What medications are recommended for a male patient with urinary urgency?

Medication for Urinary Urgency in Males

For male patients with urinary urgency, muscarinic receptor antagonists (antimuscarinics) or beta-3 agonists are the recommended first-line pharmacological treatments when storage symptoms predominate, with combination therapy using an alpha-blocker plus an antimuscarinic being superior when both voiding and storage symptoms coexist. 1

Initial Assessment and Treatment Selection

When Storage Symptoms Predominate (Urgency, Frequency, Urgency Incontinence)

Use muscarinic receptor antagonists (MRAs) in men with moderate-to-severe lower urinary tract symptoms who mainly have bladder storage symptoms. 1 Effective options include:

• Tolterodine (extended release preferred) - improves urgency, urge urinary incontinence, and daytime frequency 1
• Solifenacin - FDA-approved for overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 2
• Oxybutynin (extended release preferred) - effective for storage symptoms 1, 3

Alternatively, use beta-3 agonists (mirabegron) in men with moderate-to-severe lower urinary tract symptoms who mainly have bladder storage symptoms. 1 Mirabegron is FDA-approved for adult overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 4, and is particularly useful in elderly patients with multiple comorbidities 1.

Critical Safety Requirement Before Prescribing Antimuscarinics

Do not use antimuscarinic overactive bladder medications in men with a post-void residual (PVR) volume >150 ml. 1, 3 This is essential to prevent acute urinary retention. Measure PVR before initiating therapy and monitor during treatment 3.

Combination Therapy for Persistent Symptoms

When Storage Symptoms Persist Despite Alpha-Blocker Therapy

Use combination treatment of an alpha-blocker with a muscarinic receptor antagonist in patients with moderate-to-severe lower urinary tract symptoms if relief of storage symptoms has been insufficient with monotherapy with either drug. 1

The evidence strongly supports this approach:

• Combination therapy is superior to alpha-blockers or placebo alone in reducing urgency, urge urinary incontinence, voiding frequency, nocturia, and quality of life 1
• The NEPTUNE trial demonstrated that solifenacin plus tamsulosin in a single tablet significantly improved storage symptoms 1
• Extended-release oxybutynin combined with tamsulosin showed efficacy and safety in randomized controlled trials 1, 3
• A landmark trial by Kaplan et al. showed that 80% of men receiving tolterodine ER plus tamsulosin reported treatment benefit compared to 62% receiving placebo 5

Critical caveat: Do not prescribe combination treatment in men with a PVR volume >150 ml. 1 The risk of acute urinary retention is low (1.7% with mirabegron combinations 1, 0.4% with tolterodine combinations 5) when PVR is appropriately monitored, but increases substantially when this threshold is exceeded.

Alternative Combination: Alpha-Blocker Plus Beta-3 Agonist

Use combination treatment of an alpha-blocker with mirabegron in patients with persistent storage lower urinary tract symptoms after treatment with alpha-blocker monotherapy. 1 This combination results in mild improvement of urinary frequency and urgency episodes per day compared with alpha-blockers alone 1.

Specific Clinical Scenarios

Men with Benign Prostatic Hyperplasia (BPH) and Storage Symptoms

For men with both BPH and overactive bladder symptoms, the treatment algorithm is:

1. Start with an alpha-blocker (tamsulosin, alfuzosin, doxazosin, or terazosin) as first-line therapy 1, 3
2. Wait 4-12 weeks to assess response to alpha-blocker monotherapy 3
3. If storage symptoms persist, measure PVR 3
4. If PVR <150 ml, add an antimuscarinic or mirabegron 1, 3
5. Re-evaluate at 4-12 weeks after starting combination therapy using symptom scoring 3

Men with Prostate Size >40 ml

Use 5-alpha reductase inhibitors (5-ARIs) in men who have moderate-to-severe lower urinary tract symptoms and an increased risk of disease progression (e.g., prostate volume >40 ml). 1 This can be combined with alpha-blockers and antimuscarinics as needed for storage symptoms.

Adverse Effects and Monitoring

Antimuscarinic Side Effects

Common adverse effects include dry mouth, constipation, dizziness, and nasopharyngitis 1. However, acute urinary retention is rare in men with low PVR at baseline (<150 ml) 1. Advise men to discontinue medication if worsening voiding symptoms or urinary stream is noted after initiation of therapy. 1

Mirabegron Side Effects

The most frequent adverse effects are hypertension, urinary tract infections, headache, and nasopharyngitis 1. Mirabegron is contraindicated in patients with severe uncontrolled hypertension. 1 Importantly, mirabegron does not affect voiding urodynamic parameters, and the overall change in PVR is small 1.

Combination Therapy Adverse Effects

Adverse events observed during combination treatment are typical of both drug classes 1. The incidence of acute urinary retention requiring catheterization is low (0.4% for tolterodine ER plus tamsulosin, 0% for placebo) 5.

Alternative Pharmacological Options

Phosphodiesterase-5 Inhibitors

Use phosphodiesterase type 5 inhibitors (tadalafil 5 mg) in men with moderate-to-severe lower urinary tract symptoms with or without erectile dysfunction. 1 While PDE5 inhibitors may result in a small reduction in symptom scores, they are particularly useful when erectile dysfunction coexists 1.

Common Pitfalls to Avoid

1. Never prescribe antimuscarinics without first measuring PVR - this is the single most important safety measure 1, 3
2. Do not expect immediate results from antimuscarinics - allow adequate time (4-12 weeks) to assess response 3
3. Do not use antimuscarinics as monotherapy in men with significant voiding symptoms - alpha-blockers should be the foundation of therapy in men with BPH 1, 3
4. Do not ignore the need for regular re-evaluation - PVR and symptom scores should be monitored during treatment 1, 3