Previous changes

March 2025 — minor update. Added information to consider asking about the use of ketamine, particularly in younger people who have urinary symptoms. 

July 2024 — minor update. Minor typographical error corrected in the prescribing section for furosemide. 

March 2024 — reviewed. A literature search was conducted in March 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. Some structural changes were made, but there have been no major changes to clinical recommendations.

March 2019 — reviewed. A literature search was conducted in March 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. No major changes to clinical recommendations have been made.

November 2018 — minor update. Additions to contraindications and monitoring for desmopressin.

July 2018 — minor update. Anxiety has been added as an adverse effect for men taking 5-alpha reductase inhibitors.

September 2017 — minor update. Additions to adverse effects section for men taking 5-alpha reductase inhibitors for depression and suicidal ideation. 

July 2017 — minor update. Additions to adverse effects section for men taking finasteride or dutasteride for prostate cancer, prostate-specific antigen (PSA), and cardiovascular events. 

June 2017 — minor update. Addition to adverse effects section for depression and suicidal thoughts in men taking finasteride. 

November 2016 — minor update. Following post-market surveillance, severe hypertension, dizziness, constipation, diarrhoea, headache and dizziness have been added as adverse effects [ABPI, 2016]. Following a Medicines and Healthcare products Regulatory Agency (MHRA) Drug safety update, severe uncontrolled hypertension has been added as a contraindication [MHRA, 2015]. 

February 2015 — minor update. Following post-market surveillance, angioedema has been added as a rare adverse effect of mirabegron.

October 2014 — reviewed. A literature search was conducted in July 2014 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. Changes have been made to the indications for prostate specific antigen (PSA) testing and the choice of antimuscarinics for men with overactive bladder as a predominant symptom, with mirabegron added as a new drug option.

February 2014 — minor update. Update to the Prescribing Information text for tamsulosin to reflect that it should not be given with strong inhibitors of CYP3A4, in line with the manufacturer's Summary of Product Characteristics (SPC).

January 2013 — minor update. Removed the black triangle status from fesoterodine as this is no longer a black triangle drug.

November 2012 — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.

January 2012 — minor update. Added updated information from the manufacturer's SPC which states that dutasteride is contraindicated in people with hypersensitivity to soya, peanut, or any of the other excipients. Issued January 2012.

May 2011 — minor update. Removed the black triangle status from desmopressin prescriptions because desmopressin is no longer a black triangle drug. Issued in June 2011.

April to August 2010 — creation of a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence. This CKS topic replaces the former topic on Prostate - benign hyperplasia. The scope of this topic includes that of the previous topic on Prostate - benign hyperplasia, and also includes the management of voiding symptoms, urinary retention, stress incontinence, overactive bladder, nocturnal polyuria, and post-voiding symptoms. With one notable exception, all the management recommendations in Prostate - benign hyperplasia have been included in this topic. The new recommendation is that men who continue to have storage symptoms despite treatment with an alpha blocker should be offered combination therapy with an antimuscarinic agent and an alpha blocker.

December 2009 — minor update. The MHRA has recently advised that men taking finasteride should be advised to promptly report any changes in their breast tissue such as lumps, pain, or nipple discharge. Cases of breast cancer have rarely been reported.

October 2009 — minor update to the section on Contraindications for alpha blockers. 

August 2009 — minor update. The section on PSA testing now includes advice on when to defer testing (for example for at least 1 week after digital rectal examination). 

December 2008 to March 2009 — converted from CKS guidance to CKS topic structure.

September 2008 — minor correction to the Changes section. 

February 2006 — updated to include information on saw palmetto. 

June 2005 — reviewed. Validated in September 2005 and issued in November 2005.

December 2002 — updated to incorporate advice on PSA testing from the NHS Prostate Cancer Risk Management Programme. 

March 2002 — reviewed and updated to incorporate referral advice from the National Institute for Health and Care Excellence (NICE). Validated in March 2002 and issued in April 2002.

October 2000 — updated to incorporate the Department of Health's Referral guidelines for suspected urological cancer.

New evidence

Evidence-based guidelines

No new evidence-based guidelines published since 1 March 2024.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2024.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2024.

Systematic reviews and meta-analyses

• Wei, J.T., Dauw, C.A., Brodsky, C.N. Lower Urinary Tract Symptoms in Men: A Review. JAMA https://jamanetwork.com [Abstract]

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2024.

New policies

No new national policies or guidelines since 1 March 2024.

New safety alerts

No new safety alerts since 1 March 2024.

Changes in product availability

No new changes in product availability since 1 March 2024.

What are the causes of voiding lower urinary tract symptoms?

• The causes of urinary voiding symptoms include:
  • Benign prostatic hyperplasia or benign prostatic enlargement — the most common cause of voiding symptoms. 
  • Drugs with antimuscarinic action (such as tricyclic antidepressants, sedating antihistamines, antimuscarinic drugs for urinary incontinence, and disopyramide).
  • Diabetic autonomic neuropathy and neurogenic bladder.
  • Urethral stricture and phimosis (constriction of the foreskin). 
  • Cancer of the prostate or bladder.

[NICE, 2015; BMJ Best Practice, 2021]

What are the causes of storage lower urinary tract symptoms?

• The exact cause of overactive bladder is not well understood, and various myogenic, neurogenic and urotheliogenic factors may be involved in detrusor overactivity. These include:
  • Bladder outlet obstruction — benign prostatic hyperplasia and urethral stricture. 
  • Bladder stones. 
  • Neurological conditions (such as multiple sclerosis, dementia, Parkinson's disease, and stroke). 
  • Recurrent urinary tract infection.
  • Urothelial carcinoma. 
• Nocturnal polyuria can be caused by:
  • Medical conditions (such as diabetes mellitus, diabetes insipidus, adrenal insufficiency, hypercalcaemia, liver failure, polyuric renal failure, chronic heart failure, pyelonephritis, and chronic venous stasis).
  • Drugs (such as calcium channel blockers, diuretics, and selective serotonin reuptake inhibitor [SSRI] antidepressants).
• Stress urinary incontinence in men is the result of a malfunction of the urethral sphincter. It can be caused by:
  • Prostatectomy or other surgery in the pelvic area.
  • Injury to the urethral area. 
  • Drugs that: 
    • Increase urine production or cause bladder irritation (for example, alcohol, diuretics, or caffeine). 
    • Relax the bladder outlet and urethra (for example, alpha-blockers).
    • Can cause urinary retention, which may result in overflow incontinence (for example, sympathomimetics [such as pseudoephedrine], drugs with an antimuscarinic action [such as tricyclic antidepressants, sedative antihistamines, and some antipsychotics], and opioid analgesics).
    • Reduce awareness of the need to urinate (for example, benzodiazepines and z-drugs [such as zopiclone and zolpidem]).
  • Neurological or muscular conditions (such as multiple sclerosis and spina bifida).

[Tsakiris, 2008; Meng, 2012; NICE, 2015; Leron, 2017; Hutchinson, 2020; EAU, 2023]

What are the causes of post-micturition dribble?

• Post-micturition dribble occurs due to urine residue in the bulbar or prostatic urethra after urination. However, the cause is not fully understood. Possible causes include:
  • Weakness or failure of the pelvic floor muscles — contraction of the pelvic floor muscles normally empties the residual urine from the urethra at the end of urination. Failure or weakness may, therefore, lead to urine residue. 
  • An incompetent external urethral sphincter. 
  • Bladder neck obstruction.

[Yang, 2019]

What are the causes of acute urinary retention?

