Should trospium be continued or discontinued in a patient with urge and stress urinary incontinence?

Discontinue Trospium for Mixed Urge and Stress Incontinence

Trospium should be discontinued in patients with mixed urge and stress incontinence, as antimuscarinics like trospium are only indicated for the urge component and are strongly contraindicated for stress incontinence. The patient should transition to evidence-based nonpharmacologic therapy targeting both components of their mixed incontinence.

Clinical Reasoning

The 2014 American College of Physicians guidelines provide clear, strong recommendations that directly address this scenario 1:

Why Discontinue Trospium

• Trospium is ineffective for stress incontinence: The ACP explicitly states "ACP recommends against treatment with systemic pharmacologic therapy for stress UI" (Grade: strong recommendation, low-quality evidence) 1
• Trospium only addresses urge symptoms: The FDA label confirms trospium is indicated solely for "overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency" 2
• High discontinuation rates: Trospium has a significant adverse effect burden with an NNTH of 56 (CI: 30-228) for discontinuation due to side effects—meaning you need to treat 56 patients for one additional person to stop due to adverse effects compared to placebo 1

What to Do Instead

The evidence-based approach for mixed incontinence is pelvic floor muscle training (PFMT) combined with bladder training 1:

• First-line therapy: "ACP recommends PFMT with bladder training in women with mixed UI" (Grade: strong recommendation, moderate-quality evidence) 1
• Superior safety profile: Nonpharmacologic therapies have "low risk for adverse effects" and are "cheaper than pharmacologic therapies" 1
• Addresses both components: PFMT targets stress incontinence while bladder training addresses urgency symptoms

Treatment Algorithm for Mixed Incontinence

1. Immediately discontinue trospium (ineffective for stress component, adverse effects without full benefit)
2. Initiate PFMT + bladder training as first-line therapy
3. Add weight loss/exercise if obese (Grade: strong recommendation, moderate-quality evidence) 1
4. Consider adding pharmacotherapy ONLY if bladder training fails to control the urge component after adequate trial of behavioral therapy 1

Important Caveats

If Reconsidering Antimuscarinics Later

Should the urge component remain problematic after adequate behavioral therapy trial, the 2024 AUA/SUFU guidelines recommend 3:

• Prefer beta-3 agonists over antimuscarinics due to dementia risk with chronic antimuscarinic use
• Counsel on cognitive risks: "There is evidence to suggest an association between antimuscarinic medications and the development of incident dementia, which may be cumulative and dose-dependent" 3
• If using antimuscarinics: Choose based on tolerability—solifenacin has the lowest discontinuation rate (NNTH: 78), while trospium is intermediate (NNTH: 56) 1

Special Populations

• Elderly patients: Trospium shows similar efficacy but carries cognitive safety concerns with all antimuscarinics in chronic use 3
• Patients on multiple medications: Trospium has fewer drug interactions (not metabolized by CYP450) but still requires caution with 7+ concomitant medications 1

The evidence unequivocally supports discontinuing trospium in favor of combined PFMT and bladder training, which addresses both stress and urge components with superior safety and cost-effectiveness.