2.2. Complications

Anticholinergic use in men with overactive bladder (OAB) and benign prostatic hyperplasia (BPH) carries specific risks that require careful consideration. Acute urinary retention is a significant concern, as men with enlarged prostates are at a high risk of developing this condition while taking anticholinergics. This can lead to bladder distension, severe pain, and the need for catheterization. Incomplete bladder emptying, another potential side effect, may predispose patients to recurrent urinary tract infections (UTIs), particularly in those with obstructive uropathy. Additionally, anticholinergics can exacerbate prostate-related symptoms, such as urinary hesitancy, a weak urinary stream, and post-void dribbling, further complicating the management of men with coexisting OAB and BPH. These risks highlight the importance of thorough patient evaluation and monitoring when considering anticholinergic therapy.

2.3. Contraindications

Anticholinergics are contraindicated in men with:

Severe Benign Prostate Hyperplasia: These medications can exacerbate obstructive symptoms and lead to acute urinary retention.

Angle-Closure Glaucoma: Anticholinergics can increase intraocular pressure, making them unsuitable for patients with this condition.

Cognitive Impairment: In elderly men, anticholinergics may worsen existing cognitive decline or precipitate new cognitive symptoms.

Gastrointestinal Conditions: Disorders such as severe constipation or intestinal obstruction may be worsened by the reduced motility effects of anticholinergics.

2.4. Current Recommendations for Men with OAB and Enlarged Prostate

Given the potential risks, anticholinergics should only be prescribed to men with benign prostatic hyperplasia (BPH) after careful evaluation. This includes a thorough assessment of post-void residual (PVR) urine volume to rule out significant urinary retention. Alternative treatments, such as beta-3 adrenergic agonists, are often preferred initially due to their favorable safety profile. In cases where anticholinergics are necessary, co-prescription with alpha-blockers, such as tamsulosin, can help mitigate obstructive symptoms, provided the patient is closely monitored. The cautious use of anticholinergics, combined with regular follow-ups and comprehensive patient education, is essential to achieve effective symptom relief while minimizing the risk of complications in men with overactive bladder (OAB).

3. Neuromodulation

Techniques like sacral nerve stimulation (SNS) or genital nerve stimulation (GNS) can regulate bladder function.

Neuromodulation has emerged as a highly effective and minimally invasive treatment for Overactive Bladder (OAB) in men, particularly for those who have not responded to lifestyle modifications, medications, or behavioral therapies. By targeting the nerves that regulate bladder function, neuromodulation offers symptom relief while minimizing the systemic side effects associated with pharmacological treatments.

3.1. Sacral Nerve Stimulation (SNS) – Medtronic / Boston Scientific

Sacral neuromodulation (SNS) is a treatment method that involves implanting a small device to deliver mild electrical pulses to the sacral nerves, which play a key role in controlling bladder and pelvic floor function.
Clinical studies have demonstrated the efficacy of SNS in significantly reducing urgency, frequency, and episodes of urinary incontinence in men with overactive bladder (OAB). The procedure is typically carried out in two phases: an initial surgical trial phase (test-electrode are implanted at the sacral nerves under anesthesia, mostly general anesthesia) to evaluate the treatment’s effectiveness, followed by a permanent implantation phase if the trial is successful. While complications are rare, they may include pain at the implantation site, infection,
or device malfunctions.

3.2. Genital Nerve Stimulation (GNS) – Neurogyn AG

Genital nerve stimulation (GNS) targets the genital nerves located in front of the pubic bone, providing an alternative pathway for managing bladder overactivity and incontinence. In addition to these benefits, GNS can also address erectile dysfunction and intestinal disorders, such as fecal incontinence. This technique is particularly valuable for men with concurrent pelvic nerve dysfunction or neuropathic bladder. One of the key advantages of GNS is that it does not require a surgical trial phase. The stimulation of the genital nerves can be easily tested using two adhesive skin electrodes placed near the genital organs and a TENS device. This simplifies the process and significantly reduces the overall costs of GNS therapy compared to sacral neuromodulation (SNM). The final implantation of the neuromodulator is minimally invasive and can be completed under local anesthesia in less than 10 minutes using a percutaneous puncture technique of implantation of the stimulation’s lead electrode, with the device placed behind the pubic bone. Since the procedure requires no surgical dissection, GNS is associated with fewer adverse effects than SNS and can be performed as an outpatient procedure.