• Causes of acute urinary retention include:
  • Benign prostatic enlargement or prostate cancer. 
  • Bladder cancer.
  • Comorbid conditions — for example, spinal cord injuries or neurological disorders. 
  • Constipation. 
  • Infection — for example, urinary tract infection, sexually transmitted infection, or prostatitis. 
  • Renal stones or blood clots in the urethra.
  • Trauma to the pelvis, urethra or penis. 
  • Urethral stricture. 
  • Drugs such as: 
    • Antimuscarinics (anticholinergics) used to treat overactive bladder. 
    • Other drugs with a significant antimuscarinic action (for example, tricyclic antidepressants, sedative antihistamines, antipsychotics). 
    • Anaesthetics. 
    • Benzodiazepines. 
    • Calcium channel blockers.
    • Nonsteroidal anti-inflammatory drugs (NSAIDs). 
    • Opioids. 
    • Sympathomimetics (such as ephedrine and pseudoephedrine). 

[Verhamme, 2008; NICE, 2015; NIDDKD, 2019; BMJ Best Practice, 2021]

Urinary frequency-volume chart

• A urinary frequency–volume chart can give an indication of the voiding pattern, the severity of symptoms, and the impact on the person's daily life. They can help distinguish and diagnose the following:
  • Frequency. 
  • Polyuria (passing more urine than usual) — up to 3 L of urine in 24 hours is normal. 
  • Nocturia (waking at night to urinate). 
  • Nocturnal polyuria (passing, at night, more than 35% of the 24-hour urine production). 
• Urinary frequency–volume charts are freely available online, for example, from the Bladder Matters website (www.bladdermatters.co.uk).

[NICE, 2015]

International Prostate Symptom Score (IPSS)

• The International Prostate Symptom Score (IPSS) is a tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life.
• The IPSS questionnaire is intended to be completed by the man. It contains seven questions relating to symptom severity (each question is scored from 0 [best] to 5 [worst]) and one question relating to quality of life due to urinary symptoms (scored from 0 [best] to 6 [worst]). 
  • The IPSS severity score is interpreted as: 
    • Score 0: asymptomatic.
    • Score 1–7: mildly symptomatic.
    • Score 8–19: moderately symptomatic.
    • Score 20–35: severely symptomatic.
• Limitations of the IPSS questionnaire include lack of assessment of incontinence, post-micturition symptoms, and bother caused by each separate symptom. 
• Printable versions of the IPSS questionnaire are widely available online, for example, from the Frimley Health NHS trust website (www.fhft.nhs.uk).

[EAU, 2023]

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Lower urinary tract symptoms in men: management [NICE, 2015], and the European Association of Urology (EAU) guideline Management of non-neurogenic male LUTS [EAU, 2023], and what CKS considers good medical practice.

History and examination

• Both NICE and the EAU recommend performing a digital rectal examination in men with LUTS. However, the EAU highlights that while digital rectal examination is the simplest way to assess prostate volume, the correlation to actual prostate volume is poor [EAU, 2023].

Using a frequency-volume chart

• NICE recommends asking men with bothersome LUTS to complete a urinary frequency-volume chart [NICE, 2015].
  • The GDG felt that the frequency-volume chart is a simple, non-invasive tool that can help build on information obtained from the medical history and help the clinician to make an accurate diagnosis of the underlying cause of the symptoms.
• The EAU strongly recommends using a bladder diary to assess men with LUTS, especially those with storage symptoms and/or nocturia [EAU, 2023]. Evidence identified by the EAU suggests that:
  • Frequency-volume charts provide real-time documentation of urinary function and reduce recall bias.
  • Three- and seven-day frequency-volume charts provide a reliable measurement of urinary symptoms in people with LUTS.

Using a validated symptom score, such as the International Prostate Symptom Score (IPSS)

• NICE recommends that men who are considering any treatment for LUTS are offered an assessment of their baseline symptoms with a validated symptom score (such as the IPSS) to allow assessment of subsequent symptom change [NICE, 2015].
  • The GDG felt that it was not essential for all men with LUTS to complete a symptom score because it is time-consuming and does not add much to the medical history taking at initial assessment. However, it would be beneficial at the stage when men were considering treatment, as it would provide a baseline score to monitor their response to treatment.
  • The GDG also highlighted the fact that completing the symptom score questionnaire would be difficult or impossible for people who are blind, cannot read English, or have learning disabilities.
• The EAU strongly recommends that a validated symptom score questionnaire that includes bother and quality of life assessment is used during the assessment of men with LUTS and for re-evaluation during and/or after treatment [EAU, 2023]. 
  • Evidence identified by the EAU suggests that symptom questionnaires are sensitive to symptom changes and that symptom scores can quantify LUTS and identify which types of symptoms are predominant; however, they are not disease- or age-specific.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Lower urinary tract symptoms in men: management [NICE, 2015], and the European Association of Urology (EAU) guideline Management of non-neurogenic male LUTS [EAU, 2023].

Usefulness of urine dipstick test

• NICE and the EAU recommend offering men with lower urinary tract symptoms (LUTS) a urine dipstick test to detect conditions such as urinary tract infections (UTI), microhaematuria, and diabetes mellitus.
• The general consensus of the EAU is that despite the very limited evidence to support this recommendation, the benefits clearly outweigh the costs [EAU, 2023].

Assessing renal function

• NICE recommends offering men with LUTS a serum creatinine test (plus estimated glomerular filtration rate [eGFR] calculation) only if renal impairment is suspected, for example, if the man has a palpable bladder, nocturnal enuresis, recurrent UTI, or a history of renal stones [NICE, 2015].
• The EAU recommends assessing renal function if renal impairment is suspected based on history and clinical examination, or in the presence of hydronephrosis, or when considering surgical treatment for male LUTS [EAU, 2023].

Prostate specific antigen (PSA) testing

• Expert opinion regarding PSA testing in men varies.
• This recommendation is based on the NICE and EAU guidelines and is largely supported by the previous expert reviewers of this CKS topic.
  • NICE recommends PSA testing in men who have symptoms suggesting benign prostatic enlargement, if the prostate feels abnormal on digital examination, or if the man is concerned about prostate cancer and wishes to have a PSA test after discussing the harms and benefits [NICE, 2015].
    • This recommendation was based on the expert opinion of the NICE guideline development group as data suggesting that PSA has prognostic value in predicting symptom progression were inconsistent. NICE found no relevant studies on the effect of strategies of PSA testing on eventual clinical outcomes.
  • The EAU recommends PSA testing only if the diagnosis of prostate cancer will change management, or if the PSA result can assist in the treatment and/or decision-making process [EAU, 2023].
    • This recommendation was based on evidence suggesting that PSA has a good predictive value for assessing prostate volume and is a stronger predictor of prostate growth. Evidence identified by the EAU also suggests that baseline PSA can predict the risk of acute urinary retention and benign prostatic enlargement-related surgery.

How should I manage a man with predominantly voiding symptoms?

