Overactive Bladder in the Male Patient:

Epidemiology, Etiology, Evaluation,

and Treatment
William I. Jaffe, MD* and Alexis E. Te, MD

Address
*Temple University School of Medicine, Broad and Ontario Streets,
Suite 350 Parkinson Pavilion, Philadelphia, PA 19140, USA.
E-mail: [email protected]
Current Urology Reports 2005, 6:410418
Current Science Inc. ISSN 1527-2737
Copyright 2005 by Current Science Inc..

The urologists approach to the diagnosis and treatment

of lower urinary tract symptoms (LUTS) in male patients
has changed significantly over the past decade. Advances in
the basic science arena combined with a wealth of clinical
data have pointed to the importance of bladder pathophysiology in the development of urinary symptoms. Historically,
men with LUTS were diagnosed with prostatism, an allencompassing term that includes both voiding and storage
symptoms that may or may not be related to prostatic
obstruction. Parallel to the scientific advances in the field,
the urologic lexicon began to evolve and has allowed us
to more specifically describe, and therefore investigate
and treat, different aspects of male LUTS. It is now well
recognized that many men suffer from storage symptoms
that may be more related to bladder dysfunction than
to prostatic obstruction. It will be critical to integrate
our knowledge of prostatic growth and obstruction, the
bladder response to outlet obstruction, environmental and
lifestyle factors, and age-related changes to fully understand
the complex pathophysiology of male LUTS, specifically
overactive bladder syndrome.

Introduction
Overactive bladder (OAB) is defined by the International
Continence Society (ICS) as urgency, with or without urge
incontinence, usually with frequency and nocturia [1].
Therefore, the hallmark of OAB is urgency, which is difficult
even for experts in the field to define clearly and precisely. The
ICSs standardization report in 2002 attempted to codify the
definition of urgency as the complaint of a sudden compelling desire to pass urine, which is difficult to defer [1]. This
is in contrast to simple urge, which is the non-pathologic
desire to void. OAB may be classified further as OAB dry or
OAB wet based on the absence or presence of incontinence.

The terms detrusor instability and detrusor hyper-reflexia

have been abandoned and replaced by the term detrusor overactivity (DO), which may be idiopathic or neurogenic. DO is
the purely urodynamic observation of involuntary detrusor
contraction during filling; this is thought to be the driving
force behind OAB symptoms. The magnitude, frequency, and
volume at which involuntary contractions occur often are
reported in the literature as endpoints in OAB trials and may
be useful as such. However, there clearly are categories of
patients in which this relationship, or more precisely the definition, is not valid. Patients with sensory urgency clearly may
have OAB by history, but by definition, will not have DO.
Patients with spinal cord injury or other neurologic conditions that affect bladder sensation may have DO, but they
likely will not have urgency. These semantic differences must
be considered when critically evaluating the OAB literature
and applying the results to specific patient populations.
Why is this topic important? For years, OAB has been
considered a womens health issue and much of the research
has been focused accordingly. As we have come to realize
that this condition is equally as prevalent in men, are we to
apply what we know about female OAB to our male
patients? This paper focuses on the similarities and differences between OAB in men and women and how this ultimately affects the evaluation and treatment of these patients.

Epidemiology
Much of the uncertainty that exists regarding the true prevalence of OAB is a function of inconsistent definitions of
the condition over time. As with many other diseases, the
measured prevalence is highly dependent on multiple
factors including the criteria used to define the disease, the
populations that are studied (referral vs communitybased), and the techniques of data collection (questionnaire vs physician-patient interview). Before the ICS
formalized the definition of OAB, much of the literature
focused on measuring urge urinary incontinence (UUI) in
predominantly female populations. It was assumed that
approximately one third of patients with OAB also had
incontinence; therefore, the prevalence of OAB was determined by multiplying the prevalence of UUI by 3 [24].
However, in the past several years, several large-scale,

Overactive Bladder in the Male Patient Jaffe and Te

411

Table 1. Comparison of three epidemiologic studies

Study

Design

Stewart et al. [5] Computer-assisted

telephone interview
Temml et al. [6]
Physician visits with
OAB questionnaire
Milsom et al. [7]
Telephone interview

Patients, Patients with

n
OAB, %

Patients with
OAB with
wetness, %

5204

16.5

6.1

2418

13.5

4.1

16,776

16.6

Men
16%
(2.6% wet)
10.2%
(1.8% wet)
15.6%

Women
16.9%
(9.3% wet)
16.8%
(6.5% wet)
17.4%

OABoveractive bladder.

