What is the most likely diagnosis and recommended management for a 60‑year‑old man with a sudden strong urge to void and frequent urge incontinence?

Overactive Bladder with Urgency Incontinence

Most Likely Diagnosis

The most likely diagnosis is overactive bladder (OAB) with urgency urinary incontinence, characterized by a sudden compelling desire to void that is difficult to defer, resulting in involuntary leakage before reaching the toilet. 1, 2

• Urgency is the hallmark symptom of OAB, defined as a sudden, compelling desire to pass urine which is difficult to defer 2
• Urgency urinary incontinence (UUI) is involuntary leakage of urine associated with this sudden compelling desire to void 2
• This presentation is distinct from stress incontinence (leakage with cough/sneeze) and from voiding to relieve pain (which would suggest interstitial cystitis/bladder pain syndrome) 1

Essential Initial Workup Before Treatment

Before initiating therapy, you must perform urinalysis to exclude urinary tract infection and measure post-void residual (PVR) if the patient has any emptying symptoms, history of retention, or diabetes. 1, 3

Required Tests

• Urinalysis and urine culture to rule out infection 1, 3
• Post-void residual measurement if patient reports incomplete emptying, has history of urinary retention, or has long-standing diabetes 3
• Physical examination including digital rectal exam to assess prostate size 1
• Serum PSA if considering 5α-reductase inhibitor therapy 1

Critical Safety Consideration

• Antimuscarinics are contraindicated if PVR is 250-300 mL or higher due to risk of precipitating acute urinary retention 3, 2
• Failure to measure PVR before prescribing antimuscarinics in at-risk patients is a common and dangerous pitfall 3

Recommended Treatment Algorithm

First-Line: Behavioral Therapies (All Patients)

All patients with OAB should receive behavioral therapies as initial treatment, which can be combined with pharmacotherapy for optimal results. 1, 3

• Bladder training with scheduled voiding and urgency-suppression techniques 3
• Fluid management: reduce evening intake, optimize total daily volume, eliminate caffeine and alcohol 3
• Dietary modifications: avoid acidic foods, artificial sweeteners 3
• Pelvic floor muscle exercises with or without biofeedback 1, 3

Second-Line: Pharmacotherapy

If behavioral therapy alone is insufficient after 4-8 weeks, add either an antimuscarinic agent or a β-3 agonist; both are equally appropriate first-line pharmacologic options. 3, 4, 5, 6

Antimuscarinic Options (if PVR is normal)

• Tolterodine 2 mg twice daily or 4 mg extended-release once daily 5
• Oxybutynin 5 mg two to three times daily or extended-release formulation 6
• Other options: solifenacin, darifenacin, trospium 1, 7, 8

β-3 Agonist Option

• Mirabegron 25 mg or 50 mg once daily 4
• Mirabegron 50 mg demonstrated statistically significant reduction in incontinence episodes (0.34-0.42 fewer episodes per 24 hours vs placebo, p<0.05) and micturitions (0.42-0.61 fewer per 24 hours vs placebo, p<0.05) 4
• Effective within 4 weeks for the 50 mg dose 4

Combination Therapy for Persistent Symptoms

• α-blocker plus antimuscarinic can be used when both bladder outlet obstruction and OAB symptoms coexist, though caution is warranted due to urinary retention risk 1
• Combination of behavioral and pharmacologic therapy yields the best outcomes 1, 3

Reassessment Timeline

• Evaluate treatment response at 2-4 weeks for α-blockers and antimuscarinics 1, 3
• Wait at least 3 months to assess response to 5α-reductase inhibitors if prostatic enlargement is present 1

When to Refer to Urology

Refer to a urologist if the patient fails an adequate trial (3-6 months) of combined behavioral and pharmacologic therapy, or if any of the following are present: 1, 3

• Hematuria not attributable to infection 3
• Recurrent urinary tract infections (≥3 per year) 3
• Neurological signs suggesting neurogenic bladder 3
• Elevated PVR >250-300 mL suggesting significant outlet obstruction 3
• Patient desires consideration of third-line options (botulinum toxin injection, sacral neuromodulation, percutaneous tibial nerve stimulation) 1, 3

Common Pitfalls to Avoid

• Do not prescribe antimuscarinics without measuring PVR in patients with emptying symptoms, prior retention, or diabetes—this can worsen overflow incontinence 3
• Do not refer prematurely before completing an adequate trial of behavioral and pharmacologic therapy 3
• Do not overlook comorbidities such as constipation, obesity, or diabetes that can exacerbate OAB and should be optimized concurrently 3
• Do not assume all urgency is OAB—rule out infection, interstitial cystitis (which presents with pain), and other pathology 1, 3
• In elderly patients, be cautious with antimuscarinics due to risk of cognitive impairment and drug interactions via CYP450 metabolism 7, 8