• Exclude serious underlying causes of LUTS and manage treatable causes if possible. 
• Offer advice on lifestyle interventions and information on their condition to men whose LUTS are not bothersome or complicated.
  • Offer review if symptoms change.
  • Signpost men to the NHS England Decision support tool: making a decision about enlarged prostate (BPE) (if appropriate).
• Discuss active surveillance (reassurance and lifestyle advice without immediate treatment) and regular follow-up or active intervention (conservative management, drug treatment, or surgery) for men: 
  • With mild or moderate bothersome LUTS.
  • Whose LUTS fail to respond to drug treatment.
• Provide tailored advice to men with LUTS, for example:
  • To reduce fluid intake at specific times to reduce urinary frequency when most inconvenient (for example, at night or when going out in public).  
  • That fluid intake should not be limited excessively in an attempt to control symptoms, as this could increase the risk of complications (such as urinary tract infection). 
  • To treat constipation if present, to maintain a healthy lifestyle (reduce weight, stop smoking, and improve diet if relevant) and to avoid or moderate caffeine or alcohol intake. 
• Offer drug treatment to men with bothersome LUTS if conservative management options have been unsuccessful or are not appropriate.  
  • Take into account comorbidities and current treatment when offering men drug treatment for LUTS. 
• Offer an alpha blocker (alfuzosin, doxazosin, tamsulosin, or terazosin) to men with moderate to severe LUTS (an International Prostate Symptom Score [IPSS] of 8 or more). 
  • Review men taking alpha-blockers at 4 to 6 weeks and then every 6 to 12 months. During the review, re-assess symptoms and quality of life (for example, using the IPSS questionnaire) and assess for adverse effects of treatment. 
  • For detailed prescribing information, see the section on Alpha-blockers.
• If the man has residual storage symptoms (as well as voiding symptoms) that persist after treatment with an alpha-blocker alone, consider adding an antimuscarinic drug, such as oxybutynin (immediate release), tolterodine (immediate release) or darifenacin. 
  • If the first-line drug treatment is not effective or tolerated, offer an alternative drug.
    • If antimuscarinics are contraindicated, not tolerated, or not effective, offer mirabegron or vibegron.  
  • Review the man every 4–6 weeks until symptoms are stable, then every 6–12 months. During the review, re-assess symptoms and quality of life (for example, using the IPSS questionnaire) and assess for adverse effects and the need to continue treatment. 
  • For detailed prescribing information, see the section on Antimuscarinics. 
• Offer a 5-alpha reductase inhibitor (dutasteride or finasteride) to men with LUTS who have a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml and who are considered to be at high risk of progression.
  • The risk of progression of symptoms from benign prostatic enlargement is higher in older men and in men with poorer urine flow, higher symptom scores, evidence of bladder decompensation (such as chronic urinary retention), larger prostates, or higher prostate-specific antigen (PSA) levels.
  • Review the man at 3–6 months, then every 6–12 months. During the review, re-assess symptoms and quality of life (for example, using the IPSS questionnaire) and assess for adverse effects of treatment. 
  • For detailed prescribing information, see the section on 5-alpha reductase inhibitors.
• Consider offering a combination of an alpha-blocker and a 5-alpha reductase inhibitor to men with bothersome moderate to severe LUTS and a prostate estimated to be larger than 30 g or a PSA level greater than 1.4 ng/ml.  
• If treatment fails, refer the man for specialist urological assessment and management.
  • Secondary care treatment options include:
    • Urethral catheterization (which may be intermittent, indwelling urethral, or indwelling suprapubic).
    • Prostate surgery (including transurethral resection of the prostate, transurethral vaporization of the prostate, holmium laser enucleation of the prostate, transurethral incision of the prostate, and open prostatectomy).
• Provide advice on sources of additional information and support. 
  • NHS has online information for people with prostate enlargement, including information on the management of voiding problems and other lower urinary tract symptoms (LUTS).
  • The Bladder and Bowel Community provides information and support services on its website (www.bladderandbowel.org).  

How should I manage a man with predominantly storage symptoms?

• Exclude serious underlying causes of LUTS and manage treatable causes if possible. 
• Offer advice on lifestyle interventions and information on their condition to men whose LUTS are not bothersome or complicated.
  • Offer review if symptoms change.
• Discuss active surveillance (reassurance and lifestyle advice without immediate treatment) and regular follow-up or active intervention (conservative management, drug treatment or surgery) for men: 
  • With mild or moderate bothersome LUTS.
  • Whose LUTS fail to respond to drug treatment.
• Provide tailored advice to men with LUTS, for example:
  • To reduce fluid intake at specific times to reduce urinary frequency when most inconvenient (for example, at night or when going out in public).  
  • That fluid intake should not be limited excessively in an attempt to control symptoms, as this could increase the risk of complications (such as urinary tract infection). 
  • To treat constipation if present, to maintain a healthy lifestyle (reduce weight, stop smoking, and improve diet if relevant) and to avoid or moderate caffeine or alcohol intake. 
• Offer men with storage LUTS (particularly urinary incontinence) temporary containment products (for example, pads or collecting devices) to achieve social continence until a diagnosis and management plan have been discussed.
  • Offer a choice of containment products based on individual circumstances and in consultation with the man.
  • Do not offer penile clamps to men with storage LUTS (particularly urinary incontinence).  
  • Consider referring the man to, or obtaining advice from, a continence nurse, continence physiotherapist, or urologist. To find the local continence service, telephone the charity Bladder and Bowel UK on 0161 214 4591 or contact the local district nursing team.
  • Be aware that only products listed within the Appliances section of the Drug tariff can be prescribed on the FP10.
• Offer men with storage LUTS suggestive of overactive bladder: 
  • Supervised bladder training — this may be available from the local continence nurse, continence physiotherapist, or urology clinic.
  • Advice on fluid intake and lifestyle advice.
  • Containment products (if needed).
• Offer supervised pelvic floor muscle training to men with stress urinary incontinence caused by prostatectomy — advise them to continue the exercises for at least 3 months before considering other options.
  • Supervised pelvic floor training may be available from the local continence nurse, continence physiotherapist, or urology clinic.
• Refer all other men with stress urinary incontinence for specialist assessment.   
• Offer drug treatment to men with bothersome LUTS if conservative management options have been unsuccessful or are not appropriate.  
  • Take into account comorbidities and current treatment when offering men drug treatment for LUTS. 
• Offer an alpha blocker (alfuzosin, doxazosin, tamsulosin, or terazosin) to men with moderate to severe LUTS (an International Prostate Symptom Score [IPSS] of 8 or more). 
  • Review men taking alpha-blockers at 4 to 6 weeks and then every 6 to 12 months. During the review, re-assess symptoms and quality of life (for example, using the IPSS questionnaire) and assess for adverse effects of treatment. 
  • Consider offering an antimuscarinic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker alone. 
• Offer an antimuscarinic to men to manage the symptoms of overactive bladder — such as oxybutynin (immediate release), tolterodine (immediate release), or darifenacin.
  • Review every 4 to 6 weeks until symptoms are stable, and then every 6 to 12 months. During the review, re-assess symptoms and quality of life (for example, using the IPSS questionnaire) and assess for adverse effects of treatment. 
  • If the first-line drug treatment is not effective or tolerated, offer one of the other drugs.
• Consider offering a combination of an alpha-blocker with an antimuscarinic in men who still have storage symptoms after treatment with an alpha-blocker alone. 
• If antimuscarinics are contraindicated, not tolerated, or not effective, offer mirabegron or vibegron. 
  • Review at 4–6 weeks to assess tolerability and efficacy. During the review, re-assess symptoms and quality of life (for example, using the IPSS questionnaire) and assess for adverse effects of treatment. 
  • For detailed prescribing information, see the section on Mirabegron and Vibegron.
• For men with nocturnal polyuria, consider offering:
  • A late afternoon loop diuretic — for example, furosemide 40 mg (off-label use). For detailed prescribing information, see the section on Furosemide.
  • Oral desmopressin (if other medical causes have been excluded and they have not benefited from other treatments). For detailed prescribing information, see the section on Desmopressin.
    • Measure serum sodium 3 days after the first dose. If serum sodium is reduced to below the normal range, stop desmopressin treatment. 
• If treatment fails, refer the man for specialist urological assessment and management. 
• Provide advice on sources of additional information and support. 
  • The Bladder and Bowel Community provides information and support services on its website (www.bladderandbowel.org), including a digital Just Can't Wait toilet access card to use when the need to urinate arises while out shopping or socializing. 

How should I manage a man with post micturition dribble not due to urinary obstruction?

