What are the next steps for a 62-year-old male with persistent incontinence despite taking oxybutynin (antimuscarinic agent) 15 mg Extended Release (ER) orally daily?

Management of Persistent Incontinence in a 62-Year-Old Male on Oxybutynin ER

For a 62-year-old male with persistent urinary incontinence despite oxybutynin 15 mg ER daily, the next step should be to consider third-line therapies such as sacral neuromodulation (SNS) or peripheral tibial nerve stimulation (PTNS), as antimuscarinic therapy has failed to provide adequate symptom control.

Assessment of Current Treatment Failure

Before proceeding to advanced therapies, evaluate the following:

• Verify adherence to current medication regimen
• Assess for anticholinergic side effects (dry mouth, constipation, blurred vision, cognitive effects)
• Rule out urinary retention with post-void residual measurement
• Consider urodynamic testing to characterize the type of incontinence (stress vs. urgency vs. mixed)

Treatment Algorithm

Step 1: Optimize Current Therapy

• Consider switching to an alternative antimuscarinic with a different side effect profile:

  • Tolterodine may cause fewer adverse effects than oxybutynin 1
  • Solifenacin has the lowest risk for discontinuation among antimuscarinics 1
  • Trospium may be preferred in older adults due to reduced cognitive effects 1

• Consider transdermal oxybutynin if oral side effects are intolerable 2

Step 2: Add Behavioral Therapies (if not already implemented)

• Bladder training for urgency incontinence 3
• Pelvic floor muscle training 3
• Weight loss and exercise if patient is obese 3

Step 3: Third-Line Therapies

• Sacral neuromodulation (SNS) is recommended for patients with severe refractory symptoms who are willing to undergo a surgical procedure 3
• Peripheral tibial nerve stimulation (PTNS) can be offered as an alternative third-line treatment 3
• OnabotulinumtoxinA injections may be considered, with patient counseling about the potential need for self-catheterization 3

Special Considerations for Male Patients

For male patients specifically:

• Rule out bladder outlet obstruction due to prostatic hyperplasia
• Consider combination therapy with an alpha-blocker (e.g., tamsulosin) if there are both storage and voiding symptoms 3
• Evaluate for post-prostatectomy incontinence if relevant to patient history

Monitoring and Follow-up

• If switching to another antimuscarinic, monitor for:

  • Anticholinergic side effects, especially in older adults 1, 4
  • Signs of urinary retention, particularly with bladder outlet obstruction 4
  • Cognitive changes, which are more common with oxybutynin than other agents 1

• If proceeding to third-line therapy:

  • For SNS: Patient must accept contraindication for MRI below the head 3
  • For PTNS: Patient must be willing to comply with frequent office visits 3

Cautions and Contraindications

• Avoid antimuscarinic agents in patients with:

  • Narrow-angle glaucoma unless approved by ophthalmologist 3
  • Significant gastric emptying problems 3
  • History of urinary retention 4

• Consider cognitive impact of antimuscarinic therapy, especially in older adults 1

• If all conservative and second-line therapies fail, consider referral to a urologist for evaluation for artificial urinary sphincter, particularly if the patient has stress incontinence after prostate treatment 3