Oxybutynin Treatment for Urinary Incontinence in Men with BPH

Treatment Algorithm for Persistent Storage Symptoms

For men with BPH already on an alpha-blocker who have persistent storage symptoms, adding an anticholinergic medication like oxybutynin is appropriate, but only after confirming post-void residual (PVR) is less than 150 mL, as recommended by the European Association of Urology 1, 2
Ensure the patient has been on alpha-blocker therapy for at least 4-12 weeks, as this is the timeframe needed to assess adequate response, according to the American Urological Association 3
Obtain a PVR measurement before initiating any anticholinergic therapy, and do not use anticholinergics if PVR >150 mL due to increased risk of urinary retention, as stated by the European Association of Urology 2, 4

The European Association of Urology guidelines support combination therapy with alpha-blockers plus antimuscarinics for men with moderate-to-severe storage LUTS, showing superiority over alpha-blockers alone in reducing urgency, urgency incontinence, voiding frequency, and nocturia 1, 2
The NEPTUNE trial showed combination solifenacin plus tamsulosin significantly improved storage symptoms, with a strength of evidence rated as high 1
Meta-analysis confirmed combination treatment does not adversely affect voiding function parameters when PVR is appropriately monitored, with a moderate strength of evidence 2
Extended-release oxybutynin combined with tamsulosin showed efficacy and safety in a randomized, double-blind, placebo-controlled study, with a high strength of evidence 1, 5

Measure PVR before initiating therapy and monitor during treatment, as recommended by the European Association of Urology 2, 4
Re-evaluate at 4-12 weeks after starting combination therapy using IPSS scoring, according to the American Urological Association 3
Do not use anticholinergics if PVR >150 mL due to increased risk of urinary retention, as stated by the European Association of Urology 2

The American Urological Association recommends anticholinergic medications as the first-line pharmacological treatment for men with overactive bladder symptoms after behavioral therapies have been tried 6, 7
Behavioral therapies should be offered as initial treatment for all men with OAB symptoms, including bladder training, pelvic floor muscle exercises, fluid management, and delayed voiding techniques 7, 8
Behavioral therapies are as effective as antimuscarinic medications and have no side effects 8

Oral antimuscarinics that can be offered include darifenacin 6, oxybutynin (immediate and extended release) 6, solifenacin 9, and trospium 6
Mirabegron is an effective alternative to antimuscarinics, especially in men with concerns about cognitive side effects or dry mouth 9, 10

Alpha blockers, such as tamsulosin, are first-line therapy for men with both BPH and OAB symptoms, and antimuscarinics or beta-3 agonists can be added if storage symptoms persist 10, 11
For men with prostate size >30cc, consider adding a 5-alpha reductase inhibitor (5-ARI) 11

Antimuscarinics reduce urgency, frequency, and urgency incontinence episodes, with patients with more severe symptoms typically experiencing greater symptom reductions 6, 7
Antimuscarinics should not be used in patients with narrow-angle glaucoma unless approved by an ophthalmologist, and should be used with caution in patients with impaired gastric emptying, history of urinary retention, or cognitive impairment 6, 7, 11

If patients fail to respond to behavioral and medical therapy, they should be referred to a specialist, and third-line treatments include sacral neuromodulation, peripheral tibial nerve stimulation, and onabotulinumtoxinA injections 6, 7, 12