What is the recommended management for a 68-year-old male, status post Rezum (transurethral water vaporization) for Benign Prostatic Hyperplasia (BPH) and obstructive symptoms 2 months ago, presenting with worsening urge incontinence over the past month?

Management of Post-REZUM Urge Incontinence

For a 68-year-old male experiencing worsening urge incontinence after REZUM water vaporization for BPH, anticholinergic medication such as tolterodine should be initiated as first-line treatment.

Understanding Post-REZUM Urge Incontinence

Urge incontinence following prostate procedures like REZUM is a recognized complication that can significantly impact quality of life. In this case, the patient is experiencing:

• Worsening urge incontinence for 1 month
• Symptoms severe enough to require diapers day and night
• Symptoms beginning approximately 1 month after REZUM procedure

Diagnostic Considerations

Before initiating treatment, it's important to consider:

• The timing suggests this is likely detrusor overactivity resulting from the REZUM procedure
• REZUM water vapor thermal therapy can cause temporary irritation of the bladder and prostatic urethra
• Urge incontinence in this setting typically represents overactive bladder syndrome with detrusor overactivity 1
• The symptoms are consistent with storage symptoms as defined by the International Continence Society 1

Treatment Algorithm

First-Line Treatment:

1. Anticholinergic medication:

   • Tolterodine 2mg twice daily is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency 2
   • Anticholinergic drugs are effective for urge incontinence unresponsive to traditional therapy 3

2. Behavioral modifications:

   • Scheduled voiding
   • Fluid restriction, especially in the evening
   • Avoidance of bladder irritants (caffeine, alcohol)
   • Pelvic floor exercises 4

Second-Line Options (if first-line fails after 4 weeks):

• Beta-3 agonists (e.g., mirabegron) 5
• Combination therapy with alpha-blockers if there are persistent voiding symptoms 5
• Consider urodynamic testing to better characterize the nature of the incontinence

Third-Line Options (for refractory cases):

• OnabotulinumtoxinA injections into the detrusor muscle 4
• Neuromodulation therapy 4

Follow-up Recommendations

• Evaluate response to treatment at 4 weeks after initiating anticholinergics 5
• Assessment should include:
  • Improvement in urge incontinence symptoms
  • Evaluation of medication side effects
  • Post-void residual measurement to ensure the patient is not developing urinary retention

Important Considerations and Precautions

• Monitor for urinary retention: Anticholinergics can potentially cause or worsen urinary retention, particularly in men with BPH history 2
• Watch for side effects: Common side effects include dry mouth, constipation, blurred vision, and cognitive effects in elderly patients 2
• Contraindications: Anticholinergics should not be used in patients with urinary retention, gastric retention, or uncontrolled narrow-angle glaucoma 2
• Temporary nature: Reassure the patient that post-REZUM urge incontinence often improves over time as the prostate heals and inflammation subsides

Rationale for Recommendation

Anticholinergic medications like tolterodine are the most appropriate first-line pharmacological treatment for this patient because:

1. They directly address the underlying detrusor overactivity causing the urge incontinence
2. They have demonstrated efficacy in treating overactive bladder symptoms 2
3. The patient's symptoms are severe enough to warrant pharmacological intervention
4. The timing of symptom onset (post-procedure) suggests irritative symptoms that are likely to respond to anticholinergic therapy

This approach aligns with guidelines recommending anticholinergics for patients with persistent storage symptoms following BPH treatment 5.