• Advise the man that he can reduce the post-micturition dribbling by 'milking' his urethra after urinating. 
  • To do this, the man should press his fingers behind the scrotum and push upwards and forward to expel the pooled urine. 
  • Urethral milking eliminates post-micturition dribble when the muscles surrounding the urethra do not completely drain it of urine.
  • East Sussex NHS Healthcare NHS Trust has a patient information leaflet on Post micturition dribble - Men.
• If necessary, offer a choice of temporary urine containment products (such as sheath and leg bags, absorbent pads, and absorbent pants) to achieve social continence.
  • Consider referring the man to, or obtaining advice from, a continence nurse, continence physiotherapist, or urologist. To find the local continence service, telephone the charity Bladder and Bowel UK on 0161 214 4591 or contact the local district nursing team.
  • Be aware that only products listed within the Appliances section of the Drug tariff can be prescribed on the FP10.

How should I manage acute urinary retention in a man?

• If this is the first episode of acute urinary retention, arrange hospital admission.
  • If the expertise and facilities are available, catheterize before admission.
  • Otherwise, admit the man urgently for catheterization and investigation of the cause.
• If the man has recurrent acute retention or acute-on-chronic urinary retention, admit the man or insert a urethral catheter. Discuss and decide on treatment to prevent or manage recurrent urine retention. Options include:
  • An alpha-blocker (for example, modified-release alfuzosin 10 mg a day).
    • Offer an alpha blocker to men for managing acute urinary retention before removal of the catheter. 
    • After removing the catheter, confirm over several hours that the man can void freely.
    • For detailed prescribing information, see the section on Alpha-blockers.
  • Intermittent urethral catheterization — refer the man or his carer to a continence nurse for training in catheterization. 
  • A long-term indwelling catheter — only if intermittent catheterization is not appropriate or practical. 

How should I manage chronic urinary retention in a man?

• Check serum creatinine to assess renal function.
• Refer the man for specialist assessment. 
  • Consider seeking specialist advice about the need for imaging of the urinary tract. 
• Advise the man about management options in secondary care, including: 
  • No catheterization, but follow-up with regular monitoring of renal function, volume of urinary retention, and any changes in imaging of upper renal tract. 
  • Intermittent urethral catheterization (performed by the man or his carer). 
  • A permanent indwelling catheter. 
  • Surgery to divert the urine externally (urostomy). 

Contraindications and cautions

Alfuzosin

• Do not prescribe alfuzosin to people with:
  • A history of micturition syncope. 
  • A history of postural hypotension. 
  • Severe hepatic impairment. 
• In addition, do not prescribe alfuzosin modified-release preparations to people with:
  • Severe renal impairment (creatinine clearance less than 30 mL/minute.) 
  • Hepatic impairment. 
• Prescribe alfuzosin with caution to:
  • People with:
    • Acute heart failure. 
    • Cerebrovascular disease. 
    • A history of QT-interval prolongation. 
    • Mild to moderate hepatic impairment (for immediate-release preparations) — see the section on Doses for recommended dosage adjustments in people with hepatic impairment.
    • Renal impairment (for immediate-release preparations) — see the section on Doses for recommended dosage adjustments in people with renal impairment.
  • People undergoing cataract surgery (risk of intra-operative floppy iris syndrome). 
  • Elderly people. 

Doxazosin

• Do not prescribe doxazosin to people with:
  • A history of micturition syncope (in men with benign prostatic hypertrophy [BPH]). 
  • A history of postural hypotension. 
  • Severe hepatic impairment. 
• In addition, do not prescribe doxazosin as monotherapy to men with:
  • Anuria.
  • Overflow bladder. 
• Do not prescribe doxazosin modified-release tablets to people with:
  • Gastrointestinal obstruction, oesophageal obstruction, or any degree of stricture. 
• Prescribe doxazosin with caution to:
  • People with:
    • Heart failure. 
    • Mild to moderate hepatic impairment. 
    • Pulmonary oedema due to aortic or mitral stenosis. 
  • People undergoing cataract surgery (risk of intra-operative floppy iris syndrome). 
  • Elderly people. 

Tamsulosin

• Do not prescribe tamsulosin to people with:
  • A history of micturition syncope. 
  • A history of postural hypotension. 
  • Severe hepatic impairment. 
• Prescribe tamsulosin with caution to:
  • People with severe renal impairment (creatinine clearance less than 10 mL/minute). 
  • People undergoing cataract surgery (risk of intra-operative floppy iris syndrome). 
  • Elderly people. 

Terazosin

• Do not prescribe terazosin to people with:
  • A history of micturition syncope (in BPH). 
  • A history of postural hypotension (in BPH). 
  • Severe hepatic impairment. 
  • Advanced renal failure. 
  • Bladder overflow. 
  • Anuria. 
• Prescribe terazosin with caution to:
  • People with:
    • Mild to moderate hepatic impairment. 
    • Pulmonary oedema due to aortic or mitral valve stenosis. 
    • High output cardiac insufficiency. 
    • Right-sided cardiac insufficiency due to pulmonary embolism or pericardial effusion. 
    • Left-sided cardiac insufficiency with low filling pressure. 
  • People undergoing cataract surgery (risk of intra-operative floppy iris syndrome). 
  • Elderly people. 

[MHRA, 2022; EMC, 2023a; EMC, 2023b; EMC, 2023c; BNF, 2024; EMC, 2024a; MHRA, 2024]  

Dose

The recommended doses are:

• Alfuzosin
  • Immediate-release preparations (for benign prostatic hyperplasia [BPH]) — 2.5 mg three times daily, up to a maximum 10 mg daily. 
    • In elderly people, prescribe 2.5 mg twice daily initially, then adjust according to response up to a maximum of 10 mg daily. 
    • In mild to moderate hepatic impairment, prescribe 2.5 mg once daily, increased to 2.5 mg twice daily according to response. 
    • In renal impairment, prescribe 2.5 mg twice daily and adjust according to response. 
  • Modified-release preparations for BPH — 10 mg once daily. 
  • Modified-release preparations for acute urinary retention associated with BPH — 10 mg once daily for 2–3 days during catheterization and for one day after removal. A maximum of 4 days' treatment. 
• Doxazosin 
  • Immediate-release preparations for BPH — initially 1 mg daily. The dose may be doubled at intervals of 1–2 weeks according to response up to a maximum daily dose of 8 mg. The usual maintenance dose is 2–4 mg daily. 
  • Modified-release preparations for BPH — initially 4 mg once daily. The dose can be adjusted after 4 weeks, then increased if necessary to 8 mg once daily. 
• Tamsulosin modified-release preparations for BPH — 400 micrograms once daily. 
• Terazosin immediate-release preparations for BPH — initially 1 mg daily. 
  • If necessary dose may be doubled at intervals of 1–2 weeks according to response up to a maximum daily dose of 10 mg. The usual maintenance dose is 5–10 mg daily. 
• More cautious titration may be needed in elderly people and in those taking other drugs with a hypotensive effect. 

