What is the cause of persistent urinary frequency, urgency, and dysuria in a 76-year-old female with a history of hypertension, despite antibiotic and antimuscarinic therapy?

From the Guidelines

The patient should undergo a repeat urinalysis and urine culture to rule out persistent infection, and VESIcare (solifenacin) 5 mg once daily is an appropriate treatment for her irritative voiding symptoms. The patient's symptoms of frequency, urgency, and mild post-void pain are consistent with overactive bladder, and the recent urinalysis showing mild pyuria suggests a possible urinary tract infection. However, the patient has already completed a 5-day course of Macrobid, and the symptoms persist. According to the European Association of Urology guidelines on urological infections 1, a urine culture is recommended in situations where symptoms do not resolve or recur within 4 weeks after completion of treatment.

Treatment Options

• VESIcare (solifenacin) is an anticholinergic medication that helps reduce bladder overactivity by blocking muscarinic receptors, decreasing involuntary bladder contractions.
• The patient should be monitored for common side effects, particularly constipation, dry mouth, and blurred vision.
• Since she previously experienced hypertension with Myrbetriq (mirabegron), VESIcare is a reasonable alternative as it works through a different mechanism.
• Adequate hydration should be maintained, but the patient should consider limiting fluid intake in the evening to reduce nighttime frequency.

Follow-up

• A follow-up appointment in one month is appropriate to assess treatment efficacy and review the culture results.
• If symptoms persist despite negative cultures, further urological evaluation may be warranted to rule out other causes of her symptoms, as suggested by the AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder 1.

From the FDA Drug Label

5.1 Increases in Blood Pressure

Mirabegron, like other beta-3 adrenergic agonists, can increase blood pressure.

8.5 Geriatric Use

No dose adjustment is required in geriatric patients.

The patient is a 76-year-old female with a history of hypertension and is currently taking VESIcare for irritative voiding symptoms. Given her history of hypertension, it is essential to consider the potential for increases in blood pressure when prescribing medications.

• The patient had stopped taking Myrbetriq due to hypertension, which suggests that her blood pressure is a concern.
• Mirabegron can increase blood pressure, which may be a concern for this patient. However, the dosage of mirabegron does not need to be adjusted in geriatric patients. Considering the patient's history of hypertension and the potential for mirabegron to increase blood pressure, caution should be exercised when prescribing this medication to this patient 2.

From the Research

Patient's Condition

The patient is a 76-year-old female experiencing frequency and urgency of urination, with mild pyuria on a recent urinalysis. She had taken PO Macrobid for 5 days and stopped taking Myrbetriq due to hypertension.

Treatment and Medications

The patient is currently taking Vesicare tablet 5 mg once daily and Macrobid capsule 100 mg twice a day for 3 days. She was prescribed VESIcare 5 mg once a day for irritative voiding symptoms, and all possible side effects, including constipation, were discussed.

Relevant Studies

• A study published in 2016 3 found that adding mirabegron 50mg to solifenacin 5mg further improved OAB symptoms versus solifenacin 5 or 10mg, and it was well tolerated in OAB patients remaining incontinent after initial solifenacin 5mg.
• Another study published in 2017 4 found that combined therapy with solifenacin 5 mg + mirabegron 25 mg and solifenacin 5 mg + mirabegron 50 mg provided consistent improvements in efficacy compared with the respective monotherapies across most of the outcome parameters.
• A prespecified analysis from the BESIDE study published in 2017 5 found that efficacy and safety in the overall population is maintained in older (≥65 yr) and elderly (≥75 yr) patients treated with a combination of solifenacin and mirabegron, or solifenacin monotherapy.
• A prospective observational study published in 2024 6 found that mirabegron showed maximum improvement in the OAB-V8 scores in patients with OAB syndrome, although the solifenacin group also showed improvement.
• A randomized, multicentre phase 3 study published in 2018 7 found that mirabegron and solifenacin combination treatment for OAB symptoms was well tolerated over 12 mo and led to efficacy improvements over each monotherapy.

Key Findings

• Combination therapy with solifenacin and mirabegron may be effective in improving OAB symptoms, including frequency and urgency of urination.
• The combination therapy was well tolerated in older patients, including those aged 76 years.
• Mirabegron may have a better safety profile compared to solifenacin, with fewer adverse drug reactions reported.
• The efficacy and safety of combination therapy were maintained over a 12-month period.

Possible Treatment Options

• Continue VESIcare 5 mg once a day for irritative voiding symptoms.
• Consider adding mirabegron to the patient's treatment regimen to improve OAB symptoms.
• Monitor the patient's response to treatment and adjust the medication regimen as needed.