population-based studies focusing on OAB have been

reported [5,6,7]. Because these studies include male and
female patients across wide age groups, and, in some cases,
different geographic and socioeconomic groups, they represent our best estimate on the true prevalence and impact
of OAB. The data are summarized in Table 1. Although the
numbers varied slightly and the definition of OAB was
somewhat different among studies, there are several useful
observations and conclusions that can be made. OAB is a
common condition and affects approximately 15% of the
adult population and the prevalence increases with
advancing age. Contrary to previously held notions, men
are as likely as women to suffer from OAB, although
women are much more likely to suffer from incontinence.
The NOBLE program was an industry-sponsored study
designed to assess the prevalence and impact of OAB in the
United States. Evaluation was conducted by telephone
interviews and questionnaires in more than 5000 randomly selected subjects; the overall rates of OAB in men
and women were 16.0% and 16.9% respectively. In
women, 55% of those with OAB also had UUI whereas in
men, the incontinent rate was only 16% [5]. As in the
other studies, the ratio of OAB wet to OAB dry increased
with age in both sexes.
It also is evident from these studies and other analyses
that OAB is a significant burden on the individual and on
society. Because of the nature of the condition, it will
always be difficult to measure the true impact of OAB
because most patients with OAB will not seek medical
attention for evaluation or treatment due to embarrassment or belief that no effective treatment is available. In
the NOBLE study, only 40% of patients with OAB wet saw
a doctor for the condition in the year prior to the survey
[5]. When compared with matched control subjects, a
selected subset of men with OAB (dry and wet) from the
NOBLE study scored significantly worse on a depression
scale, sleep scale, and overall quality of life. Sixty-five
percent of men with OAB in the large European study
reported that their symptoms had an effect on their daily
living [7].
Tubaro [8], in an excellent review on the burden of
OAB, concluded that OAB has a more substantial impact
on quality-of-life measures (Short-form 36) than diabetes.

The economic costs of OAB perhaps are even more difficult to ascertain. Again, much of the literature has concentrated on measuring the costs of urinary incontinence
because it is easier to determine the direct costs of incontinence products and physician visits than the indirect costs
associated with OAB. From the Urologic Diseases in America Project, the annual direct costs of male incontinence
were 29.4 billion dollars in 1998/1999 [9]. This, of course,
includes men with sphincteric incontinence, but does not
include the costs associated with OAB dry. The nested subset from the NOBLE study was the first attempt to estimate
the direct and indirect costs associated with OAB in men
and women in the United States. The total cost was calculated to be 12.2 billion dollars, with 11.18 billion dollars
attributed to direct costs [10]. The economic burden was
approximately equivalent to that of osteoporosis (13.8
billion dollars) and gynecologic and breast cancer (11.1
billion dollars).
From the several large, population-based surveys conducted in the past few years, we now have a more complete
understanding of the epidemiology and economic burden
of OAB. OAB is clearly a common syndrome in women
and men with a significant impact on overall well-being
and health care expenditures. This knowledge hopefully
will allow a better allocation of resources and increased
patient awareness of the condition.

Male Lower Urinary Tract Symptoms, Benign

Prostatic Hyperplasia, and Overactive Bladder
Although OAB is a disorder of the storage function of the
bladder, evaluation of the male patient who presents with
lower urinary tract symptoms (LUTS) usually begins with
attention to the emptying phase. Without question, the
most common cause of voiding symptoms in the adult
male patient is related to prostatic obstruction secondary
to benign prostatic hyperplasia (BPH). It is well known
that LUTS, such as those measured by the American Urological Association Symptom Index, International Prostate
Symptom Score (IPSS), or ICSmale questionnaire, do not
correlate well with objective parameters such as free
urinary flow rates, degree of obstruction on pressure-flow
studies, or prostate size [11,12] On the other hand,

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Overactive Bladder

prostate size and LUTS increase with aging whereas peak

urinary flow rates decrease [1315]. To say the least, the
relationship among prostate size, degree of obstruction,
and LUTS is poorly understood. If we solely consider
storage symptoms (ie, OAB), we know that they can exist in
conjunction with BPH (or other causes of outlet obstruction) or independently. Approximately 50% of men with
benign prostatic obstruction also will have DO when evaluated with urodynamics [16,17]. However, in men with
LUTS who are younger than 60 years of age, 60% will not
have an enlarged prostate or a history of BPH [18]. What
remains unclear is to what extent prostatic hyperplasia and
obstruction causes storage symptoms. This is one of the
key questions in understanding the difference between
men and women with OAB because most women with
OAB are not obstructed.