[MHRA, 2022; EMC, 2023a; EMC, 2023b; EMC, 2023c; MHRA, 2023a; BNF, 2024; MHRA, 2024]  

Adverse effects

• There is a risk of first-dose hypotension and postural hypotension with alpha-blockers — vasodilatory effects may cause a rapid reduction in blood pressure, particularly in elderly people. 
  • Advise the man to take the first dose of standard-release alpha-blocker at bedtime. 
  • If symptoms do occur, advise the man to lie or sit down until the symptoms (such as dizziness, fatigue, or sweating) have abated. 
• Other adverse effects of alfuzosin include: 
  • Common or very common — asthenia, diarrhoea, dizziness, dry mouth, headache, malaise, nausea, postural hypotension, vertigo, and vomiting. 
  • Uncommon — abdominal pain, arrhythmias, chest pain, drowsiness, flushing, oedema, palpitations, rhinitis, skin reactions, syncope, and visual impairment. 
  • Rare or very rare — angina pectoris and angioedema.
  • Frequency not known — cerebral ischaemia, floppy iris syndrome, hepatic disorders, neutropenia, priapism, and thrombocytopenia. 
• Other adverse effects of doxazosin include: 
  • Common or very common — arrhythmias, asthenia, chest pain, cough, cystitis, dizziness, drowsiness, dry mouth, dyspnoea, gastrointestinal discomfort, headache, increased risk of infection, influenza like illness, muscle complaints, nausea, oedema, pain, palpitations, skin reactions, urinary disorders, and vertigo.
  • Uncommon — angina pectoris, anxiety, abnormal appetite, arthralgia, constipation, depression, diarrhoea, gastrointestinal disorders, gout, haemorrhage, insomnia, myocardial infarction, abnormal sensation, sexual dysfunction, stroke, syncope, tinnitus, tremor, vomiting, and weight gain.
  • Rare or very rare — alopecia, bronchospasm, blurred vision, flushing, gynaecomastia, hepatic disorders, leucopenia, malaise, muscle weakness, and thrombocytopenia.
  • Frequency not known — floppy iris syndrome.
• Other adverse effects of tamsulosin include:
  • Common or very common — dizziness and sexual dysfunction. 
  • Uncommon — asthenia, constipation, diarrhoea, headache, nausea, palpitations, postural hypotension, rhinitis, skin reactions, and vomiting. 
  • Rare or very rare — angioedema, Stevens-Johnson syndrome, and syncope. 
  • Frequency not known — dry mouth, epistaxis, and vision disorders. 
• Other adverse effects of terazosin include: 
  • Frequency not known — angioedema, anxiety, arrhythmias, arthritis, asthenia, chest pain, conjunctivitis, constipation, cough, depression, diarrhoea, dizziness, drowsiness, dry mouth, dyspnoea, epistaxis, fever, flatulence, gastrointestinal discomfort, gout, headache, hyperhidrosis, increased risk of infection, insomnia, joint disorders, myalgia, nasal congestion, nausea, oedema, pain, palpitations, paraesthesia, sexual dysfunction, skin reactions, syncope, thrombocytopenia, tinnitus, urinary disorders, vasodilation, vertigo, vision disorders, vomiting, and weight gain.

[MHRA, 2022; EMC, 2023a; EMC, 2023b; EMC, 2023c; BNF, 2024; EMC, 2024a; MHRA, 2024]  

Drug interactions

Important drug interactions include:

• Phosphodiesterase-5 inhibitors (PDE5 inhibitor) — concurrent use of a PDE5 inhibitor (such as sildenafil, tadalafil, or vardenafil) with an alpha-blocker may lead to symptomatic postural hypotension.
  • To minimize the risk the person should be stable on the alpha-blocker before initiating a PDE5 inhibitor. The PDE5 inhibitor should be started at the lowest recommended dose and dosing timed so that the peak concentrations of both drugs do not coincide. 
• Other drugs that can cause hypotension — there is an increased risk of first-dose hypotension and additive hypotensive effect in people taking drugs such as angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, calcium channel blockers, diuretics, and nitrates. Initiate therapy with the new drug at low dose or reduce the maintenance dose of the existing drug and titrate as necessary.
• Cytochrome P450 3A4 (CYP3A4) inhibitors — potent CYP3A4 inhibitors (such as clarithromycin, itraconazole, and ritonavir) are predicted to increase the exposure to tamsulosin, alfuzosin, and doxazosin, increasing the risk of adverse effects. Use the minimum dose of alpha-blocker and titrate as required.  
  • Alfuzosin — avoid concurrent use with ritonavir. 
  • Terazosin is not metabolized by this enzyme and is therefore not expected to interact with CYP3A4 inhibitors.

[Preston, 2024]

Contraindications and cautions

• Dutasteride
  • Do not prescribe dutasteride to people with:
    • Severe hepatic impairment.
  • Prescribe dutasteride with caution to people with:
    • Mild-to-moderate hepatic impairment. 
• Finasteride
  • Prescribe finasteride with caution to people with:
    • Obstructive uropathy. 
    • Hepatic impairment — the manufacturer advises that there are no data on finasteride in people with liver disease. 
• Finasteride and dutasteride can both be absorbed through the skin and are excreted in semen. 
  • Advise the man:
    • That women should not handle crushed or broken tablets of finasteride, or leaking capsules of dutasteride, if they are pregnant or may be pregnant.
    • To use a condom if his sexual partner is pregnant or likely to become pregnant.

[BNF, 2024; EMC, 2024b; EMC, 2024c]

Dose

• The recommended doses are:
  • Finasteride — 5 mg once daily.
  • Dutasteride — 500 micrograms once daily.
• Note: it may take up to 6 months for a beneficial response to be achieved. 

[BNF, 2024; EMC, 2024b; EMC, 2024c]

Adverse effects

• Reproductive system and breast disorders — impotence, decreased libido, ejaculation disorder, breast disorders.
  • Advise the man to promptly report any changes in their breast tissue (such as lumps, pain, or nipple discharge) as cases of breast cancer have (rarely) been reported. 
• Other adverse effects of dutasteride include:
  • Uncommon — alopecia and hypertrichosis. 
  • Frequency not known — angioedema, depression, hypersensitivity and skin reactions, localized oedema, and testicular disorders. 
• Other adverse effects of finasteride include:
  • Uncommon — skin reactions. 
  • Frequency not known — angioedema, depression, male infertility, palpitations, and testicular pain. 
    • The Medicines and Healthcare products Regulatory Agency (MHRA) has received reports of depression and, in rare cases, suicidal thoughts in men taking finasteride (Propecia^®) for male pattern hair loss; depression is also associated with Proscar^® for benign prostatic hyperplasia.
    • Advise men taking to stop finasteride immediately and inform a healthcare professional if they develop depression [MHRA, 2017].
• After 6 months of treatment, 5-alpha reductase inhibitors can cause a decrease in mean serum prostate-specific antigen (PSA) levels by approximately 50%.  
  • Men being treated with dutasteride or finasteride should have a new PSA baseline established after 6 months of treatment. It is recommended to monitor PSA values regularly thereafter. Any confirmed increase from lowest PSA level while on a 5-alpha reductase inhibitor may signal the presence of prostate cancer or noncompliance to treatment and should be carefully evaluated, even if those values are still within the normal range for people not taking a 5-alpha reductase inhibitor. In the interpretation of a PSA value for a man taking a 5-alpha reductase inhibitor, previous PSA values should be sought for comparison. 
  • Digital rectal examination, and other evaluations for prostate cancer, must be performed prior to initiating a 5-alpha reductase inhibitor and periodically thereafter. 
  • Total serum PSA levels return to baseline within 6 months of discontinuing treatment. The ratio of free to total PSA remains constant even under the influence of 5-alpha reductase inhibitors. If clinicians elect to use percent free PSA as an aid in the detection of prostate cancer in men undergoing 5-alpha reductase inhibitor treatment, no adjustment to its value appears necessary.
  • Treatment with a 5-alpha reductase inhibitor does not interfere with the use of PSA as a tool to assist in the diagnosis of prostate cancer after a new baseline has been established. 

[BNF, 2024; EMC, 2024b; EMC, 2024c]

Drug interactions

Important drug interactions include:

• Dutasteride 
  • CYP3A4 inhibitors (such as itraconazole, ritonavir, clarithromycin) — levels of dutasteride may be increased. If adverse effects occur, consider reducing the dosing frequency of dutasteride. 
• Finasteride 
  • There are no clinically important drug interactions. 

