What to do when a patient requires multiple anticholinergic medications and develops urinary retention?

Management of Urinary Retention in Patients Requiring Multiple Anticholinergic Medications

When a patient develops urinary retention while on multiple anticholinergic medications, the first step should be to discontinue or reduce the anticholinergic medication used for managing side effects of other drugs, while maintaining those essential for treating the underlying disorders.1

Assessment of Anticholinergic Burden

• Evaluate all medications the patient is taking to identify those with anticholinergic properties, as many drugs including antipsychotics, antidepressants, muscle relaxants, and respiratory agents can cause urinary retention 2
• Determine which anticholinergic medications are treating primary conditions versus those managing side effects of other medications 1
• Assess for risk factors that increase susceptibility to urinary retention, including age, benign prostatic hyperplasia, and existing bladder outflow obstruction 3, 2

Prioritization for Medication Adjustment

• If a patient is taking an anticholinergic medication to manage side effects of another medication (e.g., anticholinergic for extrapyramidal symptoms from antipsychotics), this should be the first medication to be discontinued or reduced 1
• For patients on multiple anticholinergics for different primary conditions, prioritize discontinuing the medication for the disorder that is less severe or more likely to be in remission 1
• When discontinuing anticholinergics used for managing extrapyramidal symptoms, maintain the anticholinergic medication well after the antipsychotic is discontinued to prevent delayed emergence of extrapyramidal symptoms 1

Medication Management Strategies

• Consider gradual tapering of anticholinergic medications rather than abrupt discontinuation to avoid withdrawal symptoms or rebound worsening of symptoms 1
• For patients with overactive bladder requiring anticholinergic therapy, consider switching to a beta-3 adrenergic receptor agonist which has less risk of urinary retention 4, 5
• If anticholinergic therapy must be continued, consider using trospium which has less central nervous system penetration and potentially fewer cognitive side effects 3

Urinary Retention Management

• For acute urinary retention, urinary catheterization may be necessary in combination with dose reduction or discontinuation of the causal anticholinergic medication 2
• Monitor post-void residual urine volume to assess for improvement after medication adjustments 1
• Exclude or treat constipation, which can exacerbate urinary retention and is a common side effect of anticholinergic medications 1, 6

Special Populations and Considerations

• Elderly patients are at higher risk for anticholinergic-induced urinary retention and should be started on lower doses with careful monitoring 2
• Patients with clinically significant bladder outflow obstruction should use anticholinergic medications with extreme caution due to increased risk of urinary retention 3, 6
• Patients with neurogenic lower urinary tract dysfunction may require specialized management approaches, including possible intermittent catheterization 4

Important Contraindications and Precautions

• Anticholinergic medications are contraindicated in patients with uncontrolled narrow-angle glaucoma 3, 6
• Use with caution in patients with gastrointestinal obstructive disorders, as anticholinergics can decrease gastrointestinal motility 3
• Monitor for other anticholinergic side effects including dry mouth, constipation, blurred vision, and cognitive impairment, which may necessitate further dose adjustments 6, 5

Long-term Monitoring

• Regularly assess the continued need for anticholinergic medications through periodic drug holidays 1
• Monitor for urinary tract infections, which can occur with increased post-void residual urine 7
• Evaluate bladder function periodically, especially in patients with chronic indwelling catheters or those requiring intermittent catheterization 4