Bladder Response to Outlet Obstruction and

Promotion of Detrusor Overactivity
There is a tremendous amount of basic science literature
regarding the pathophysiology of DO and OAB. Although
historically much of the focus has been on the central role
of muscarinic receptors, more recent work involves investigation into alternative pathways. Targets include the role of
the urothelium, non-cholinergic neurotransmission, interstitial cells, and the suburothelium, afferent nerves, and
central nervous system pathways [19]. Clinical observations suggesting a cause-effect relationship between bladder outlet obstruction and OAB have pointed toward new
avenues for research.
In animal models of partial bladder outlet obstruction,
the bladder undergoes compensatory changes in response
to increased outlet resistance. These changes include
smooth muscle hypertrophy, increased collagen deposition, vascular changes, and alterations in neuroanatomic
structure and neurotransmission [20,21,22]. In the initial
compensated state, there is increasing bladder mass with
areas of focal hypoxia and angiogenesis. Contractile
response remains good and the bladder is able to empty.
With further changes and prolonged obstruction, a
decompensated state is reached that involves further
increases in mass, decreasing compliance and contractile
response, and connective tissue replacement [23]. Levin et
al. [22,23,24] compared bladder tissue from a rabbit with
partial bladder outlet obstruction model with human bladder tissue specimens from obstructed bladders and healthy
control subjects. They identified at least five common features associated with partial bladder outlet obstruction in
rabbit and human tissue: increased mass, reduced cholinergic nerve density, reduced mitochondrial substrate use,
decreased sarcoplasmic-endoplasmic reticulum calcium
ATPase activity, and increased and redistributed connective
tissue. Increased mass and connective tissue may lead to a
decrease in compliance and functional capacity. This may
or may not lead to urodynamically demonstrable involun-

tary contractions, but certainly would lead to symptoms of

frequency and nocturia that could be interpreted as OAB.
Other investigators have attempted to define specific
changes in the obstructed bladder that may contribute to
the development of DO. Charlton et al. [20] demonstrated
areas of focal denervation in obstructed bladder tissue,
which they postulated may lead to autonomous activity of
smooth muscle modules (denervation supersensitivity).
The increased role of ATP and purinergic receptors also has
been demonstrated in animal and human obstructed bladder tissue. OReilly et al. [25] showed that the P2X1 was the
predominant purinergic receptor subtype in the human
bladder and that it was present in higher concentrations in
smooth muscle in the obstructed bladder compared with
control subjects. Smith and Chapple [26] quantified a 25%
contribution of nonadrenergic, noncholinergic pathways
in the obstructed human bladder. Kim et al. [27] showed
increased mRNA expression for nerve growth factor and
vanilloid receptor in unstable rat bladders after relieving
outlet obstruction, which may contribute to increased
afferent nerve activity. Other factors that may contribute to
the development of OAB in bladder outlet obstruction
models include alterations in prostaglandin-cAMP and
nitric oxide-cGMP pathways [28,29] and increased endothelin-1 activity [30].
Although there clearly are morphologic and cellular
changes that occur in the obstructed bladder that are associated with DO, a comprehensive explanation has not been
developed. On a cellular level, it is still unknown if DO in
the obstructed bladder is pathophysiologically the same as
idiopathic or neurogenic DO. Advances in this area may
allow us to develop novel therapeutic strategies in groups
of patients with specific subtypes of OAB.

