A man referred with worsening lower urinary tract symptoms has usually had his prostate examined and his flow measured before anyone has looked at his drug chart. That order is backwards, because the drug list is free, immediate, and reversible.
The usual culprits are easy to miss because patients do not think of them as medicines. Anticholinergics - including over-the-counter antihistamines, some antiemetics and tricyclics - worsen voiding and precipitate retention. Diuretics taken in the evening produce nocturia that has nothing to do with the prostate. Calcium channel blockers impair detrusor contractility. Sympathomimetics in cough and cold preparations tighten the bladder neck. And in India, the list must include anything bought without a prescription and anything ayurvedic or herbal, both of which are commonly omitted when a patient is asked what they take.
Ask for the physical packets rather than a recitation. Then look at timing as well as drug: moving a diuretic from evening to morning resolves a proportion of nocturia referrals without a single investigation, and it is worth trying before a bladder diary is even started.
- Ask the patient to bring every packet, including over-the-counter, ayurvedic and herbal preparations
- Look specifically for anticholinergics, calcium channel blockers, sympathomimetics and evening diuretics
- Move evening diuretic doses to the morning before investigating nocturia further
- Ask about drugs taken intermittently - a cold remedy taken for a week can precipitate retention
- Record what you changed and re-assess symptoms before proceeding to flow studies or imaging
Why it matters
The cheapest and most reversible cause of worsening urinary symptoms is the one that is not in the referral letter.
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