Can Seroquel (quetiapine) cause urinary retention in older adults with benign prostatic hyperplasia?

Can Seroquel Cause Urinary Retention in Older Adults with BPH?

Yes, Seroquel (quetiapine) can cause urinary retention in older adults with benign prostatic hyperplasia and should be used with extreme caution or avoided in this population.

Mechanism and FDA Warning

The FDA drug label explicitly states that quetiapine should be used with caution in patients with a current diagnosis or prior history of urinary retention or clinically significant prostatic hypertrophy 1. This warning stems from quetiapine's anticholinergic (antimuscarinic) effects, which are mediated through its active metabolite norquetiapine, which has moderate to strong affinity for several muscarinic receptor subtypes 1.

Clinical Evidence in Older Adults

While the American Geriatrics Society guidelines identify urinary retention as a recognized adverse effect of antipsychotic medications in older adults 2, a large Finnish cohort study of 4,579 men with Alzheimer disease found that antipsychotic use (including quetiapine) was not associated with increased risk of initiating BPH medication compared to non-users (HR 0.92,95% CI 0.74-1.15) 3. However, this study has important limitations—it only measured initiation of BPH medication as a proxy outcome, not actual urinary retention episodes, and may have missed acute events requiring emergency intervention.

Serious Safety Concerns Beyond Urinary Retention

More concerning is that low-dose quetiapine in older adults carries significantly elevated risks of mortality, dementia, and falls 4. A 2025 retrospective cohort study of 375 older adults (≥65 years) found that compared to trazodone, quetiapine was associated with:

• 3.1-fold increased mortality risk (HR 3.1,95% CI 1.2-8.1) 4
• 8.1-fold increased dementia risk (HR 8.1,95% CI 4.1-15.8) 4
• 2.8-fold increased fall risk (HR 2.8,95% CI 1.4-5.3) 4

Compared to mirtazapine, quetiapine showed a 7.1-fold increased dementia risk (HR 7.1,95% CI 3.5-14.4) 4.

Specific Risk Factors in BPH Patients

The combination of BPH with quetiapine creates a particularly hazardous situation through multiple mechanisms:

• Anticholinergic effects directly impair detrusor contractility and bladder emptying 1
• Alpha-receptor blockade can worsen voiding dysfunction in men with existing bladder outlet obstruction 3
• Dopamine D2-receptor blockade may contribute to voiding dysfunction 3
• Constipation (a common quetiapine adverse effect) represents a risk factor for intestinal obstruction and can worsen urinary symptoms 1

Clinical Recommendation Algorithm

For older adults with BPH considering quetiapine:

1. Avoid quetiapine entirely if possible—the mortality and dementia risks outweigh potential benefits for most indications 4

2. If quetiapine must be used, perform baseline assessment:

   • Measure post-void residual (PVR) volume—do not use if PVR >150 mL 2
   • Document International Prostate Symptom Score (IPSS) 5
   • Assess for concurrent anticholinergic medications that increase risk 1

3. Monitor closely after initiation:

   • Reassess voiding symptoms within 1 week 5
   • Instruct patient to discontinue immediately if worsening urinary stream or inability to void occurs 2
   • Measure repeat PVR if any voiding symptoms worsen 5

4. Consider safer alternatives:

   • For insomnia: trazodone or mirtazapine have superior safety profiles 4
   • For agitation in dementia: behavioral interventions first, then consider alternatives with lower anticholinergic burden 2

Critical Pitfalls to Avoid

• Do not assume low-dose quetiapine is safe—the 2025 study demonstrated significant harms even at low doses used for insomnia 4
• Do not overlook the cumulative anticholinergic burden—quetiapine combined with other anticholinergic medications exponentially increases urinary retention risk 1
• Do not continue quetiapine chronically without clear indication—47% of patients continue antipsychotics after ICU discharge and 33% after hospital discharge without clear indication 2
• Do not ignore baseline prostate size—men with enlarged prostates (>30 cc) have higher baseline urinary retention risk 5