Efficacy and safety of tolterodine extended-release in men with overactive bladder symptoms treated with an α-blocker: effect of baseline prostate-specific antigen concentration

Chronic kidney disease, preoperative use of antispasmodics and lower resected prostate volume ratios are risk factors for postoperative use of adrenergic Alpha-blockers and antispasmodics

OBJECTIVES

Transurethral resection of prostate (TURP) and laser prostate surgery are common surgeries for benign prostate hyperplasia (BPH). We conducted an investigation using hospital database to evaluate the clinical factors associated with post-operative usage of alpha-blockers and antispasmodics.

METHODS

This study was conducted using retrospective clinical data from the hospital database, which contained newly diagnosed BPH patients between January 2007 and December 2012 who subsequently received prostate surgery. The study end-point was the use of alpha-blockers or antispasmodics for at least 3 months duration after 1 month of surgery. The exclusion criteria was prostate cancer diagnosed before or after the surgery, recent transurethral surgeries, history of open prostatectomy, and history of spinal cord injury. Clinical parameters, including age, body mass index, preoperative prostate specific antigen value, comorbidities, preoperative usage of alpha-blockers, anstispasmodics and 5-alpha reductase inhibitors, surgical methods, resected prostate volume ratios, and preoperative urine flow test results, were evaluated.

RESULTS

A total of 250 patients receiving prostate surgery in the database and confirmed pathologically benign were included. There was significant association between chronic kidney disease (CKD) and the usage of alpha-blockers after prostate surgery (OR = 1.93, 95% CI 1.04-3.56, p = 0.036). Postoperative antispasmodics usage was significantly associated with preoperative usage of antispasmodics (OR = 2.33, 95% CI 1.02-5.36, p = 0.046) and resected prostate volume ratio (OR = 0.12, 95% CI 0.02-0.63, p = 0.013).

CONCLUSIONS

BPH patients with underlying CKD were more likely to require alpha-blockers after surgery. In the meantime, BPH patients who required antispasmodics before surgery and who received lower prostate volume resection ratio were more liable to antispasmodics after prostate surgery.

Detrusor Overactivity May Be a Prognostic Factor for Better Response to Combination Therapy Over Monotherapy in Male Patients With Benign Prostatic Enlargement and Storage Lower Urinary Tract Symptoms

Purpose

Several trials have shown that in men with overactive bladder (OAB) and benign prostate enlargement (BPE), the combination of an α-blocker with an anticholinergic is superior to α-blocker monotherapy. The purpose of this study is to explore whether urodynamic detrusor overactivity (DO) affects clinical outcomes in men with BPE and OAB.

Methods

This is a post hoc analysis of a prospective, randomized trial, designed to evaluate the changes of morphometric parameters of the prostate following monotherapy or combination therapy in men with BPE-OAB. The initial study recruited men aged ≥50 years, with BPE and predominantly storage lower urinary tract symptoms (LUTS). Patients were randomized to receive tamsulosin monotherapy or a combination of tamsulosin and solifenacin for 26 weeks. All participants completed a 3-day bladder diary and the International Prostate Symptom Score (IPSS), and then underwent pressure-flow and ultrasonographic studies. Data were stratified and analysed based on the urodynamic observation of DO at baseline (DO vs. non-DO). The primary endpoint was the mean change in urgency episodes from baseline. Secondary outcomes were the changes in nocturia, total IPSS, and urodynamic parameters.

Results

Sixty-nine men were initially randomized, but only 60 men were included in this analysis. Urgency episodes significantly improved in men with DO who received combination therapy compared to the DO monotherapy subgroup (P=0.04) or to the non-DO combination treatment subgroup (P=0.038). Nocturia also improved in the DO combination treatment subgroup as compared to the non-DO combination subgroup (P=0.037). The 24-hour frequency and total IPSS significantly improved from baseline without significant differences among the subgroups.

Conclusions

The present study suggests that baseline DO could be a prognostic factor for a better response to combination therapy over monotherapy in men with BPE and storage LUTS.