[Preston, 2024]

Contraindications and cautions

• Do not prescribe an antimuscarinic drug to people with:
  • Angle-closure glaucoma.
  • Gastrointestinal obstruction or intestinal atony.
  • Myasthenia gravis.
  • Paralytic ileus.
  • Pyloric stenosis.
  • Severe ulcerative colitis.
  • Significant bladder outflow obstruction or urinary retention.
  • Toxic megacolon.
• Prescribe an antimuscarinic drug with caution to:
  • People with:
    • Acute myocardial infarction.
    • Arrhythmias — may be worsened.
    • Autonomic neuropathy.
    • Cardiac insufficiency or cardiac surgery — due to association with tachycardia.
    • Conditions characterized by tachycardia.
    • Congestive heart failure or coronary artery disease — may be worsened.
    • Diarrhoea.
    • Gastro-oesophageal reflux disease.
    • Hepatic impairment — see the section on Doses for recommended dosage adjustments in people with hepatic impairment.
    • Hiatus hernia with reflux oesophagitis.
    • Hypertension.
    • Hyperthyroidism — due to association with tachycardia.
    • Prostatic hyperplasia.
    • Pyrexia.
    • Renal impairment — use oxybutynin and tolterodine with caution. See the section on Doses for recommended dosage adjustments in people with renal impairment.
    • Ulcerative colitis.
  • Elderly people (especially if frail).
  • People susceptible to angle-closure glaucoma.
• In addition:
  • Prescribe oxybutynin with caution to people with acute porphyrias.
  • Prescribe tolterodine with caution to people with a history of QT-interval prolongation. 

[EMC, 2022a; EMC, 2023d; MHRA, 2023b; BNF, 2024]

Dose

The recommended doses are:

• Oxybutynin 
  • Immediate-release preparations — initially 5 mg two to three times daily, increased if necessary up to 5 mg four times daily. 
    • In elderly people, initially 2.5–3 mg twice daily, increased if tolerated to 5 mg twice daily, adjusted according to response. 
  • Modified-release preparations — initially 5 mg once daily, increased in steps of 5 mg every week, adjusted according to response up to a maximum of 20 mg daily. 
  • Transdermal patch — one patch twice a week. 
    • The patch should be applied to clean, dry unbroken skin on the abdomen, hip or buttock. It should be removed every 3–4 days and a new patch applied to a different area. The same area should be avoided for 7 days. 
• Darifenacin modified-release preparations — initially 7.5 mg once daily, increased if necessary to 15 mg daily after 2 weeks. 
  • Prescribe a maximum of 7.5 mg daily in moderate hepatic impairment.
• Tolterodine immediate-release preparations — 2 mg twice daily, reduced if not tolerated to 1 mg twice daily.  
  • Reduce dose to 1 mg twice daily in hepatic impairment. 
  • Reduce dose to 1 mg twice daily in severe renal impairment (eGFR less than 30 mL/minute/1.73m²). 
• Tolterodine modified-release preparations — 4 mg once daily. 
  • Reduce dose to 2 mg once daily in hepatic impairment. 
  • Reduce dose to 2 mg once daily if eGFR is 30 mL/minute/1.73m² or less. 
• Review the person every 4–6 weeks until symptoms are stable, and then every 6–12 months. Assess symptoms, quality of life, adverse effects, and the need for continuing treatment.

[EMC, 2022a; EMC, 2023d; MHRA, 2023b; BNF, 2024]

Adverse effects

• Adverse effects of antimuscarinics are common, and elderly or frail people may be more susceptible.
  • The impact of adverse effects can be reduced by using a small starting dose and titrating the dose slowly. See the section on Initiation and titration for more information.
  • If unacceptable adverse effects persist, reduce the dose or stop treatment with the antimuscarinic drug.
• Adverse effects of antimuscarinic drugs include: 
  • Common or very common — constipation, dizziness, drowsiness, dry mouth, dyspepsia, flushing, headache, nausea, palpitations, skin reactions, tachycardia, urinary disorders, vision disorders, and vomiting.
  • Rare or very rare — confusion (more common in elderly).
• In addition for oxybutynin:
  • With oral use:
    • Common or very common — dry eyes. 
    • Uncommon — abdominal discomfort, appetite decreased, and dysphagia.
    • Frequency not known — anxiety, arrhythmia, cognitive disorder, depressive symptom, drug dependence, gastrointestinal disorders, glaucoma, hallucination, heat stroke, hypohidrosis, mydriasis, nightmare, paranoia, photosensitivity reaction, seizure, and urinary tract infection (UTI). 
  • With transdermal use:
    • Common or very common — gastrointestinal discomfort and increased risk of infection. 
    • Uncommon — back pain, hot flush, and injury. 
• In addition for darifenacin: 
  • Common or very common — abdominal pain, dry eye, and nasal dryness.
  • Uncommon — asthenia, bladder pain, cough, diarrhoea, dyspnoea, erectile dysfunction, flatulence, hyperhidrosis, hypertension, increased risk of infection, injury, insomnia, oedema, oral ulceration, taste altered, thinking abnormal, and urinary tract disorder.
• In addition for tolterodine: 
  • Common or very common — abdominal pain, bronchitis, chest pain, diarrhoea, dry eye, fatigue, gastrointestinal disorders, paraesthesia, peripheral oedema, vertigo, and weight gain.
  • Uncommon — arrhythmia, heart failure, memory loss, and nervousness.
  • Frequency not known — angioedema and hallucination.​​​​​​

[EMC, 2022a; EMC, 2023d; MHRA, 2023b; BNF, 2024]

Drug interactions

Important drug interactions include:

• Other drugs with antimuscarinic action — concurrent use of antimuscarinic drugs with other drugs with antimuscarinic action (such as tricyclic antidepressants and sedating antihistamines) will cause additive adverse effects (such as dry mouth, blurred vision, urinary retention, constipation, and confusion). Adjust treatment as required. 
• Drugs that increase the risk of QT interval prolongation (for example, amiodarone, domperidone, ketoconazole, antipsychotics, tricyclic antidepressants, sotalol) — tolterodine may also increase QT interval prolongation which has an additive effect. which can lead to dangerous QT interval prolongation and potentially fatal torsade de pointes arrhythmia. Avoid concurrent use.  
• Centrally acting anticholinesterases (for example, rivastigmine, donepezil) — antimuscarinics and anticholinesterases are expected to lead to opposition of effects. Monitor concurrent use.  
• Potent CYP2D6 inhibitors (for example, paroxetine, terbinafine, cimetidine, quinidine) — exposure to darifenacin may be increased. Initiate treatment with 7.5 mg daily and increase dose if tolerated and necessary. 
• Potent CYP3A4 inhibitors (for example, clarithromycin, itraconazole, ritonavir) — darifenacin and tolterodine are metabolized by the cytochrome P450 enzyme CYP3A4. Concurrent use with a potent CYP3A4 inhibitor can increase exposure to the antimuscarinic.
  • Darifenacin —  concurrent use is contraindicated.
  • Tolterodine — avoid concurrent use.

[Preston, 2024]

Contraindications and cautions

• Do not prescribe mirabegron to people with:
  • End-stage renal disease (eGFR less than 15 mL/minute/1.73m²), or severe renal impairment (eGFR 15-29 mL/minute/1.73m²) if concomitantly taking a strong CYP3A inhibitor. 
  • Moderate hepatic impairment if concomitantly taking a strong CYP3A inhibitor.
  • Severe hepatic impairment.  
  • Severe uncontrolled hypertension (systolic blood pressure 180 mmHg or higher and/or diastolic blood pressure 110 mmHg or higher).
• Prescribe mirabegron with caution to people with:
  • A history of QT-interval prolongation, or taking medicines known to cause QT-interval prolongation. 
  • Bladder outlet obstruction. 
  • Severe renal impairment, or mild to moderate renal impairment (eGFR 30-89 mL/minute/1.73m²) concomitantly taking a strong CYP3A inhibitor  — reduce dose to 25 mg daily.
  • Moderate hepatic impairment, or mild hepatic impairment if concomitantly taking a strong CYP3A inhibitor — reduce dose to 25 mg daily.
  • Stage 2 hypertension (systolic blood pressure of 160 mm Hg or higher, or diastolic blood pressure of 100 mm Hg or higher). 