Nonobstructive Overactive Bladder

Most women and many men who present with OAB will
not have evidence of bladder outlet obstruction. Men can
be divided into those without any history of bladder outlet
obstruction and those previously treated (often surgically)
for it, but remain bothered by OAB. Approximately one
third of older men with LUTS will not have bladder outlet
obstruction [17,31] and only 50% of men with preoperative DO will have resolution of DO after outlet reduction
surgery [32]. Therefore, large numbers of men have OAB
syndrome without any evidence of obstructive pathology,
even if we exclude those with relieved obstruction. There
are a myriad of other causes of DO, including neurologic
lesions, infection, bladder cancer (especially carcinoma in
situ), and lifestyle factors (eg, fluid intake, caffeine). By
definition, OAB syndrome excludes these known metabolic and pathologic causes of overactivity.
It is clear from epidemiologic studies that the prevalence
of OAB increases with age in men and women; this appears
to be the common pathway in both sexes and is why the condition often is referred to as the aging bladder. This refers to

Overactive Bladder in the Male Patient Jaffe and Te

an increase in involuntary activity and disturbances in contractility, sensation, compliance, and outlet function. There
are, of course, numerous changes that occur in individuals as
they age, which may lead to alterations in detrusor function.
These include decreases in circulating levels of sex hormones,
atherosclerosis, urine production (especially nocturnal),
other comorbidities, and programmed cell death (apoptosis)
[33]. However, what are the ultimate pathophysiologic
effects of aging on the human bladder and do they contribute to overactivity? In a study of 15 human detrusor biopsies
in elderly patients (12 women and three men), Elbadawi et
al. [34] identified a dysjunctional pattern with protrusion
junctions, widened intracellular spaces, muscle and axonal
degeneration, and ultra-close cell abutments that they postulated to be the driving force behind DO in these patients.
Some of these pathologic findings were duplicated in a
different subset of seven patients (six men and one woman)
with urodynamically proven bladder outlet obstruction [35].
DO in the aging bladder, similar to the obstructed unstable
bladder, may be related to a shift from a purely cholinergic to
a partially purinergic receptor profile [36]. The clinical relevance of further discoveries relating to the etiology of OAB
remains to be seen. Currently, our pharmacologic armamentarium for OAB is limited to one class of drugsanticholinergic therapy. Anticholinergic therapy often is employed as a
first-line empiric therapy in women without any additional
evaluation; however, in men, we must at least consider the
role of outlet obstruction in the disease process before instituting therapy. The next section discusses the evaluation of
men who present with OAB syndrome.

Evaluation
Unlike that for BPH, there are no expert-panel recommended guidelines for evaluating the male patient with
OAB. However, the American Urological Association
(AUA) Guideline on the Management of Benign Prostatic
Hyperplasia can serve as a framework for the evaluation of
any male patient who presents with LUTS [37]. The panels
recommendation for initial evaluation includes a history
and physical examination, with a focused neurologic and
digital rectal examination to estimate prostate size. Urinalysis also was recommended to screen for hematuria and
urinary tract infection. Prostate-specific antigen testing
should be offered to select men, including those with a life
expectancy greater than 10 years and for those in whom the
prostate-specific antigen result may change the management of their voiding symptoms. The patient should
complete the AUA symptom index (or IPPS) to assess the
severity of symptoms and monitor treatment results. Urine
cytology, although optional, should be ordered for men
with predominantly storage symptoms to rule out transitional cell carcinoma. All other testing, including
noninvasive uroflowmetry and postvoid residual (PVR)
determination, is considered optional. A voiding diary may
be useful to corroborate the patients symptoms and better
quantify the number of daytime and nighttime voids, fluid

413

intake, and associated symptoms such as urgency and

incontinence episodes.
The primary goal of any additional evaluation should be
to diagnose or rule out bladder outlet obstruction that may
be the cause of or be the contributing factor to the pathogenesis of OAB. This is vital for several reasons. First and foremost, treatment of men with bladder outlet obstruction and
OAB will commonly involve medical or surgical treatment of
the outlet obstruction because 50% of these patients will
have resolution of storage symptoms in addition to the beneficial impact on emptying symptoms [32]. Restoration to
lower voiding pressures also should prevent further detrimental changes to the bladder. Second, we can better counsel
patients regarding outcomes of outlet reduction surgery
(particularly with respect to their storage symptoms) after
determining the severity of their obstruction. For example,
Machino et al. [38] performed urodynamic evaluation before
and after transurethral resection of the prostate (TURP) in 62
patients and found that patients with preoperative DO without clear evidence of obstruction had the worst outcomes.
Third, men with outlet obstruction theoretically may be at
higher risk of urinary retention when treated with anticholinergic therapy, although this has not been demonstrated in a
randomized, controlled trial.
Measurement of noninvasive urinary flow and PVR measurement are useful screening tests in men who present with
OAB syndrome. Because uroflowmetry cannot differentiate
bladder outlet obstruction from impaired contractility,
numerous authors have attempted to correlate maximum
flow rate values on uroflowmetry with a definitive diagnosis
of bladder outlet obstruction on pressure-flow studies.
Reynard et al. [39] calculated sensitivities of 82% and 47%
and specificities of 38% and 70% for noninvasive maximum
flow rate values of 15 mL/sec and 10 mL/sec, respectively.
Porru et al. [40] correctly identified 32 of 37 (86.4%) patients
with bladder outlet obstruction by using a combination of
maximum flow rate less than 10 mL/sec with IPSS higher
than 16. PVR measurement also may be a useful adjunct in
these patients. PVR higher than 50 mL has been associated
with an increased risk of BPH complications [41], but no
definitive correlation has been made with the severity of outlet obstruction or LUTS [42]. However, larger residual volumes may be associated with a sensation of incomplete
emptying and thus may contribute to storage symptoms.

