What are the further recommendations for a 59-year-old male with a history of prostatitis, balanitis, and overactive bladder symptoms, currently managed with Ditropan XL (oxybutynin) and behavioral modifications, with elevated Hemoglobin A1c (Hgb A1c) levels?

From the Guidelines

For this 59-year-old male with prostatitis, balanitis, and overactive bladder symptoms who wishes to postpone medication, I recommend continuing his current approach while adding several targeted interventions. He should maintain his behavioral modifications (timed voiding, bladder training, limiting evening fluids, and double voiding) but also incorporate pelvic floor exercises (Kegels) - 10-15 contractions held for 5 seconds, three times daily - which can strengthen urinary control, as supported by the AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder 1. For his balanitis, meticulous genital hygiene with gentle cleansing using warm water and mild soap, followed by thorough drying, is essential. Loose-fitting cotton underwear can reduce moisture and irritation. Given his elevated HgbA1c, which can worsen urinary symptoms through polyuria and neuropathy, aggressive diabetes management is crucial, focusing on preventing hypoglycemia and managing hyperglycemia using blood glucose testing, as recommended for a stable patient with diabetes 1. He should follow up with his PCP within 1-2 months to reassess his glycemic control and urinary symptoms. If symptoms worsen despite these measures, reconsideration of Ditropan XL (starting at 5mg daily) or alternative medications like mirabegron (Myrbetriq) 25mg daily would be appropriate. Regular urological follow-up every 3-6 months is also recommended to monitor his prostate health and reassess the need for medication. Key aspects of his care include:

• Continuing behavioral therapies as first-line treatment for overactive bladder, which may be combined with pharmacologic management if necessary 1
• Managing diabetes to prevent complications that could exacerbate urinary symptoms
• Regular follow-up to adjust the treatment plan as needed based on symptom control and side effects.

From the FDA Drug Label

Oxybutynin chloride should be used with caution in patients with pre-existing dementia treated with cholinesterase inhibitors due to the risk of aggravation of symptoms. Oxybutynin chloride should be used with caution in patients with Parkinson’s disease due to the risk of aggravation of symptoms Oxybutynin chloride should be used with caution in the frail elderly, in patients with hepatic or renal impairment, and in patients with myasthenia gravis. Oxybutynin chloride may aggravate the symptoms of hyperthyroidism, coronary heart disease, congestive heart failure, cardiac arrhythmias, hiatal hernia, tachycardia, hypertension, myasthenia gravis, and prostatic hypertrophy

The patient has a history of prostatitis and prostatic hypertrophy may be a concern. However, there is no direct information in the drug label that supports a specific recommendation for this patient.

• The patient is encouraged to continue with behavioral and lifestyle modifications.
• The patient should continue regular follow-ups with his PCP for better control of elevated Hgb A1c.
• No changes to the current treatment plan are recommended based on the provided information 2.

From the Research

Current Treatment and Recommendations

The patient is currently prescribed Ditropan XL for overactive bladder symptoms but would like to postpone starting any new medications. The patient is mostly satisfied with his micturition and will continue with behavioral and lifestyle modifications.

Alternative Treatment Options

• Mirabegron, a selective agonist of the β3 adrenergic receptor, has been shown to be effective in treating overactive bladder symptoms 3, 4, 5, 6.
• Studies have compared the efficacy and tolerability of mirabegron with antimuscarinic monotherapy or combination therapies, and found that mirabegron has similar efficacy with fewer anticholinergic side effects 5.
• Another option is vibegron, which has been shown to be effective in reducing total incontinence episodes and improving volume voided compared to mirabegron and tolterodine 7.

Considerations for Treatment

• The patient's history of prostatitis, balanitis, and current overactive bladder symptoms should be taken into account when considering treatment options.
• The patient's elevated Hgb A1c levels may contribute to frequency and nocturia, and regular follow-ups with his PCP are recommended to better control this condition.
• Behavioral and lifestyle modifications, such as timed voiding, bladder training, limiting evening fluids, and double voiding as needed, should be continued and may be sufficient to manage the patient's symptoms without the need for additional medication.