[Male non-neurogenic overactive bladder]

INTRODUCTION

Male lower urinary tract symptoms (LUTS) and in particular overactive bladder (OAB) are a frequent reason for consultation in urology and have a significant functional impact in patients.

OBJECTIVE

To synthesize current knowledge on non-neurogenic OAB in male patients.

METHOD

A systematic literature review based on Pubmed, Embase, Google Scholar was conducted in June 2020.

RESULTS

The prevalence of OAB and benign prostatic hyperplasia increases with age. Symptoms of OAB, on the one hand, and symptoms of prostatic bladder outlet obstruction, on the other hand, can be concomitant and the causal link between the two types of symptoms is difficult to establish. In case of mixed symptoms, it is recommended to treat the most troublesome type of symptoms first and to inform the patient of the risks of failure or deterioration. Indeed, many patients remain symptomatic after prostate surgery and the predictive factors for failure remain to be defined. Thus, preoperative urodynamics is not routinely performed even in case of OAB. De novo detrusor overactivity after radical prostatectomy can reach 77% and persists in the majority of cases. The overall relative risk of storage symptoms after radiotherapy and brachytherapy is higher than that after prostatectomy. The etiology of OAB after prostate surgery is multifactorial. While drug treatments have proven to be effective, little data exists on second-line treatments for OAB after prostate surgery.

CONCLUSION

OAB in men is often linked to a prostatic bladder outlet obstruction. It is essential to inform patients about the possibility of persistence, deterioration, or occurrence of OAB after prostate surgery while the predictors of surgical failure are not clearly defined.

Benign Prostatic Hyperplasia: A Brief Overview of Pathogenesis, Diagnosis, and Current State of Therapy

As prostatic artery embolization is assuming an increasingly important role in the management of benign prostatic hyperplasia, it is important for the practicing interventional radiologist to have a deep understanding of all aspects of the disease process and the available treatment options. This paper provides a comprehensive overview of the pathophysiology, diagnosis and management options for benign prostatic hyperplasia with an emphasis on the surgical and medical treatments.

Review of the epidemiology of overactive bladder

Overactive bladder (OAB) is common in both men and women. It is a symptom complex that causes significant detriment to quality of life in patients. Although the prevalence of OAB is similar in both sexes, there are sex-specific differences in individual symptoms and the impact on quality of life. The coexistence of benign prostatic hyperplasia with OAB can worsen quality of life in men. This review examines the major studies that looked at the epidemiology of OAB as it relates to both sexes. It focuses on both the overall prevalence rates and the incidence of individual symptoms. This paper also addresses the level of bother and quality of life in men and women with OAB. In addition, the relationship between OAB and benign prostatic hyperplasia is reviewed.

A Randomized, Open-Label, Comparative Study of Efficacy and Safety of Tolterodine Combined with Tamsulosin or Doxazosin in Patients with Benign Prostatic Hyperplasia

Background

Benign prostatic hyperplasia (BPH), a common disease in men over age 50 years, often causes bladder outlet obstruction and lower urinary tract symptoms (LUTS). Alpha blockers in combination with muscarinic receptor antagonists may have the potential to improve symptoms. This study aimed to assess the efficacy and safety of doxazosin or tamsulosin combined with tolterodine extend release (ER) in patients with BPH and LUTS.

Material/Methods

In a prospective, randomized, open-label study (ChiCTR-IPR-15005763), 220 consecutive men with BPH and LUTS were allocated to receive doxazosin 4 mg and tolterodine ER 4 mg per day (doxazosin group) or tamsulosin 0.2 mg and tolterodine ER 4 mg per day (tamsulosin group). Treatment lasted 12 weeks. The primary endpoint was the international prostatic symptom score (IPSS). Secondary endpoints were quality of life (QoL) and maximum flow rate (Q_max), which were evaluated at 0, 6, and 12 weeks, and urodynamic parameters assessed at 0 and 12 weeks.

