© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
8
Rosenberg ET AL.
in the prescribing information. Common side effects
include hypertension, nasopharyngitis, urinary tract
infections or headaches. It is not recommended for
use in severe uncontrolled hypertension. It should be
usedwith caution in patients with urinary retention or
with bladder outlet obstruction or in patients taking
an antimuscarinic.
20
Although the antimuscarinic and beta 3 agonist
class are the first line of pharmacologic therapy
for OAB there may be a role for other medications.
Estrogen therapy (transvaginal) also may have a role
in treatment of the irritative symptoms of urgency
and frequency associated with vaginal and urogenital
atrophy; however, there is a lack of data which support
any particular dosing regimen, route of administration,
or treatment duration.
22
Treatment choices: prostate relatedLUTS (BPH)
This should be considered for the symptomatic male patient
with obstructive symptoms alone or mixed with irritative
symptoms who desires therapy.
OAB and BPH can certainly both occur in the male
so the question becomes which to treat first. There is
an understandable concern that the inhibitory effect
of antimuscarinics and beta 3 agonists may worsen
voiding difficulties or result in retention, especially in
men at risk.
20,23,24
Although the risk is low, a logical and
safe approach is to treat the obstructive symptoms first.
Furthermore, there are data showing that treatment of
the voiding component of LUTS can also improve the
storage symptoms.
25
Then, if symptoms persist, the
provider can add on or substitute treatment for the
irritative symptoms.
26
Initiating treatment with an alpha-blocker, or
alpha antagonist, is an option for the obstructive
patient with a small prostate (< 30 mL). The currently
recommended medications include the non-selective
second generation alpha-blockers (doxazosin and
terazosin) and more uroselective third generation
alpha-blockers (alfuzosin, tamsulosin, silodosin).
20
By
inhibiting alpha1-adrenergic-mediated contraction of
prostatic smoothmuscle, alpha-blocker therapy relieves
the bladder outlet obstruction with a noticeable effect
for the patient within a few days.
1
For many men, this
is sufficient for satisfactory relief of symptoms. Patients
with smaller prostates tend to benefit themost from this
monotherapy. Treatment failure with alpha-blockers is
higher inmenwith larger prostate volumes.
27
Common
side effects reportedwith alpha-blocker therapy include
orthostatic hypotension, dizziness, tiredness, ejaculatory
problems and nasal congestion.
1
The uroselective
alpha-blockers seem to have fewer side effects than the
non-selective ones; however, they can be associatedwith
light-headedness and a higher incidence of ejaculatory
dysfunction. An additional risk is floppy iris syndrome
noted during cataract surgery.
28
As a result of this risk,
ophthalmologists preparing the patient for cataract
surgery should be aware of current alpha-blocker use.
As a class, the alpha-blockerswork quickly, withpatients
possibly noting a response within a few days.
TABLE 3.
Medications for overactive bladder
20
Drug
Brand name
Dose
Dosing
Indications
Antimuscarinics - immediate release (IR)
Oxybutynin IR
Ditropan
5 mg
2-4 x/day
OAB
Tolterodine IR
Detrol
1 mg-2 mg
Twice daily
OAB
Trospium chloride
Sanctura (US)
20 mg
Twice daily
OAB
Trosec (Canada)
Antimuscarinics - extended release (ER)
Darifenacin ER
Enablex
7.5 mg, 15 mg
Daily
OAB
Fesoterodine ER
Toviaz
4 mg, 8 mg
Daily
OAB
Oxybutynin ER
Ditropan XL
5 mg-30 mg
Daily
OAB
Oxybutynin TDS
Oxytrol
3.9 mg = 1 patch
Twice weekly
OAB
Oxybutynin 10% gel
Gelnique
100 mg = 1 g of gel
Daily
OAB
Solifenacin
Vesicare
5 mg, 10 mg
Daily
OAB
Tolterodine ER
Detrol LA
2 mg-4mg
Daily
OAB
Trospium chloride
Sanctura XR (US)
60 mg
Daily
OAB
Beta 3 agonists
Mirabegron
Myrbetriq
25 mg, 50 mg
Daily
OAB
