In an older man on tamsulosin for BPH who is presenting with recurrent falls, how do you manage the medication, in light of urinary symptom control and fall risk?

Tamsulosin carries the risk of orthostatic hypotension and falls, especially in older adults¹. In the situation of an older adult man taking tamsulosin for BPH symptoms who is presenting with recurrent falls, I would first check orthostatic vitals and if positive, I would discuss this finding with the patient and his family/caregiver(s) and weigh the risk of recurrent falls (with continuing the tamsulosin) against the risk of enduring BPH symptoms (with discontinuing the tamsulosin). Even if the orthostatic vitals were normal, I would have this risk-benefit discussion. A large population-based cohort study found that tamsulosin was associated with a small but statistically significant risk of falls in older men². A review in JAMA also corro...

Tamsulosin increases the risk of orthostatic hypotension and falls. While untreated lower urinary tract symptoms, including urgency, frequency, incontinence, and nocturia, are also associated with a high risk of falls. In some cases, BPH leads to AKI and functional incontinence with poor quality of life.

Beta-3 agonists may be beneficial in an overactive bladder. 5 alpha reductase inhibitors take months to take effect and are not effective when used as monotherapy. Tamsulosin remains the mainstay of the treatment for BPH-induced bothersome LUTS after lifestyle modifications and behavioral interventions.

Orthostatic hypotension is most often a treatable condition. You can start with encouraging hydration and salt intake, an abdominal binder,...

When managing LUTS (lower urinary tract symptoms), the standard of care is to treat empirically, based on a presumptive diagnosis of obstruction (then offer behavioral management followed by alpha blockers, 5 alpha reductase inhibitors, or phosphodiesterase type 5 inhibitors) or overactive bladder (then offer behavioral management and pelvic floor exercises, followed by a beta-3 agonist). These are generally low-risk interventions.

However, when there is a serious risk, such as falls in the elderly, then it is more important to make a precise diagnosis of obstruction versus overactive bladder versus polyuria versus sleep disorder versus other uncommon causes of LUTS. Alternatively, one could decide that the risk of any treatment may be unne...

A physical examination including orthostatics, DRE, and an ultrasound of the residual or pelvic US, as well as a urinalysis and/or culture if necessary, would be fundamental in the evaluation and then treatment of a patient in this situation. Prostate volume may predict outcome of treatment with five DHT inhibitors. Consideration of a voiding diary may help assess total fluid intake. Knowing the amount of time a person is resting in bed may also be useful. A surprisingly large portion of elderly men and women will get up once or twice at night to urinate. Congestive heart failure and treatment with diuretics may also precipitate nocturia, and sometimes adjusting the dose or timing of dosing may relieve symptoms of nocturia. One can always c...