Results

A total of 192 patients completed the trial. Baseline measurements showed no differences between the groups. After 6 weeks, IPSS improved in both groups and QoL was significantly better in the doxazosin group (P=0.01). After 12 weeks, Q_max, IPSS, QoL, intravesical pressure (Pves), and bladder compliance (BC) in the doxazosin group were significantly better than in the tamsulosin group (P=0.03, P<0.001, P<0.001, P=0.027, and P=0.044, respectively).

Conclusions

Administration of alpha blockers combined with muscarinic receptor blocker for 12 weeks improved LUTS in men with BPH.

Urinary incontinence in men: current and developing therapy options

INTRODUCTION

Urinary incontinence in men is a significant and often underappreciated problem. Men can have urgency and or stress incontinence. Urgency incontinence as part of the overactive bladder (OAB) syndrome and can often coexist with benign prostatic obstruction (BPO) in men and the initial treatment of this is conservative lifestyle changes and then medical therapy.

AREAS COVERED

This literature review aims to cover synthetic drugs currently utilised to treat urinary incontinence in men that are phase III and onwards. Neurological incontinence and surgical treatment options for male urinary incontinence are beyond the scope of this review.

EXPERT OPINION

The most common form of urinary incontinence in men is urgency incontinence secondary to an OAB, which often co-exists in men, with bladder outflow obstruction (BOO). The pharmacotherapy options to treat OAB include antimuscarinics, β3 agonists and phosphodiesterase inhibitors. Antimuscarinics and β3 agonists are effective in treating OAB, and have been found to have no increased urinary retention risk in the group of patients with co-existing BPO. Emerging medications include the alternative β3 agonists - solabegron and ritobegron. The future may include novel combinations of these therapies.

Defining response and non-response to treatment in patients with overactive bladder: a systematic review

OBJECTIVE

There is currently a lack of formal guidance for assessing treatment response and non-response in patients with overactive bladder (OAB). Such guidance would be useful for both clinical practice and the design of clinical trials. Our purpose was to review and assess definitions of treatment response and non-response used in patients with OAB.

METHODS

We conducted a systematic review of articles published between January 1, 2005 and August 8, 2013 using PubMed. Search terms included (overactive bladder) AND ('treatment response' OR responder OR success OR satisfied OR goal OR refractory OR nonresponder OR fail OR persistent OR dissatisfied). Limits were 'humans' and 'English'. Studies conducted in subjects with neurogenic detrusor overactivity, conditions other than OAB, or OAB symptoms following lower urinary tract/pelvic surgery were excluded; case reports and letters were also excluded.

RESULTS

The literature search returned 423 articles, of which 75 met the inclusion criteria and defined a specific threshold by which treatment response or non-response was determined for patients receiving behavioral therapy and/or treatment with an antimuscarinic, β3-agonist, botulinum toxin, or neural stimulation. One published abstract from congress proceedings and three additional articles that were not identified by the search were included; thus, a total of 79 records were included. A wide variety of symptom-based definitions and patient-reported outcomes (PROs) were used. Symptom-based definitions frequently used a threshold of 50-100% improvement in general or specific symptoms; urgency urinary incontinence (UUI) was often used in studies with incontinent patients. Definitions based on PROs frequently used measures of satisfaction, general improvement, or goal achievement. Studies of patients with refractory OAB often referred to a failure to respond to ≥1 other therapy, or to poor efficacy or unacceptable tolerability, without further specification. Limitations of this review are that only English language articles were included and that only the PubMed database was used for the literature search.

CONCLUSIONS

There is considerable heterogeneity in the definitions of treatment response and non-response in trials of patients with OAB; some standardization would be beneficial. However, there is also heterogeneity among patients of what constitutes treatment success or failure, and conceptualizations of treatment response and non-response in both clinical trials and clinical practice must take patient characteristics into account. For patients with UUI, it is recommended that the criteria for treatment response include this symptom, as measured by change in the absolute number of UUI episodes or achievement of continence, given its impact on patients' lives and associated bother. PROs provide important information that confirm symptom-based measures by demonstrating that observed changes in symptoms are meaningful to the patient. In clinical practice, measures of treatment satisfaction and goal achievement can be highly useful.