[EMC, 2022b; BNF, 2024]

Dose

• The recommended starting dose of mirabegron is 50 mg once daily.
• A recommended starting dose of 25 mg daily is recommended for people with:
  • Mild to moderate renal impairment (eGFR 30-89 mL/minute/1.73m²) if concomitantly taking a strong CYP3A inhibitor. 
  • Severe renal impairment.
  • Mild hepatic impairment concomitantly taking a strong CYP3A inhibitor.
  • Moderate hepatic impairment. 

[EMC, 2022b; BNF, 2024]

Adverse effects

• Cardiac — tachycardia (common), palpitations, atrial fibrillation. 
• Gastrointestinal —nausea, constipation, diarrhoea (common), dyspepsia, gastritis.
• Skin and subcutaneous tissue — urticaria, rash, pruritus, lip swelling.
• Other adverse effects include:
  • Eyelid oedema.
  • Headache, dizziness.
  • Hypertensive crisis.
  • Joint swelling. 
  • Urinary retention. 

[EMC, 2022b; BNF, 2024]

Drug interactions

• Dabigatran — mirabegron is predicted to slightly increase exposure to dabigatran. Monitor for signs of bleeding or anaemia. 
• Digoxin — concurrent use with mirabegron slightly increases digoxin exposure. Give the lowest possible starting dose of digoxin, monitor plasma concentrations and titrate as necessary.
• Metoprolol, propranolol — mirabegron moderately increases the plasma concentration of metoprolol and propranolol. If concurrent use is necessary, monitor for adverse effects and adjust dose of metoprolol or propranolol if necessary.
• Strong cytochrome P450 inhibitors (such as ketoconazole, clarithromycin, ritonavir) — concurrent use with strong cytochrome P450 inhibitors increases plasma concentrations of mirabegron. 
  • Avoid concurrent use, or reduce the starting dose of mirabegron in people with hepatic or renal impairment who are also taking a strong cytochrome P450 inhibitor.

[Preston, 2024]

Monitoring

• Monitor blood pressure before starting treatment and regularly during treatment, especially in people with pre-existing hypertension.

[EMC, 2022b; BNF, 2024]

What are the contraindications and cautions for vibegron?

• Do not prescribe vibegron to women with:
  • Rare hereditary problems of galactose intolerance.
  • Total lactase deficiency.
  • Glucose-galactose malabsorption.
  • End-stage renal disease (estimated glomerular filtration rate [eGFR] less than 15 mL/minute/1.73 m² with or without haemodialysis) — vibegron has not been studied in this group.
  • Severe hepatic impairment (Child-Pugh C) — vibegron has not been studied in this group.
• Avoid vibegron in: 
  • Pregnant women — toxicity in animal studies.
  • Breastfeeding women — present in milk in animal studies.
• Prescribe vibegron with caution to:
  • Women with bladder outlet obstruction or conditions predisposing to bladder outlet obstruction — increased risk of urinary retention.
  • Women taking a muscarinic antagonist concurrently with vibegron — increased risk of urinary retention.

[EMC, 2024d; BNF, 2025]

How should I start and titrate vibegron?

• Vibegron is licensed for the symptomatic treatment of overactive bladder in adults.
  • The recommended dosage for this indication is  75 mg once daily.
• No dose adjustment is recommended for mild, moderate, or severe renal impairment (estimated glomerular filtration rate [eGFR] 15–89 mL/minute/1.73 m²). Do not prescribe if eGFR is less than 15 mL/minute/1.73 m² with or without haemodialysis.
• No dose adjustment is recommended for mild to moderate hepatic impairment (Child-Pugh A and B). Do not prescribe in people with severe hepatic impairment (Child-Pugh C).

[EMC, 2024d; BNF, 2025]

What are the adverse effects of vibegron?

• The most common adverse effects are:
  • Constipation.
  • Diarrhoea.
  • Headache.
  • Nausea.
  • Urinary tract infection.
  • Increased residual urine volume.
• Other adverse effects include (uncommon):
  • Hot flush.
  • Rash (including rash pruritic and rash erythematous).
  • Urinary retention (including urinary straining).

[EMC, 2024d; BNF, 2025] 

What are the key drug interactions of vibegron?

• Drug interactions of vibegron include:
  • Digoxin — vibegron may increase plasma concentrations of digoxin.
    • If concurrent use is indicated, prescribe the lowest dose of digoxin initially.
    • Monitor serum digoxin concentrations and adjust the dose to achieve the desired clinical effect.
  • Cytochrome P450 (CYP) 3A4 and P-gp inhibitors — vibegron is a substrate for CYP 3A4 and P-gp. Plasma concentrations may be increased by potent and moderate inhibitors of CYP3A/P-gp, such as ketoconazole and diltiazem, respectively.
    
    • The manufacturer states that no vibegron dose adjustment is needed. However, consider this interaction in the event of increased adverse effects.
  • P-gp substrates — vibegron is a substrate for P-gp.
    • Consider the potential for interaction if vibegron is combined with a sensitive P-gp substrate with a narrow therapeutic index, such as dabigatran, apixaban, or rivaroxaban.

 [EMC, 2024d] 

What monitoring is required for vibegron?

• Monitor for signs and symptoms of urinary retention before and during the treatment with vibegron, particularly in women with clinically significant bladder outlet obstruction, in conditions predisposing for bladder outlet obstruction, and in women who are also taking a muscarinic antagonist.

[EMC, 2024d] 

Contraindications and cautions

• Do not prescribe furosemide to people with:
  • Addison's disease. 
  • Anuria. 
  • Comatose and precomatose states associated with liver cirrhosis. 
  • Digitalis intoxication. 
  • Electrolyte disturbances (severe hyponatraemia, severe hypokalaemia, hypovolaemia), dehydration and/or hypotension. 
  • Renal failure due to nephrotoxic or hepatotoxic drugs. 
  • Severe hyponatraemia or hypokalaemia. 
  • Severe renal impairment (creatine clearance less than 30 mL/minute). 
• Prescribe furosemide with caution to:
  • People with:
    • Diabetes mellitus — furosemide could worsen glucose control. 
    • Gout — electrolyte imbalance caused by furosemide may aggravate gout. 
    • Hepatic impairment — hypokalaemia may precipitate encephalopathy, and there is an increased risk of hypomagnesia in alcoholic cirrhosis, leading to arrhythmias. 
    • Hypoproteinaemia (for example, nephrotic syndrome) — the effect of furosemide may be impaired and its ototoxicity potentiated. Cautious dose titration is required. 
    • Hypotension — correct before starting furosemide, and monitor blood pressure. 
    • Hypovolaemia or acute hypercalcaemia — correct before starting furosemide. 
    • Mild to moderate renal impairment — higher doses may be needed. However, large doses can cause deafness. 
    • Prostatic enlargement or impaired micturition — furosemide may worsen urinary flow. 
  • Elderly people — furosemide is excreted more slowly in the elderly. Treatment should be started with 20 mg and titrated upwards as required. 
  • People who are at risk from a pronounced fall in blood pressure. 

[EMC, 2023e; BNF, 2024]

Dose

• CKS recommends prescribing 20–40 mg of furosemide once a day.
  • In elderly people, treatment should be started with 20 mg and titrated upwards as required, as furosemide is excreted more slowly in the elderly. 
• Although the use of furosemide is off label for men with nocturnal polyuria, these doses are consistent with those recommended for people who have oedema.