GNS is often recommended for men with overactive bladder (OAB) and enlarged prostate.

3.3. Percutaneous Tibial Nerve Stimulation (PTNS)

Percutaneous tibial nerve stimulation (PTNS) is a less invasive neuromodulation technique that involves stimulating the tibial nerve using an electrode placed near the ankle. The tibial nerve shares pathways with the pelvic nerves, enabling indirect modulation of bladder activity. PTNS is particularly suitable for men with milder symptoms of overactive bladder (OAB) or as a preliminary step before considering permanent neuromodulation implants. This approach offers a promising and less invasive treatment option for managing bladder dysfunction.

3.4. Indications, advantages and complications of neuromodulation

Neuromodulation is a therapeutic option for managing overactive bladder (OAB) and bladder dysfunction in men, particularly when other treatments have proven ineffective. It is typically considered when medications fail to provide adequate relief or cause intolerable side effects. Additionally, neuromodulation becomes a viable option when OAB symptoms severely impair a man’s quality of life, leading to sleep disturbances, social withdrawal, or difficulties at work. It is also recommended for men with underlying conditions such as complications from prostate surgery, spinal cord injuries, or neuropathies that contribute to bladder dysfunction.
Neuromodulation offers several key benefits. It serves as a non-pharmacological approach, reducing dependence on medications and their potential side effects. Many neuromodulation treatments, particularly genital nerves stimulation (GNS), are reversible or adjustable, ensuring flexibility if the therapy is not well tolerated. The targeted nature of neuromodulation allows for precise symptom relief by directly modulating nerve activity.
Importantly, it has minimal impact on sexual function, unlike some medications for OAB or benign prostatic hyperplasia (BPH), which may negatively affect erectile function or libido. In contrast, GNS has shown potential to improve erectile function and possibly enhance libido. While neuromodulation is generally effective, it is not without challenges.

Technical issues, such as device malfunctions or electrode dislodgement (commonly seen in sacral neuromodulation), may require reprogramming or surgical intervention. Implantation procedures carry a small risk of infection, emphasizing the need for proper wound care and monitoring. A subset of patients may not experience sufficient symptom relief, even after completing the trial phase. Additionally, the initial cost of neuromodulation therapies can be high (SNS, GNS 60% cheaper). However, these treatments are often cost-effective in the long term due to reduced reliance on medications and the significant improvement in quality of life they provide.

Overall, neuromodulation represents a promising and adaptable treatment option for men with OAB and bladder dysfunction, particularly in cases where conventional therapies have failed.

Long-Term Outcomes and Follow-Up
Men undergoing neuromodulation require regular follow-ups to monitor device performance and symptom management. While in GNS patients can control own neuromodulation (preprogrammed setting), periodic adjustments to the stimulation parameters may be necessary after SNS to optimize efficacy. Studies indicate high patient satisfaction rates, with many reporting sustained symptom relief over several years.

Neuromodulation represents a promising frontier in the treatment of OAB in men, offering a blend of efficacy, safety, and precision. With advancements in technology and techniques, it is becoming an increasingly accessible
option for patients seeking lasting relief from OAB symptoms.

4. Botox Injections:

Botulinum Toxin A (Botox) has emerged as a highly effective treatment for Overactive Bladder (OAB), particularly in cases where medications fail to provide adequate relief or cause intolerable side effects. Botox works by temporarily paralyzing the bladder muscle (detrusor), reducing overactivity and improving symptoms of urgency, frequency, and incontinence.