Predictors of successful first-line antimuscarinic monotherapy in men with enlarged prostate and predominant storage symptoms

OBJECTIVE

To identify predictors of successful first-line antimuscarinic monotherapy for patients with enlarged prostate and predominant storage symptoms.

METHODS

Men aged ≥ 50 years with total International Prostate Symptom Score (IPSS-T) ≥ 8, total prostate volume (TPV) ≥ 20 mL, IPSS quality of life (QOL) index ≥ 2, IPSS voiding to storage (IPSS-V/S) subscore ratio ≤ 1, and post-void residual (PVR) ≤ 250 mL were recruited into a prospective open-label study. All men received tolterodine ER (4 mg) daily. Global response assessment (GRA) ≥ 1 after treatment was considered successful treatment and an indication for continued antimuscarinic monotherapy.

RESULTS

One hundred ninety-seven men aged 50-89 years (average TPV 44.4 mL) received first-line tolterodine monotherapy. Mean IPSS-T, IPSS storage (IPSS-S) subscore, and QOL improved significantly at 2, 4, and 12 weeks. Average PVR increased significantly; no patient developed acute urinary retention. One hundred thirty-six patients (69.0%) showed improvement (GRA ≥ 1) at both 2 and 4 weeks. Regression analysis showed that IPSS-S (P = .039) and maximum urine flow (Qmax, P = .033) were significant predictors of therapeutic success. Patients with smaller baseline TPV, higher IPSS-S, and higher Qmax had significantly higher treatment success rates.

CONCLUSION

First-line antimuscarinic monotherapy is safe and effective within 12 weeks in selected patients with benign prostatic hyperplasia (BPH) Higher baseline IPSS-S, higher baseline Qmax, and lower TPV were predictors of successful antimuscarinic monotherapy.

Systematic review of combination drug therapy for non-neurogenic male lower urinary tract symptoms

BACKGROUND

Several drugs are approved for the treatment of lower urinary tract symptoms (LUTS) in men, but these are mostly used by clinicians as monotherapies. The combination of different compounds, each of which targets a different aspect of LUTS, seems appealing. However, only few clinical trials have evaluated the effects of combination therapies.

OBJECTIVE

This systematic review analyzes the efficacy and adverse events of combination therapies for male LUTS.

EVIDENCE ACQUISITION

PubMed and Cochrane databases were used to identify clinical trials and meta-analyses on male LUTS combination therapy. The search was restricted to studies of level of evidence ≥ 1b. A total of 49 papers published between January 1988 and March 2012 were identified.

EVIDENCE SYNTHESIS

The α1-adrenoceptor antagonist (α1-blocker)/5α-reductase inhibitor (5-ARI) combination provides the most data. This combination seems to be more efficacious in terms of several outcome variables in patients whose prostate volume is between 30 ml and 40 ml when treatment is maintained for >1 yr; when given for <1 yr, α1-blockers alone are just as effective. The combination of α1-blocker/5-ARI shows a slightly increased rate of adverse events. It remains unknown whether its safety and superiority over either drug as monotherapy are sustained after >6 yr. The α1-blocker/muscarinic receptor antagonist (antimuscarinic) combination was most frequently assessed as an add-on therapy to already existing α1-blocker therapy. Inconsistent data derive from heterogeneous study populations and different study designs. Currently, the α1-blocker/antimuscarinic combination appears to be a second-line add-on for patients with insufficient symptom relief after monotherapy. The combination seems to be safe in men with postvoid residual <200 ml. However, there are no trials >4 mo concerning safety and efficacy of this combination. The α1-blocker/phosphodiesterase type 5 inhibitor combination is a new treatment option with only preliminary reports. More studies are needed before definitive conclusions can be drawn.

