence related to benign prostatic hyperplasia (BPH), start with an alpha-blocker such as tamsulosin 0.4 mg daily, and for men with enlarged prostates (>30 mL) and moderate-to-severe symptoms, initiate combination therapy with tamsulosin 0.4 mg plus dutasteride 0.5 mg daily for superior long-term outcomes. 1, 2, 3

Initial Treatment Approach

Alpha-Blockers as First-Line Therapy

• Alpha-blockers (tamsulosin, alfuzosin, doxazosin, silodosin, terazosin) are the cornerstone of initial medical management for men with bothersome lower urinary tract symptoms, providing rapid symptom relief within 4 weeks by relaxing smooth muscle in the prostate and bladder neck. 1, 4, 5

• Tamsulosin 0.4 mg once daily is the most commonly prescribed alpha-blocker because it requires no dose titration, has a fast onset of action, and has minimal effects on blood pressure compared to other alpha-blockers. 6, 5, 7

• Alpha-blockers improve symptom scores by 3-10 points on the International Prostate Symptom Score (IPSS) and increase peak urinary flow rate by 1.4-3.6 mL/sec. 5, 8

• Alternative alpha-blockers include alfuzosin, doxazosin, silodosin, and terazosin, which are equally effective but differ in side effect profiles—the choice should be based on patient comorbidities and tolerability. 4

Critical Caveat for Alpha-Blockers

• All alpha-blockers are associated with intraoperative floppy iris syndrome during cataract surgery—patients must inform their ophthalmologist before any eye procedure, even if they have discontinued the medication. 1, 6, 4, 9

• Tamsulosin has a higher risk of ejaculatory dysfunction (4.5-14%) compared to other alpha-blockers, which should be discussed with patients. 6, 7

Combination Therapy for Enlarged Prostates

When to Add a 5-Alpha-Reductase Inhibitor

• For men with prostate volume ≥30 mL and moderate-to-severe symptoms (IPSS >8), combination therapy with an alpha-blocker plus a 5-alpha-reductase inhibitor (finasteride 5 mg or dutasteride 0.5 mg daily) is superior to monotherapy. 2, 10, 3

• Combination therapy reduces overall BPH clinical progression by 67%, acute urinary retention by 79%, and need for surgery by 67% compared to alpha-blocker monotherapy (39% reduction) or 5-alpha-reductase inhibitor monotherapy (34% reduction). 2

• Patients with larger prostates (≥40 mL) and higher PSA levels (≥1.5 ng/mL) derive the greatest benefit from combination therapy due to higher baseline risk of disease progression. 2

Choosing Between Finasteride and Dutasteride

• Dutasteride is preferred over finasteride as it reduces serum DHT by approximately 95% (versus 70% with finasteride) and achieves 15-25% prostate volume reduction after 6 months with sustained improvement for up to 6-10 years. 2

• Both medications reduce PSA levels by approximately 50% after 1 year—the measured PSA value must be doubled after 1 year of therapy for accurate prostate cancer screening interpretation. 2, 10

• 5-alpha-reductase inhibitors have a slower onset of action (3-6 months) compared to alpha-blockers, so patients should be counseled about delayed symptom improvement. 2, 4

Important Side Effects of 5-Alpha-Reductase Inhibitors

• Sexual dysfunction occurs with dutasteride and finasteride, including erectile dysfunction (4-15%), decreased libido (6.4% in first year), and ejaculatory dysfunction (3.7% in first year)—these effects typically decrease after the first year but may persist in some patients even after discontinuation. 2

Storage Symptom Management

Adding Anticholinergics or Beta-3 Agonists

• For men with persistent storage symptoms (urgency, frequency, nocturia) despite alpha-blocker therapy, adding an anticholinergic (tolterodine, solifenacin, oxybutynin) or beta-3 agonist (mirabegron) is reasonable. 1

• The American Urological Association recommends starting with alpha-blockers alone and adding anticholinergics in selected cases due to variable efficacy and increased drug-related adverse events with combination therapy. 1

• Anticholinergics reduce voiding frequency by 2-4 times per day and urinary incontinence episodes by 10-20 times per week. 5

• Beta-3 agonists (mirabegron) combined with alpha-blockers may provide symptom improvement similar to anticholinergics for persistent overactive bladder symptoms, with careful monitoring for urinary retention risk. 1, 2

Critical Safety Consideration

• A post-void residual (PVR) urine volume should be obtained before starting anticholinergics and monitored at follow-up to assess for urinary retention risk, particularly in men with bladder outlet obstruction. 1

Alternative Medication: Tadalafil

• Tadalafil 5 mg once daily is FDA-approved for BPH and improves lower urinary tract symptoms by 1.74 points on IPSS compared to placebo, though this effect is modest compared to alpha-blockers. 1

• Tadalafil monotherapy is an option for men with both erectile dysfunction and LUTS, providing dual benefit. 1, 5

• Combining tadalafil with alpha-blockers does not offer greater symptom improvement than either medication alone and increases side effect risk—this combination is not recommended. 1

Acute Urinary Retention Management

• For men presenting with acute urinary retention related to BPH, prescribe an oral alpha-blocker (alfuzosin or tamsulosin) and complete at least 3 days of therapy before attempting trial without catheter (TWOC). 1

• Alpha-blockers improve successful TWOC rates: alfuzosin 60% versus placebo 39%; tamsulosin 47% versus placebo 29%. 1

• Patients who pass successful TWOC remain at increased risk for recurrent urinary retention and should be counseled accordingly. 1

Treatment Algorithm Summary

1. Start all men with bothersome LUTS with an alpha-blocker (tamsulosin 0.4 mg daily preferred) and assess response at 4 weeks. 1, 4, 5

2. For men with prostate volume ≥30 mL and moderate-to-severe symptoms, add dutasteride 0.5 mg daily for long-term disease modification and prevention of progression. 2, 3

3. For persistent storage symptoms despite alpha-blocker therapy, add an anticholinergic or beta-3 agonist after checking PVR to ensure no significant retention. 1, 2

4. For men with both erectile dysfunction and LUTS, consider tadalafil 5 mg daily as monotherapy rather than combination with alpha-blockers. 1

Common Pitfalls to Avoid

• Do not use combination therapy in men without prostatic enlargement (<30 mL)—this exposes patients to unnecessary side effects without benefit. 2

• Do not assume alpha-blocker therapy constitutes optimal management of concomitant hypertension—patients may require separate antihypertensive management. 2

• Do not forget to inform patients about floppy iris syndrome risk before cataract surgery—this applies to all alpha-blockers. 1, 6, 4

• Do not forget to double PSA values after 1 year of 5-alpha-reductase inhibitor therapy for accurate prostate cancer screening. 2, 10