In males over 50, how do you tell the difference between prostatism (LUTS) and irritable bladder syndrome, and how do you manage the symptoms? Grant Gibbings, MD, White Rock, BC

An enlarged prostate can choke the urinary passage and create symptoms that are obstructive, i.e. weak stream, slow start, interrupted stream, and feeling of incomplete emptying of the bladder. There can also be irritative symptoms, i.e., having to go frequently, urgently, and often during the night. Usually, when the urethra is choked by an enlarged prostate, there are both types of symptoms.

For the obstructive symptoms, use alpha I blockers, like tamsulosin (Flomax) or alfuzosin (Xatral) to relax the choking muscles. When the prostate is sufficiently enlarged (> 35 g), add a 5-alpha reductase inhibitor like finasteride (Proscar) or dutasteride (Avodart) to the regime.

When the irritative symptoms are sufficiently bothersome, pills for the unstable bladder, like oxybutynin (Ditropan) are added. Oxybutynin can be associated with cognitive dysfunction, and a very dry mouth. Detrol and Vesicare have largely replaced oxybutynin, and even better drugs are on the horizon.

There was a time when this family of drugs were discouraged for this indication because of concerns over urinary retention. We now know that we can safely use these medications for men with an enlarged prostate. Of course, they’re also used for women with unstable bladder.

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