CONCLUSIONS

An α1-blocker/5-ARI combination is beneficial for patients whose prostate volume is between 30 ml and 40 ml when medical treatment is intended for >1 yr. Based on short-term follow-up studies, add-on of antimuscarinics to α1-blockers is an option when postvoid residual is <200 ml.

[Update of the usefulness of α-blockers in the treatment of different urologic pathologies]

OBJECTIVE

To review the role of α-blockers in various urological conditions such as benign prostatic hyperplasia, overactive bladder, chronic prostatitis, and erectile dysfunction and as expulsive treatment of distal ureteral stones.

MATERIAL AND METHODS

We reviewed the latest scientific evidence in all the fields mentioned above, performing a critical analysis.

CONCLUSION

α-blockers are now considered first-line treatment in lower urinary tract symptoms secondary to benign prostatic hyperplasia, but the indications go beyond, and are able to improve, alone or in combination with other drugs, the previously mentioned pathologies. The uroselective properties of some α-blockers make them a highly safe medication.

Therapeutic effect of α-blockers and antimuscarinics in male lower urinary tract symptoms based on the International Prostate Symptom Score subscore ratio

AIMS

To investigate if the International Prostate Symptom Score (IPSS) voiding-to-storage subscore ratio (IPSS-V/S) can help to guide the treatment for male lower urinary tract symptoms (LUTS).

METHODS

Men aged 40 years or older with a total IPSS (IPSS-T) 8 or more were constitutively enrolled from January 2010 to December 2010. The IPSS voiding (IPSS-V) and storage subscore (IPSS-S) were recorded separately, and the IPSS-V/S was calculated. Patients were divided into two groups according to the baseline IPSS-V/S value. First-line doxazosin (4 mg per day) and tolterodine (4 mg per day) monotherapy were given to patients with IPSS-V/S > 1 and IPSS-V/S ≤ 1, respectively. The IPSS-T, IPSS-V, IPSS-S, quality of life (QoL), maximum flow rate (Qmax), voided volume and postvoid residual (PVR) were measured at 1 month (visit 1) and 3 months (visit 2) after treatment.

RESULTS

After medical treatment for 1 month, 89/116 (76.7%) patients receiving tolterodine and 218/279 (78.1%) patients receiving doxazosin reported an improved outcome (global response assessment, GRA ≥ 1 point). The mean IPSS-T, IPSS-S decreased, and QoL improved significantly in both groups. Significant increased Qmax, voided volume, decreased IPSS-V and PVR were noted only in patients receiving doxazosin. There was no significant increase of PVR (from 50.1 to 60.4 ml, p = 0.106), and no patient developed urinary retention after tolterodinie monotherapy for 1 month. However, patients aged more than 70 years had significant association with increased PVR (≥ 50 ml).

CONCLUSION

Initial treatment with doxazosin for patients with IPSS-V/S > 1 and tolterodine for patients with IPSS-V/S ≤ 1 is safe and feasible. Elderly people (≥ 70 years) and patients with Qmax < 10 ml/s are more likely to have increased PVR (≥ 50 ml).

Nocturia in older men

Nocturia is a common and bothersome symptom that impacts on sleep-quality and quality of life. Nocturia often has a multi-factorial etiology which makes thorough assessment of the complaint indispensable. This review summarizes the definition of nocturia, its epidemiology, clinical presentation, pathophysiology, diagnostics, and treatment options with special reference to older men. Nocturia is defined as a nocturnal voiding frequency of two or more, based on impact on quality of life. It is very prevalent in older men. Apart from the negative effects of sleep-disruption, it may be a risk-factor for hip fractures and increased mortality. Most common causes are: nocturnal polyuria, 24-h polyuria, overactive bladder (sometimes due to BPH) and sleep disturbance. A clear understanding of the etiology in the individual patient is indispensable when addressing the various possible causes and co-morbidities. Most important tool for this is the frequency-volume chart, but also patient history, physical examination and serum analysis. For treatment, lifestyle adjustments are often helpful. Medical therapy with 5-alpha reductase inhibitors, alpha-blockers, a combination of the two, or anti-muscarinics, has a limited effect. Most important medical option is desmopressin (arginine vasopressin analogue); however, treatment with this drug is limited to men under 65 years mainly due to the risk of hyponatraemia.