4.1 How Botox Works

Botulinum Toxin A (Botox) works by blocking the release of acetylcholine at the neuromuscular junction, which relaxes the bladder muscle and prevents involuntary contractions. The treatment is administered through a minimally invasive procedure in which Botox is injected directly into the detrusor muscle using a cystoscope. This procedure is typically performed under local anesthesia, ensuring both precision and patient comfort.

4.2. Benefits of Botox for Men with OAB

Botulinum Toxin A (Botox) offers significant benefits for men with overactive bladder. It can effectively reduce urinary urgency, frequency, and episodes of incontinence, providing substantial symptom relief. Many patients also experience an improved quality of life following treatment, with better sleep, increased confidence, and fewer disruptions to their daily activities. Although the effects are temporary, typically lasting between 6 and 12 months, the procedure can be safely repeated as needed to maintain these benefits.

4.3. Complications and Side Effects

Although generally considered safe, Botox treatment is associated with some potential complications. The most common side effect in men is urinary retention, particularly in those with pre-existing urinary obstruction, such as an enlarged prostate, which may necessitate intermittent self-catheterization. There is also an increased risk of urinary tract infections (UTIs), often linked to incomplete bladder emptying or catheter use. Mild bleeding (hematuria) can occur after the procedure, but it is typically self-limiting and resolves without intervention. In rare but severe cases, bladder overdistension may occur, which can potentially lead to bladder
damage if not addressed promptly.

4.4. Contraindications of Botox in Men with OAB

Botox is contraindicated or used with caution in the following scenarios : 

 Benign Prostatic Hyperplasia (BPH):

o Men with an enlarged prostate are at higher risk for urinary retention following Botox injections.
o Caution is required, and pre-treatment evaluation of post-void residual (PVR) volume is essential.
o Botox is often avoided in severe cases of BPH unless the obstruction is addressed (e.g., with alpha-blockers or surgical intervention).

 Neuromuscular Disorders:

o Conditions like Myasthenia Gravis, Amyotrophic Lateral Sclerosis (ALS), or Lambert-Eaton Syndrome may be exacerbated by Botox.

o These disorders increase the risk of systemic botulinum toxin spread, leading to generalized muscle weakness.

Active Urinary Tract Infection:

o Botox should not be administered if there is an active UTI, as it may worsen the infection or
delay healing.
o Prophylactic antibiotics are often prescribed to reduce the risk of post-procedure infection.

Anticoagulant Therapy:

o Men on blood thinners (e.g., warfarin or direct oral anticoagulants) are at increased risk of bleeding during or after the procedure. Temporary cessation of anticoagulants may be recommended, but this should be coordinated with the prescribing physician.

Previous Allergic Reactions:

o A history of hypersensitivity to botulinum toxin or its components is a contraindication.

Bladder Outlet Obstruction:

o Incomplete bladder emptying due to anatomical or functional obstruction may worsen after Botox treatment. A thorough urological assessment is essential.

Elderly Patients with Limited Mobility:

o Men who have difficulty performing self-catheterization may not be ideal candidates for Botox, as urinary retention may necessitate catheter use.

4.5. Special Considerations for Men

Proper preparation and monitoring are essential for men undergoing Botox treatment for overactive bladder.
Pre-treatment counseling is crucial to ensure patients are fully informed about potential risks, including urinary retention and the possibility of requiring intermittent catheterization. Post-treatment care involves regular follow-
ups, including assessments of post-void residual (PVR) volumes and monitoring for infections, to ensure safety and effectiveness. For men with both overactive bladder (OAB) and benign prostatic hyperplasia (BPH), combining Botox with alpha-blockers or other complementary therapies can optimize treatment outcomes whileminimizing associated risks.

5. Surgical Options

For rare, severe cases, surgical interventions such as bladder augmentation or urinary diversion may be
considered.