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Year : 2006  |  Volume : 22  |  Issue : 3  |  Page : 284-285

Anticholinergic in bladder outflow obstruction: Is it the last straw on the camel's back?

Department of Urology, Christian Medical College, Vellore, India

Correspondence Address:
J C Singh
Department of Urology, Christian Medical College, Vellore
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How to cite this article:
Singh J C, Kekre N S. Anticholinergic in bladder outflow obstruction: Is it the last straw on the camel's back?. Indian J Urol 2006;22:284-5

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Singh J C, Kekre N S. Anticholinergic in bladder outflow obstruction: Is it the last straw on the camel's back?. Indian J Urol [serial online] 2006 [cited 2022 Jul 4];22:284-5. Available from:

Abrams P, Kaplan S, De Koning Gans HJ, Millard R. Safety and tolerability of tolterodine for the treatment of overactive bladder in men with bladder outlet obstruction. J Urol 2006;175:999-1004.

   Summary Top

The objective of this prospective randomized trial[1] was to study the effect of antimuscarinics on detrusor contraction and voiding. Men above 40 years of age with urinary frequency and urgency and urodynamically proven detrusor instability were included in the study. Extent of bladder outlet obstruction (BOO) was measured using the bladder outflow obstruction index. All participants underwent urodynamic evaluation at entry and 12 weeks after enrolment. Those who underwent prior procedures for BOO, high postvoid residue, recent retention, indwelling catheter or self catheterization, recent bladder training, treatment with 5 alpha reductase inhibitors or other investigational drugs were excluded. Urodynamic evaluation was done initially at inclusion and subsequently after 12 weeks. After an initial run-in period, subjects were randomized in a 2:1 ratio to either 2 mg twice daily tolterodine or placebo for 12 weeks. Assuming that the difference of 3 ml per second maximum flow rate (Qmax) and 15 cm water detrusor pressure at maximum flow (PdetQmax) between the two groups was equivalent, a sample size of 85 and 170 in the placebo and tolterodine group respectively was arrived at for 90% power and unequal size study groups at 2:1 ratio. Baseline data were comparable and 87% completed the study. There was no significant difference in Qmax or PdetQmax after 12 weeks of tolterodine. Volume to first detrusor contraction and maximum cystometric capacity were significantly increased in the tolterodine group compared to the placebo group after 12 weeks. Though the postvoid residue was larger after 12 weeks in the tolterodine group, it was not considered clinically significant. The bladder contractility index decreased in the tolterodine group and this was attributed to the greater decrease in PdetQmax. Adverse effect profile was similar except for dry mouth which was complained by 24% in the tolterodine group and 1.4% in the placebo group. After treatment with tolterodine, no aggravation of voiding difficulties was noted. Hence the authors have concluded that tolterodine is safe in men with urodynamically documented DO and mild to severe BOO.

   Comments Top

BOO, a common cause of lower urinary tract symptoms (LUTS) / benign prostatic hyperplasia (BPH) symptoms, often produces detrusor instability, a common cause of overactive bladder (OAB) symptoms. This overlap in the types of symptoms in LUTS/BPH and the OAB is hardly surprising because BOO and detrusor instability may coexist in the same man.[2] In men with BPH or BOO, storage symptoms are mainly attributable to detrusor instability, which is thought to occur in up to 40 to 60% of patients.[3] Though it was earlier suggested that the addition of an anticholinergic would theoretically increase the chance of developing acute urinary retention,[4],[5] this has not been observed in clinical studies.[6] Large tolerability and safety studies of anticholinergic drug treatment, which include many men (many of whom are likely to have BOO) suggest that anticholinergic medication is likely to be safe in men with LUTS/BPH.[7] In another study done on men who were being treated for BOO, addition of 2 mg tolterodine twice daily to 0.4 mg tamsulosin daily was found to significantly improve QOL in patients with overactive bladder and BOO, compared to patients treated with tamsulosin monotherapy.[6] The present study was conducted among men presenting primarily with voiding symptoms and only 15% of the participants had severe obstruction. The study by Athanapoulos et al[6] included only men with mild or moderate obstruction. Hence it is unclear if these results can be generalized to men primarily presenting with voiding symptoms with documented severe obstruction.[7] The effect of varying the dose of tolterodine was studied by Larsson et al[8] in overactive bladder. The incidence of acute urinary retention was higher in the group which was on 4mg twice daily compared to that on 2 mg twice daily of tolterodine in the treatment of overactive bladder. This emphasizes the fact that the response to higher doses of anticholinergics is another area that requires further evaluation. Also, caution has to be exercised in men with significant PVR as there is potential for increased risk of infection, further bladder decompensation or renal insufficiency.[8] Close monitoring is recommended in these patients. Though caution has to be exercised in these specific situations, the existing literature provides clear evidence that the combination of an alpha1-blocker with an anticholinergic extends the ability to manage lower urinary tract symptoms caused by bladder outlet obstruction and overactive bladder syndrome.[9]

   References Top

1.Abrams P, Kaplan S, De Koning Gans HJ, Millard R. Safety and tolerability of tolterodine for the treatment of overactive bladder in men with bladder outlet obstruction. J Urol 2006;175:999-1004.  Back to cited text no. 1    
2.Gosling JA, Kung LS, Dixon JS, Horan P, Whitbeck C, Levin RM. Correlation between the structure and function of the rabbit urinary bladder following partial outlet obstruction. J Urol 2000;163:1349-56.  Back to cited text no. 2    
3.Rosier PF, de la Rosette JJ, Wijkstra H, Van Kerrebroeck PE, Debruyne FM. Is detrusor instability in elderly males related to the grade of obstruction? Neurourol Urodyn 1995;14:625-33.  Back to cited text no. 3    
4.Appell RA. Overactive bladder in special patient populations. Rev Urol 2003;5:S37.  Back to cited text no. 4    
5.British National Formulary. British Medical Association and The Royal Pharmaceutical Society of Great Britain: London; 2003.  Back to cited text no. 5    
6.Athanasopoulos A, Gyftopoulos K, Giannitsas K, Fisfis J, Perimenis P, Barbalias G. Combination treatment with an alpha-blocker plus an anticholinergic for bladder outlet obstruction: A prospective, randomized, controlled study. J Urol 2003;169:2253-6.  Back to cited text no. 6    
7.Reynard JM. Does anticholinergic medication have a role for men with lower urinary tract symptoms/benign prostatic hyperplasia either alone or in combination with other agents? Curr Opin Urol 2004;14:13-6.  Back to cited text no. 7    
8.Larsson G, Hallen B, Nilvebrant L. Tolterodine in the treatment of overactive bladder: Analysis of the pooled phase II efficacy and safety data. Urology 1999;53:990-8.  Back to cited text no. 8    
9.Athanasopoulos A, Perimenis P. Efficacy of the combination of an alpha1-blocker with an anticholinergic agent in the treatment of lower urinary tract symptoms associated with bladder outlet obstruction. Exp Opin Pharmacother 2005;6:2429-33.  Back to cited text no. 9    


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