Add-on fesoterodine for residual storage symptoms suggestive of overactive bladder in men receiving α-blocker treatment for lower urinary tract symptoms

Study Type - Therapy (RCT) Level of Evidence 1b What's known on the subject? and What does the study add? Male lower urinary tract symptoms are often attributed to bladder outlet obstruction secondary to benign prostatic hyperplasia and treated with drugs targeting the prostate. However, many men with storage lower urinary tract symptoms may not respond adequately to these agents. Antimuscarinics, with or without an α-blocker, may be effective for the treatment of the storage symptoms of overactive bladder in some men. Flexible-dose fesoterodine as an add-on treatment significantly improved urinary frequency and symptom bother, but not urgency episodes (primary endpoint), versus add-on placebo and was well tolerated in men with persistent overactive bladder symptoms despite receiving α-blocker.

OBJECTIVE

• To evaluate flexible-dose fesoterodine vs placebo in men with persistent overactive bladder (OAB) symptoms despite receiving α-blocker treatment

SUBJECTS AND METHODS

• This was a double-blind, 12-week, flexible-dose trial. • Men with persistent storage symptoms (≥ 8 micturitions and ≥ 3 urgency episodes per 24 h) after receiving an α-blocker for ≥ 6 weeks were randomized to add-on fesoterodine 4 mg or placebo, with optional dose escalation to 8 mg at week 4 and reduction back to 4 mg at week 8 (or matching placebo adjustments). • Subjects completed 3-day diaries, International Prostate Symptom Score (IPSS), Overactive Bladder Questionnaire (OAB-q), Patient Perception of Bladder Condition (PPBC), and Urgency Perception Scale (UPS) at baseline and weeks 4 and 12.

RESULTS

• A total of 943 men were randomized and received at least one dose of study treatment (fesoterodine, n= 471; placebo, n= 472). • Among these, 251 (53%) in the fesoterodine group and 300 (64%) in the placebo group requested dose escalation at week 4 and 35 (7%) and 15 (3%) requested dose reduction at week 8. Changes from baseline to week 12 in urgency episodes (primary endpoint) in the fesoterodine (-3.2) and placebo (-2.9) groups were not significantly different (P= 0.196), but improvements in micturitions (P= 0.009) and OAB-q symptom bother score (P= 0.007) were significantly greater with fesoterodine. • At week 4, significantly greater improvements in micturitions (P= 0.006), severe urgency episodes (P= 0.006), IPSS storage score (P= 0.022), OAB-q symptom bother score (P= 0.004), and OAB-q health-related quality of life (P= 0.041), but not urgency episodes (P= 0.062), were observed with add-on fesoterodine. • Dry mouth (fesoterodine, 21%; placebo, 6%) and constipation (fesoterodine, 6%; placebo, 2%) were the most common adverse events. Dysuria and urinary retention were reported by 3% and 2% of subjects, respectively, in the fesoterodine add-on group vs 1% and <1% of subjects, respectively in the placebo add-on group. One subject in each group had acute urinary retention requiring catheterization.

CONCLUSIONS

• Flexible-dose fesoterodine was well tolerated as an add-on treatment in men with persistent storage symptoms. • Changes in urgency episodes at week 12 (primary endpoint) and many secondary endpoints were not significantly different between fesoterodine and placebo add-on treatment; however, improvements in frequency and symptom bother were significantly greater with fesoterodine. • These data suggest that there remains a limited understanding of the optimal evaluation and treatment of men with LUTS.