[EMC, 2023e; BNF, 2024]

Adverse effects

• Gastrointestinal
  • Uncommon — dry mouth, thirst, nausea, bowel motility disturbances, vomiting, diarrhoea, constipation.
• Metabolism and nutrition disorders 
  • Very common — dehydration, hyponatraemia, hypochloremic metabolic alkalosis, hypocalcaemia, hypomagnesemia.  
  • Common — hypovolaemia, hypochloraemia.
  • Uncommon — impaired glucose tolerance, hyperuricaemia, gout, reduction of serum HDL-cholesterol, elevation of serum LDL-cholesterol, elevation of serum triglycerides, hyperglycaemia.
• Vascular disorders 
  • Very common — reduced blood pressure. If pronounced this may cause impairment of concentration and reactions, light-headedness, sensations of pressure in the head, headache, dizziness, drowsiness, weakness, disorders of vision, dry mouth, orthostatic intolerance.
  • Uncommon — hypotension, hypovolaemia. 
• Other adverse effects include:
  • Aplastic anaemia.
  • Fatigue.
  • Hepatic disorders
  • Malaise, fever.
  • Muscle cramps, muscle weakness.
  • Paraesthesia, confusion, headache, dizziness. 
  • Psychiatric disorder.
  • Rash, pruritus, urticaria. 
  • Tinnitus and reversible or irreversible hearing loss.
  • Urinary incontinence, reduced diuresis, acute kidney injury.
  • Visual disturbance, blurred vision, yellow vision.

[EMC, 2023e; BNF, 2024]

Drug interactions

• Digoxin — hypokalaemia can be caused by loop diuretics, which increases the risk of digoxin toxicity. Monitor potassium levels. 
• Drugs that cause hypotension — an additive hypotensive effect may occur during concurrent use with furosemide and other drugs that can cause hypotension, such as angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, calcium channel blockers, other diuretics, and nitrates. 
• Drugs that cause hypokalaemia — an additive hypokalaemic effect may occur during concurrent use with furosemide and other drugs that can cause hypokalaemia, such as thiazide diuretics, theophylline, tacrolimus, reboxetine, fluconazole, and beta-2 agonists. Monitor potassium levels if hypokalaemia is suspected.
• Lithium — furosemide reduces lithium excretion, leading to an increased risk of lithium toxicity. There is an increased risk of torsades de pointes as furosemide can cause hypokalaemia which might be additive with the effects of lithium. Monitor lithium and potassium levels and adjust lithium dose if necessary. 
• Nonsteroidal anti-inflammatory drugs (NSAIDs) — NSAIDs may antagonize the diuretic effect of furosemide and increase the risk of nephrotoxicity. Consider an alternative non-NSAID analgesic. If concurrent use is necessary, monitor the diuretic effects, renal function, electrolytes and hearing. Increase the furosemide dose if necessary.

[Preston, 2024]

Monitoring

• Measure blood pressure, renal function and serum electrolytes before starting furosemide treatment. 
• Check renal function and serum electrolytes:
  • Within 1–2 weeks after starting treatment and after each dose increase. Earlier monitoring (within 5–7 days) may be required in higher-risk people (including people with existing renal impairment and people on combination therapy). 
  • Every 3-6 months thereafter (up to annually), depending on renal function.
  • If the person's clinical condition changes or a potential interacting drug is added. 

[Smellie, 2007] 

Contraindications and cautions

• Do not prescribe desmopressin to people with:
  • Cardiac insufficiency. 
  • Conditions treated with diuretics. 
  • A known history of hyponatraemia. 
  • Moderate to severe renal impairment (creatinine clearance below 50 mL/minute).  
  • Nocturia associated with multiple sclerosis.
  • Psychogenic polydipsia or alcohol abuse. 
  • Syndrome of inappropriate antidiuretic hormone secretion. 
• Prescribe desmopressin with caution to elderly people (aged 65 years and over), and people with:
  • Cardiovascular disease. 
  • Chronic renal disease. 
  • Conditions that might be aggravated by water retention. 
  • Cystic fibrosis. 
  • Epilepsy. 
  • Hypertension. 
  • Nocturia or nocturnal enuresis — limit fluid intake to minimum from 1 hour before dose until 8 hours afterwards. 

[MHRA , 2021; BNF, 2024]

Dose

• The recommended dose of oral lyophilisate desmopressin (Noqdirna^®) for idiopathic nocturnal polyuria in men is 50 micrograms once daily taken one hour before bedtime, administered sublingually without water. 
• To reduce the risk of hyponatraemia, advise the person to:
  • Avoid fluid overload and stop taking desmopressin during periods of diarrhoea or vomiting (until fluid balance is normal). 
  • Limit fluid intake from 1 hour before to 8 hours after taking desmopressin.
  • Avoid using over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) as they may worsen water retention and increase the risk of hyponatraemia.
• Assess the man's response after a trial of 1–2 weeks' treatment.
  • A dose increase with this product is not recommended in elderly people (age 65 years and older). 

[MHRA , 2021; BNF, 2024]

Adverse effects

• Common or very common adverse effects include: 
  • Fluid retention and hyponatraemia — this can lead to headache, nausea and vomiting, weight gain, and in severe cases, convulsions.
    • In the event of signs or symptoms of water retention and/or hyponatremia (headache, nausea/vomiting, weight gain, and, in severe cases, convulsions), treatment should be interrupted and reassessed. If restarting treatment, strict fluid restriction should be enforced and serum sodium levels monitored.
    • The risk of hyponatraemia is higher in people aged 65 years or older.
    • To reduce the risk of hyponatraemia, advise the person to avoid fluid overload and stop taking desmopressin during periods of diarrhoea or vomiting (until fluid balance is normal), limit fluid intake from 1 hour before to 8 hours after taking desmopressin, and avoid using over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), as they may worsen water retention and increase the risk of hyponatraemia. 
  • Diarrhoea.
  • Dizziness.
  • Headache.
  • Nausea.
• Other possible adverse effects include:
  • Abdominal discomfort.
  • Constipation.
  • Fatigue.
  • Peripheral oedema. 

[MHRA , 2021; BNF, 2024]

Drug interactions

• Drugs that can cause water retention or hyponatraemia (for example, tricyclic antidepressants, selective serotonin reuptake inhibitors, chlorpromazine, diuretics, nonsteroidal anti-inflammatory drugs, carbamazepine) — these may have an additive effect with desmopressin and cause water retention and/or hyponatraemia. 
  • If concurrent is necessary, increase monitoring frequency of serum sodium. 
• Loperamide — absorption of oral desmopressin may be markedly increased and sublingual desmopressin may be similarly affected. Monitor the effects of desmopressin and reduce the dose or frequency if necessary. 

[MHRA , 2021; Preston, 2024]

Monitoring

• Elderly people are at increased risk of developing hyponatraemia with desmopressin treatment and may also have impaired renal function. 
  • The manufacturer advises that in elderly men (age 65 years and older): 
    • Daily doses above 50 micrograms should not be used.
    • Serum sodium levels must be within the normal range before starting treatment and should be monitored in the first week of treatment (4–8 days after initiation) and again at one month. Desmopressin treatment should be discontinued if the serum sodium level falls below the lower limit of normal range (135 mmol/L).
    • Treatment should be reviewed if there is no therapeutic benefit after 3 months.
• Periodic blood pressure and body weight checks are recommended to monitor fluid overload. 
• In the event of signs or symptoms of water retention and/or hyponatremia (headache, nausea/vomiting, weight gain, and, in severe cases, convulsions), treatment should be interrupted and reassessed. 
  • If restarting treatment strict fluid restriction should be enforced and serum sodium levels monitored.

[MHRA , 2021; BNF, 2024]