What is the best course of action for an older adult patient with difficulty controlling urine and urgency, but a normal urinalysis (UA), considering their age, medical history, and potential neurological disorders?

Management of Urinary Urgency and Difficulty Controlling Urine with Normal Urinalysis

This patient has overactive bladder (OAB) and should begin with behavioral treatments, followed by antimuscarinic medications or beta-3 agonists if behavioral therapy is insufficient. 1

Diagnostic Confirmation

With urgency and difficulty controlling urine plus a normal urinalysis, this presentation is consistent with OAB. The key diagnostic steps include:

• Document that urgency is the hallmark symptom - defined as "a sudden, compelling desire to pass urine which is difficult to defer" 1
• Confirm bothersome symptoms - when urinary frequency and urgency, with or without urgency incontinence, are self-reported as bothersome, the patient may be diagnosed with OAB 1
• The normal urinalysis rules out urinary tract infection and hematuria, which are critical exclusions 1

Additional Evaluation to Consider

At the clinician's discretion, obtain:

• Bladder diary to reliably measure voiding frequency (traditionally up to 7 micturitions during waking hours is normal, though highly variable) 1
• Post-void residual assessment to exclude urinary retention 1
• Review current medications to ensure symptoms are not medication-related 1
• Assess for neurologic diseases and other genitourinary conditions that directly impact bladder function, as these patients may require specialist referral 1

Important caveat: In older adults, assess cognitive impairment and ability to dress independently, as these relate to symptom severity and therapeutic implications 1

Treatment Algorithm

First-Line: Behavioral Treatments

Begin with behavioral interventions, which can be combined with antimuscarinics if partially effective 1:

• Pelvic floor muscle training (biofeedback-assisted when available) 2, 3
• Timed voiding at specific intervals 3
• Fluid restriction and advice on suitable fluid intake 4, 3

Second-Line: Pharmacologic Therapy

If behavioral treatments fail to meet treatment goals and the patient desires further treatment:

Antimuscarinic medications with active management of adverse events (dry mouth, constipation) 1:

• Consider dose modification or alternate antimuscarinic if effective but adverse events are intolerable 1

Beta-3 adrenergic agonists are an alternative option:

• Mirabegron is FDA-approved for OAB in adults with symptoms of urge urinary incontinence, urgency, and urinary frequency 5
• Starting dose is 25 mg orally once daily, may increase to 50 mg after 4-8 weeks 5
• Beta-3 agonists reduce voiding frequency by 2-4 times per day and reduce incontinence episodes by 10-20 times per week 3

Critical monitoring: Mirabegron can increase blood pressure; periodically monitor blood pressure, especially in hypertensive patients, and avoid in severe uncontrolled hypertension 5

Third-Line: Reassess or Refer

If treatment goals are not met despite behavioral and pharmacologic therapy:

• Consider urine culture, post-void residual, bladder diary, symptom questionnaires, and other diagnostic procedures as necessary for differentiation 1
• Refer to specialist for consideration of advanced therapies including botulinum toxin type A injections, sacral neuromodulation, or other interventions 6

Common Pitfalls to Avoid

• Do not assume all urgency in older adults is due to UTI - the normal urinalysis excludes infection, and treating asymptomatic bacteriuria causes harm without benefit 7
• Do not overlook reversible causes including medications, constipation, or neurologic conditions that may require different management 1, 8
• Do not delay treatment if symptoms are bothersome - quality of life impact is significant and warrants intervention 1, 4
• In patients with mixed incontinence (both stress and urgency), it can be difficult to distinguish subtypes; a cough stress test may help differentiate 1

Follow-Up Strategy

• Monitor for efficacy and adverse events at regular intervals 1
• Reassess treatment goals - if the patient is not significantly bothered by symptoms, there is less compelling reason to escalate treatment 1
• Consider urodynamic studies only when invasive, potentially morbid, or irreversible treatments are being considered, or when the nature of incontinence is unclear 1