Overactive bladder in men: symptoms, causes and treatment

The bladder is a muscular bag that normally relaxes while it fills. Patient.info explains that in overactive bladder the muscle squeezes suddenly, without control, and when the bladder is not full, and that in most people no clear cause is found. It adds that OAB is more common in women than in men but can affect men, and that it is not due to a urine infection or an enlarged prostate in the strict definition of the syndrome.

In men, bladder symptoms are grouped as storage symptoms and voiding symptoms. Patient.info says storage symptoms include increased frequency, urgency, urge incontinence and needing to get up to pass urine at night, while voiding symptoms include poor stream, hesitancy, intermittent flow and straining. OAB mainly causes storage symptoms; an enlarged prostate more commonly produces voiding symptoms, although the two often occur together.

Patient.info lists the symptoms of overactive bladder as urgency, a sudden urgent desire to pass urine that cannot be put off; frequency, going more often than normal, usually more than eight times a day; nocturia, waking more than once at night to pass urine; and urge incontinence, which is leaking of urine, sometimes in large amounts, before you can get to the toilet. It describes latch-key urgency, the urgent need as you arrive home.

Age matters. Patient.info says that at the age of 65 and over it can be normal to pass urine at least once a night because the body finds it harder to reduce night-time urine production. Symptoms can be worsened by stress, caffeine and alcohol, according to the same source.

Patient.info says the cause of OAB syndrome is not fully understood, and that in most cases the reason is unknown. In some people, symptoms follow a nerve- or brain-related disease such as stroke, Parkinson's disease, multiple sclerosis or a spinal cord injury, which is termed neurogenic OAB, and similar symptoms can occur with a urine infection or a bladder stone.

In men, other causes of urinary symptoms have to be considered. The Patient.info guide to lower urinary tract symptoms in men lists an enlarged prostate gland, overactive bladder and water balance problems as the most common causes, and less common causes including diabetes, urinary infections, bladder stones, prostate cancer, bladder cancer and neurological conditions. Medicines can also contribute; NICE recommends reviewing current medication, including herbal and over-the-counter medicines.

NICE guideline CG97 on lower urinary tract symptoms in men sets out the initial assessment: a general medical history to identify possible causes and other conditions, a review of current medicines, a physical examination including the abdomen and external genitalia and a digital rectal examination, a urinary frequency volume chart for bothersome symptoms, and a urine dipstick test to detect blood, glucose, protein, leucocytes and nitrites. It says men should be given information, advice and time to decide whether they wish to have a PSA test if symptoms suggest benign prostate enlargement, the prostate feels abnormal or they are concerned about prostate cancer.

NICE advises against routinely offering cystoscopy, upper tract imaging, flow-rate measurement or post-void residual measurement at the initial assessment of uncomplicated symptoms. It recommends referral for specialist assessment for bothersome symptoms not responding to conservative or drug treatment, and for symptoms complicated by recurrent or persistent urinary infection, retention, suspected kidney impairment from the lower tract or suspected urological cancer. See a GP promptly if you cannot pass urine, see blood in your urine or have pain; Patient.info says that being unable to pass any urine when the bladder feels full and painful needs a doctor immediately.

NICE recommends that men with storage symptoms suggestive of OAB are offered supervised bladder training, advice on fluid intake, lifestyle advice and, if needed, containment products. Patient.info describes self-help for men: reducing drinks in the evening, avoiding fizzy and caffeinated drinks, stopping smoking, sitting to pass urine, bladder training by gradually holding on for longer, distraction techniques for urgency and pelvic floor exercises. For OAB generally, it says bladder training is the main treatment and can work well in up to half of cases, and that normal fluid intake is advised rather than cutting back, because concentrated urine can irritate the bladder.

If symptoms persist, NICE says to offer an anticholinergic to manage OAB symptoms in men, to review men taking anticholinergics every 4 to 6 weeks until symptoms are stable and then every 6 to 12 months, and to consider adding an anticholinergic in men who still have storage symptoms after treatment with an alpha blocker alone, as would be the case where an enlarged prostate is also present. Surgery for storage symptoms is considered only for men whose symptoms have not responded to conservative and drug treatment, with a urologist, who will explain that effectiveness, side effects and long-term risks are uncertain. Containment products, such as pads or external collecting devices, are offered to manage incontinence while a plan is made.

Plan toilet access, know where facilities are on journeys, and use containment products if needed. The NHS says that you should see a GP about any type of urinary incontinence and not feel embarrassed, and that it is a common problem. A continence adviser or specialist physiotherapist can help with bladder training and pelvic floor exercises, as Patient.info describes. Review caffeine, alcohol and evening fluids, and keep a bladder diary, which helps your clinician choose treatment.

GPs manage most men with OAB symptoms, with referral to continence services and urology where needed. The NICE guideline applies in the NHS. Private urology assessment, flow tests and ultrasound are available in the UK and follow similar principles; a PSA test should be preceded by information about its benefits and limits.