Pressure-flow urodynamics
The purpose of the initial evaluation of the male OAB patient
is to identify and quantify the patients symptoms and to
exclude known causes. The urologist then should attempt to
classify patients as likely obstructed or nonobstructed because
this will significantly alter treatment decisions. We have found
pressure-flow urodynamic studies (PFUDs) useful in several
circumstances. PFUDs are the gold-standard study to document high-pressure, low-flow voiding that defines bladder
outlet obstruction. Simultaneous fluoroscopic imaging
(videourodynamics) also should provide information regard-

414

Overactive Bladder

Figure 1. Algorithm for the evaluation of overactive bladder in the male patient. BOObladder outlet obstruction; OABoveractive bladder;
PVRpostvoid residual.

ing the anatomic site of obstruction. In younger men with

LUTS in whom BPH is less likely, videourodynamics may be
warranted because primary bladder neck obstruction may be
present in almost 50% of the patients [43]. In men with
persistent LUTS after prostatectomy, further testing will be
quite useful to determine the etiology of the symptoms. Half
of these patients will have persistent DO, but approximately
16% will have residual obstruction [32,44]. For the OAB
patient, the examiner also may gain useful information about
the nature of DO. Hyman et al. [17] evaluated 160 neurologically intact men with LUTS; 43% overall had DO and 68%
had bladder outlet obstruction (of whom 46% also had DO).
There was a strong correlation between urge incontinence and
DO. Wadie et al. [45] evaluated 459 men over the age of 45
years with PFUDs and found that patient perception of urge
and urodynamic severity of bladder outlet obstruction correlated strongly with the presence of DO. PFUDs also will help
differentiate OAB due to DO from abnormalities of compliance or sensation. The examiner always should keep in mind
that the absence of DO does not exclude its existence, and
vice versa. For this reason, we do not routinely use PFUDs to
diagnose DO specifically.

Treatment
Based on the above evaluation, it is possible to divide male
OAB patients into the following four separate groups:

obstructed patients with low PVR (< 40% of functional

capacity); obstructed patients with high PVR; nonobstructed patients with low PVR; and nonobstructed
patients with high PVR. Evaluation and management of
patients in these four groups is summarized in Figure 1;
this is a modification of the algorithm introduced by
Gonzalez and Te [46] in 2003. At best, these are rough
guidelines; variability in symptoms, degree of bother,
severity of obstruction, response to treatment, and
patients willingness to accept different forms of therapy
will all affect therapeutic choices.

Bladder outlet obstruction with

overactive bladder and low postvoid residual
Because most men with LUTS who seek medical attention
will have bladder outlet obstruction, this represents the
most common clinical scenario. In general, these men
should be treated first with respect to the cause of outlet
obstruction. We discussed previously that at least half of
all men will have resolution of their storage symptoms
after a surgical procedure. Delay in relieving the obstruction may result in worsening of OAB and may make it
irreversible. Although older men have been shown to
have a lower rate of resolution of DO after TURP than
younger men [47], this may have as much to do with the
affects of aging on the bladder as the duration of obstruc-

