The Case of the Stop and Go Pills

Phil Casey ran into some bad luck recently. Like many men in their sixties, he has an enlarged prostate, which slows his urine flow. He’s on medication to ease his symptoms, and it works pretty well.

But Phil ran out of his tamsulosin last Thursday and his urologist’s office did not renew the prescription before the weekend. A minor, unfortunate hiccup, it seemed.

Tamsulosin is a GO-pill for men in his predicament. It relaxes the muscles within the prostate gland and bladder. This helps improve speed and completeness of bladder emptying and reduces delayed start and afterdrip

That interruption may not have caused much trouble if it wasn’t for another unfortunate coincidence.

Phil threw his back out over the weekend. In the back of his medicine cabinet was a bottle of cyclobenzaprine, a muscle relaxer he had taken for back spasms in 2018.

Cyclobenzaprine’s powerful anticholinergic effects can slow urine flow. It is a powerful STOP-pill for men like Phil. The fact that he took this medication when his tamsulosin had just run out was a case of double trouble, a hackneyed “perfect storm” for urinary retention.

The better his back felt, the slower his urine flow got. Monday morning, in my office, his blood pressure was high and his lower abdomen sore with a palpable bladder.

His urologist is 20 miles away. They agreed to see him as soon as he could get there. We don’t have catheters in our office like we used to in the old days. I actually also remember when we got rid of the spinal needles 35 years ago. You just don’t do spinal taps in the office anymore. That’s a very good thing. But I’m not so sure we shouldn’t have some Foley catheters, just in case.


GO-pills that improve urine flow are mostly peripheral alpha blockers like tamsulosin, doxazosin and terazosin. Finasteride and its sister drugs, which also end in -steride, don’t do much in the short run but may slow down worsening of symptoms over time. Then there is tadalafil, a cousin of sildenafil (Viagra) that can also help.

STOP-pills come from several drug classes, from those that are pure anticholinergics to those with anticholinergic side effects

Anticholinergic drugs inhibit salivation, stomach acid production, urination and bowel movements. They are used to treat intestinal cramps (dicyclomine) and frequent urination (Toviaz and many others but not Myrbetriq). The motion sickness patch scopolamine is an anticholinergic. Cogentin (benztropine), used to stop involuntary movements from antipsychotics or Parkinson’s disease is also an anticholinergic.

Other medications with anticholinergic side effects men with prostate problems need to be careful with are older antidepressants like amitriptyline (closely related to cyclobenzaprine) and older antihistamines like diphenhydramine (Benadryl).

What about inhaled anticholinergics, commonly used to treat COPD?

I don’t know how often they cause full blown urinary retention, but I have seen it at least once, in a patient whose COPD and Beningn Prostatic Hyperplasia (BPH) were equally severe.

On the other hand, I once used an anticholinergic inhaler to control severe acid reflux in a patient!

Inhaler Cures GERD?(!)

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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