What should be done for a 59-year-old male with type 2 diabetes, who recently stopped taking Mounjaro (tirzepatide) and started Jardiance (empagliflozin) due to travel, and now presents with inability to urinate?

Acute Urinary Retention in a Diabetic Patient on Jardiance

This patient requires immediate bladder decompression with urethral catheterization or suprapubic catheter placement, followed by urgent discontinuation of Jardiance (empagliflozin) and evaluation for diabetic cystopathy versus medication-induced urinary retention. 1

Immediate Management (Within Hours)

• Measure post-void residual volume immediately using portable ultrasound to confirm urinary retention and quantify severity 2, 3
• Catheterize the bladder urgently if the patient cannot void, as acute urinary retention is a medical emergency requiring immediate decompression 2, 4
• Discontinue Jardiance immediately - the FDA label specifically warns about urinary tract problems and advises patients to tell their doctor about "problems with urination" before starting the medication 1
• Obtain urinalysis and urine culture to exclude bacterial cystitis, as diabetic patients have increased susceptibility to E. coli infections that can precipitate retention 2, 3, 5

Critical Diagnostic Workup (Within 24-48 Hours)

• Assess for diabetic cystopathy - this patient's longstanding type 2 diabetes puts him at 25% risk for diabetic bladder dysfunction, which causes detrusor muscle paralysis and impaired bladder sensation 2, 4
• Measure serum creatinine and assess kidney function - sudden kidney injury can occur with SGLT2 inhibitors, especially when patients reduce food/liquid intake or lose fluids 1
• Check blood glucose control - poor glycemic control exacerbates urinary symptoms and autonomic neuropathy progression 3, 5, 4
• Perform neurological examination including perineal sensation, sphincter tone, and bulbo-cavernosus reflex to identify peripheral neuropathy consistent with diabetes 2, 5

Understanding the Dual Etiology

This patient likely has both medication-induced and diabetes-related urinary retention:

SGLT2 Inhibitor Contribution (Jardiance)

• Jardiance increases urine volume through glycosuria, which can overwhelm an already compromised bladder in diabetic patients 6, 7
• Recent research shows that 19.6% of adults ≥55 years with type 2 diabetes meeting SGLT2i indications have frequent urinary incontinence, with 32.4% having frequent symptoms when specifically indicated for SGLT2i 8
• The FDA label warns patients to inform their doctor if they have "problems with urination" before starting Jardiance 1

Diabetic Cystopathy Contribution

• Diabetic bladder dysfunction affects 25% of type 2 diabetic patients, causing detrusor muscle paralysis, impaired bladder sensation, and increased post-void residual 2, 4
• The correlation between diabetic cystopathy and peripheral neuropathy ranges from 75-100% 2
• Common symptoms include weak stream, incomplete emptying, and urinary retention 2

Treatment Algorithm After Acute Stabilization

If Post-Void Residual >300 mL (Chronic Retention)

• Intermittent catheterization is the treatment of choice for acontractile bladder from diabetic cystopathy 3, 4
• Implement scheduled voiding regimen to prevent overflow incontinence 3, 5
• Do NOT use antimuscarinic medications - they worsen detrusor contractility and are contraindicated in significant retention 5, 4

If Post-Void Residual 100-300 mL (Moderate Dysfunction)

• Continue intermittent catheterization until bladder function recovers after Jardiance discontinuation 4
• Optimize glycemic control to prevent progression of autonomic neuropathy 3, 5, 4
• Reassess in 2-4 weeks after medication washout 5

If Post-Void Residual <100 mL After Initial Decompression

• Monitor closely as this suggests primarily medication-induced retention that may resolve with Jardiance discontinuation 4
• Consider urodynamic studies if symptoms persist beyond 2-4 weeks after stopping Jardiance 2, 5, 4

Alternative Diabetes Management

• Resume Mounjaro (tirzepatide) once urinary function stabilizes, as GLP-1 receptor agonists do not cause urinary retention and are guideline-recommended for cardiovascular protection 2
• If SGLT2 inhibitor is specifically needed for heart failure or chronic kidney disease indications, consider switching to a GLP-1 RA instead, as both classes provide cardiorenal protection 2, 8
• Metformin should be considered if eGFR >30 mL/min/1.73 m² 2

Urodynamic Testing Indications

Proceed to complete urodynamic studies if: 2, 5, 4

• Initial management fails after 2-4 weeks
• Diagnostic uncertainty exists between detrusor overactivity and impaired contractility
• Symptoms persist despite Jardiance discontinuation and glycemic optimization
• Complex dysfunction requiring precise characterization

The most common urodynamic findings in diabetic cystopathy are detrusor overactivity (48%), impaired detrusor contractility (30%), and impaired bladder sensation with increased capacity 4

Long-Term Monitoring

• Perform yearly post-void residual volume and urine dipstick screening in all patients with insulin-dependent diabetes 3, 4
• Screen for other manifestations of autonomic neuropathy, as bladder dysfunction often coexists with gastroparesis 3, 4
• Maintain optimal glycemic control to minimize progression of autonomic neuropathy 3, 5, 4

Critical Pitfalls to Avoid

• Do not restart Jardiance without first confirming resolution of urinary retention and establishing baseline bladder function 1
• Do not attribute all symptoms to infection without culture confirmation - diabetic cystopathy mimics UTI symptoms 2, 3, 5
• Do not prescribe antimuscarinic medications without measuring PVR first, as significant retention is an absolute contraindication 5, 4
• Do not overlook the medication-induced component - stopping Jardiance may significantly improve or resolve symptoms 1, 8
• Do not delay catheterization in acute retention - this is a urological emergency that can cause permanent bladder damage and kidney injury 2, 4