Overactive Bladder in the Male Patient Jaffe and Te

tion. In a study that removes the effects of aging, Leng et

al. [48] retrospectively reviewed the outcomes of 15
female patients after urethrolysis for post-sling voiding
dysfunction. Patients were stratified into two outcome
groups after urethrolysis: seven who did not have persistent symptoms and eight who required anticholinergic
therapy for irritative symptoms. The only statistically significant difference between the two groups was time to
urethrolysis with a mean of 9 months in group 1 and
31.25 months in group 2. In a perhaps more pertinent
study of male patients, de Nunzio et al. [49] restudied 101
patients a mean of 24 months after their original
evaluation for LUTS. Eighty percent of these patients had
received surgical or medical therapy for BPH in the interval. Eleven of 20 patients in the no treatment group had
DO on follow-up urodynamic study, including all nine
who had it previously. There was a trend toward lower
rates of DO in the medical treatment group and the transurethral incision group, and a statistically significant difference was noted when compared with the TURP group.
Patients with BPH/LUTS who are candidates for medical therapy usually are started on -blockade, which has
well-documented effects on obstructive voiding symptoms
and parameters. Although many men will have persistent
storage symptoms after treatment, urologists traditionally
were reticent to place these men on anticholinergic therapy
because of the risk of urinary retention. This concern
specifically was put to rest by Abrams et al. [50] in a randomized, placebo-controlled study. Tolterodine 2 mg was
administered twice daily to men with bladder outlet
obstruction and DO. Men with residuals higher than 40%
of the cystometric capacity and those with a history of
prostate or bladder surgery were excluded. Medical treatment for BPH was not permitted during the study. Of 221
patients, only one in each group suffered from acute urinary retention during the 3-month study period and the
tolterodine group had a only a mild mean increase (25
mL) in PVR compared with placebo. Maximum flow rates
and maximum detrusor pressure at maximum flow essentially were identical between the two groups at the end of
the study. However, it should be kept in mind that patients
with larger residuals were excluded from this study. There
is only one randomized study that has assessed the efficacy
of combination therapy with -blockade and anticholinergic therapy in this group of patients. Athanasopoulos et
al. [51] observed 50 consecutive men with mild or moderate bladder outlet obstruction and DO during a 3-month
study. Exclusion criteria included glaucoma, severe
obstruction, previous prostate or bladder surgery, neurourologic disease, bladder or prostate cancer, or medical
therapy for BPH in the preceding 3 months. All of the
patients were administered tamsulosin 0.4 mg daily for 1
week and then randomized into two equal groups. The first
group continued on tamsulosin while the second group
also was treated with tolterodine 2 mg twice daily. No placebo was used. No episodes of urinary retention were

415

noted. The mean PVR in both groups before treatment was

27 mL. Both groups had statistically significant improvements in maximum flow rate and volume at first involuntary contraction. In group 2 versus group 1, there was a
statistically significant increase in cystometric capacity and
a decrease in maximum involuntary contraction pressure
and volume at first involuntary contraction. Group 2 also
had a statistically significant increase in a BPH-related
quality-of-life questionnaire scores from baseline when
compared with group 1 at the end of treatment. Even the
patients receiving tamsulosin monotherapy had an
increase in the volume at first involuntary contraction
(197227 mL). Indeed, there are studies that show that blockade has a significant impact on symptom scores in
men, even in the absence of obstruction [52]. In addition
to their relaxation effects on prostatic smooth muscle, blockers may have effects on the storage function of the
lower urinary tract at the bladder or spinal cord level.
Although the -1A receptor subtype predominates in prostatic smooth muscle, the -1D predominates in the bladder
and spinal cord [53]. All of the commercially available
agents block both receptors.
Although these initial studies are encouraging, this
area of pharmacotherapy is still in its early stages of
development and several questions remain unanswered.
What is the long-term safety and efficacy of anticholinergic or combination therapy? Are either of these
treatment choices safe for men with larger residual or
severe degrees of obstruction? Are anticholinergic agents
other than tolterodine more or less effective/safe? At our
current state of knowledge, it is reasonable to recommend
that men with bladder outlet obstruction and OAB be
treated surgically or medically first for outlet obstruction.
If OAB persists, anticholinergic therapy should be instituted with regular monitoring of residual volumes. In
obstructed men with predominant storage symptoms or
severe OAB, it may be reasonable to institute anticholinergic therapy up front. A small number of patients may
benefit from monotherapy with anticholinergic medication, although this has not been well studied in the long
term. These men, as discussed previously, risk deterioration and permanency of their storage symptoms.

