A 70-year-old man seeks advice for continuing bladder problems. Over the last several years, the patient has had a slow decrease in the volume and force of his urinary stream associated with nocturia and urinary frequency. When seen in the office 12 months ago, his American Urological Association symptom score was 18 (indicating significant symptoms). Digital rectal examination showed a slightly enlarged, smooth, nontender prostate. Urinalysis and prostate-specific antigen were normal. The patient was prescribed a long-acting alpha adrenergic blocker and his symptoms improved. However, he now has intermittent urinary incontinence associated with a strong urge to void. This usually occurs when he senses a full bladder, but it is also triggered by the sound of running water or with exposure to cold. Limiting his fluid intake and scheduling himself to void frequently have not helped. The patient has had no associated dysuria and has not added any new medications in the past year.
Genitourinary examination including prostate examination is unchanged from a year ago. Urinalysis is normal. Ultrasound bladder scan estimates a residual urine volume of 60 mL.
Which of the following is the best next step in management of this patient's urinary symptoms?

Question

A 70-year-old man seeks advice for continuing bladder problems.  Over the last several years, the patient has had a slow decrease in the volume and force of his urinary stream associated with nocturia and urinary frequency.  When seen in the office 12 months ago, his American Urological Association symptom score was 18 (indicating significant symptoms).  Digital rectal examination showed a slightly enlarged, smooth, nontender prostate.  Urinalysis and prostate-specific antigen were normal.  The patient was prescribed a long-acting alpha adrenergic blocker and his symptoms improved.  However, he now has intermittent urinary incontinence associated with a strong urge to void.  This usually occurs when he senses a full bladder, but it is also triggered by the sound of running water or with exposure to cold.  Limiting his fluid intake and scheduling himself to void frequently have not helped.  The patient has had no associated dysuria and has not added any new medications in the past year.
Genitourinary examination including prostate examination is unchanged from a year ago.  Urinalysis is normal.  Ultrasound bladder scan estimates a residual urine volume of 60 mL.
Which of the following is the best next step in management of this patient's urinary symptoms?

Quizplus · Accepted Answer

11ec193a_98f6_52b3_853d_21dbaba46925_MD0002_00 This patient has benign prostatic hyperplasia (BPH) and initially had typical obstructive voiding symptoms (eg, nocturia, decreased force of stream). However, he has developed urge incontinence, which is caused by detrusor hyperactivity leading to involuntary urine leakage associated with a sudden urge to void. The causes of detrusor hyperactivity are not always apparent, although it frequently occurs in the setting of neurologic disorders and urinary tract infections. Initial management of urge incontinence should include behavioral modification (eg, bladder training, fluid management strategies). Some men with urge incontinence in the setting of BPH may see improvement with alpha-adrenergic antagonist therapy (eg, terazosin, tamsulosin). Persistent symptoms often respond to antimuscarinic agents (eg, tolterodine, oxybutynin). Low-dose antimuscarinic drugs have been shown to be safe and effective for urge incontinence in men with underlying BPH; however, postvoid residual volume (PVR) should be measured prior to initiating therapy. Antimuscarinic agents should be used with caution to avoid causing urine retention in patients with PVR >200 mL. Common side effects include dizziness, dry mouth, and constipation. (Choice A) 5-alpha reductase inhibitors (eg, finasteride) improve lower urinary tract symptoms in men with BPH and large prostate volumes. However, these agents require several weeks to work and are not effective in men without large prostate volumes, such as this patient. (Choice C) It is unlikely that switching to another alpha-adrenergic blocking agent would improve this patient's urge incontinence symptoms. (Choice D) Sacral nerve stimulation via surgical lead placement is the most common and effective long-term surgical intervention for urge incontinence, but it is reserved for patients who fail combined medical therapy. (Choice E) Urodynamic studies provide information on bladder sensation, capacity, detrusor activity, outlet obstruction, and urine flow. However, these tests are invasive and are reserved for evaluation of individuals with unclear or possible multifactorial etiology. Educational objective: Urge incontinence in the setting of benign prostatic hyperplasia (BPH) often responds to alpha-adrenergic blockers. Antimuscarinic agents can be added for patients with persistent symptoms, but postvoid residual volume should be measured before initiating these medications in men with BPH. __________ References: The use of pharmacotherapy for male patients with urgency and stress incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/25144147)

A 70-Year-Old Man Seeks Advice for Continuing Bladder Problems