The role of antimuscarinics in the management of men with symptoms of overactive bladder associated with concomitant bladder outlet obstruction: an update

CONTEXT

This review focuses on the contemporary role of antimuscarinics in the management of men with symptoms of bladder outlet obstruction (BOO) and concomitant overactive bladder (OAB). Safety issues of antimuscarinics in this subpopulation of men are also reviewed.

OBJECTIVE

We reviewed the current literature and performed an analysis of the efficacy, suitability, and the safety of antimuscarinics in this subpopulation of men.

EVIDENCE ACQUISITION

We performed a systematic search of Medline/PubMed, Embase, Scopus, and the Cochrane Database of Systematic Reviews for relevant articles published between 1990 and September 2010, restricted to studies in humans published in English. In addition, published abstracts presented at the annual meetings of the European Association of Urology, the American Urological Association, and the International Continence Society in the last decade (2000-2010) were hand-searched and evaluated. Each article's title and abstract were reviewed for their appropriateness and relevance to the use of antimuscarinics in patients with BOO and concomitant OAB. Relevant articles were fully reviewed and included in the final data acquisition.

EVIDENCE SYNTHESIS

Treatment options include combination treatment with α-blockers and antimuscarinics, sequential use of α-blockers and antimuscarinics, monotherapy with antimuscarinics, and a combination of antimuscarinics and 5α-reductase inhibitors. The sequential use of α-blockers and antimuscarinics seems to be the most appropriate approach, and the use of antimuscarinics and α-blockers appears generally to be safe and efficacious. Data are insufficient for a possible stratification of patients for a specific sequence of the drugs reviewed.

CONCLUSIONS

This review infers that the existing data confirm the safety of antimuscarinics administered for the treatment of these patients. The efficacy of antimuscarinics has been proven in different trials regarding different storage symptom end points, but not all end points regarding OAB reached significance. All the reported trials are of short duration (4-12 wk) and include only men with low postvoid residual urine volumes at baseline (<200ml). Overall, the addition of an antimuscarinic to the treatment of a patient with BOO and concomitant OAB seems to offer an amelioration of the symptoms and a moderate improvement in quality of life.

Antimuscarinics for treatment of storage lower urinary tract symptoms in men: a systematic review

Despite potential benefits, primary care clinicians may avoid using antimuscarinics in men with overactive bladder (OAB) symptoms because of safety concerns. To review the efficacy and safety of antimuscarinics, alone or in combination with an α-blocker, for the treatment of men with OAB symptoms, we conducted a systematic review of articles published before 22 July 2010, using PubMed. Data from 12-week, randomised, double-blind, placebo-controlled trials of tolterodine extended release (ER), oxybutynin and solifenacin show that combined antimuscarinic+α-blocker treatment is generally more effective than monotherapy or placebo in men with OAB symptoms. The efficacy and safety of tolterodine ER+α-blocker treatment was not affected by prostate size or prostate-specific antigen (PSA) level. In men meeting entry criteria for OAB and benign prostatic obstruction trials, tolterodine ER alone was effective selectively in men with prostate size or PSA level below study medians. Incidence of acute urinary retention (AUR) in men receiving antimuscarinics with or without an α-blocker was ≤3% in all of these trials; changes in postvoid residual volume and maximum flow rate did not appear clinically meaningful. Post hoc analyses from double-blind, placebo-controlled trials and prospective studies of fesoterodine, oxybutynin, propiverine, solifenacin and tolterodine also suggest that antimuscarinics are generally safe and efficacious in men. A retrospective database study found that risk of AUR in men was the highest in the first month of treatment and decreased considerably thereafter. Antimuscarinics, alone or with an α-blocker, appear to be efficacious and safe in many men with predominant OAB symptoms or persistent OAB symptoms despite α-blocker or 5-α-reductase inhibitor treatment. However, antimuscarinics are not approved for the treatment of benign prostatic hyperplasia. Monitoring men for AUR is recommended, especially those at increased risk, and particularly within 30 days after starting antimuscarinic treatment.