Bladder outlet obstruction with overactive bladder

and high postvoid residual
Patients with evidence of significant obstruction and
elevated residual urine volumes should be evaluated first
for outlet reduction measures. Although urinary retention remains a hard indication for TURP, some of these
patients may be treated successfully with pharmacotherapy initially. Monotherapy with anticholinergic
medication is unwise in this subset of patients because,
theoretically, they are at the highest risk for urinary retention. After outlet reduction measures, these patients can
be restratified into one of the next two groups and
treated accordingly.

416

Overactive Bladder

Nonobstructed with low postvoid residual

These patients with true idiopathic OAB generally can be
treated in a similar fashion to female patients with OAB.
The efficacy and safety of anticholinergic therapy is well
documented in mixed populations [54]. Men who do not
respond to initial therapy may be candidates for other
therapies, including botulinum toxin and other intravesical agents, neuromodulation, vasopressin therapy, and
even augmentation cystoplasty.
Nonobstructed with high postvoid residual
From a treatment standpoint, this represents the most
challenging group of patients. There obviously is no clear
role for outlet reduction surgery and there are no data to
support the safety of anticholinergic therapy for these
patients. Many of these patients will have, by definition,
detrusor hyperactivity with impaired contractility, a term
coined by Resnick and Yalla [55] in 1987 to describe a condition in elderly patients with DO and elevated PVR in the
absence of obstruction. The etiology of this counterintuitive condition is unknown; however, it is likely caused by a
combination of pathologic alterations that are seen in the
aging bladder, as discussed previously. Regardless, it is reasonable to start these patients on a trial of anticholinergic
therapy, with close attention being paid to their PVR.
Patients may need adjunctive measures to improve their
emptying ability, including intermittent catheterization. In
our experience, many patients suffer no ill-effects from
even large residual urine volumes, as long as bladder compliance is normal and they are not prone to urinary tract
infections. We also have treated some patients with a combination of outlet reduction surgery, biofeedback (to teach
pelvic floor relaxation techniques), and Valsalva or crede
voiding. One intriguing concept would be to treat these
patients with sacral neuromodulation; this has proven to
be efficacious for OAB symptoms and for urinary retention
in nonobstructed patients [56]. However, most of the
patients treated for retention have been women and there
may be some difficulties with stimulation settings for treating both disorders simultaneously.

Conclusions
Men who present to a urologist complaining of LUTS
frequently will be diagnosed with OAB syndrome and
obstruction secondary to BPH. A smaller number may have
OAB without evidence of obstruction. Although treatments
should be individualized based on type and severity of
symptoms, bother, and presence or absence of obstruction,
some generalizations can be made. Men with documented
outlet obstruction should be treated with medical or surgical therapy as appropriate because many of them will have
improvement or resolution of the OAB component. Anticholinergic therapy in patients with bladder outlet obstruction has been shown to be safe and effective in the short
term, either alone or in combination with -blockade. It is

useful as first-line therapy or for patients with residual

symptoms after prostatectomy. Male patients with OAB
without obstruction generally can be treated in a similar
fashion to female OAB patients.
We have learned a great deal from the laboratory
regarding the pathophysiology of DO and the alterations
in bladder outlet obstruction models. However, most of
this work has not been transformed into advances in the
treatment of these patients.

References and Recommended Reading

Papers of particular interest, published recently,
have been highlighted as:

Of importance
Of major importance
1. Abrams P, Cardozo L, Fall M, et al.: The standardization of
terminology of lower urinary tract function: report from
the Standardisation Sub-committee of the International
Continence Society. Neurourol Urodyn 2002, 21:167178.
This is essential reading for anyone and everyone who treats patients
with LUTS. Urologists should be encouraged to adopt the standardized
terminology set forth by the leading experts in voiding dysfunction.
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This is the first and only large-scale population-based study in the
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15.

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This is an extremely thorough study and review of the pathologic
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48. Leng WW, Davies BJ, Tarin T, et al.: Delayed treatment of bladder outlet obstruction after sling surgery: association with
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The tolterodine group had better overall symptom improvement in
addition to the moderate urodynamic benefits.

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52.

Overactive Bladder

Gerber G, Kim J, Contreras B, et al.: An observational

urodynamic evaluation of men with lower urinary tract
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53. Schwinn DA, Price DT, Perinchery N: Alpha-1 adrenoreceptor
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This is an extensive review on the title topic by one of the leading
scientists in the field.

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Herbison P, Hay-Smith J, Ellis G, et al.: Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive bladder: systematic review. BMJ 2003, 326:841844.
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