Examine for retention, prostatic hyperplasia/poor rectal tone, and neurological signs.
Check urinalysis. Consider C&S, PSA, glucose, and urodynamics.
Behavioural changes: Scheduled/double voiding, avoidance of irritants, training of pelvic floor muscles, smoking cessation. Online patient resource from EAU. Downloadable list of bladder irritants/potential substitutes; the most important are alcohol, tobacco, caffeine, artificial sweeteners and chocolate, but there are quite a few others, including aged cheese, sour cream, and yoghurt, none of which I would ever have anticipated being a problem.
Note that there is some evidence for some herbal remedies, but not recommended by NICE at this point.
Pharmacological treatment: Often first-line is treatment for bladder outflow obstruction symptoms; anticholinergics can be added to that. Oxybutinin has the most SEs and it’s now recommended that it be avoided. The authors said they often start with either fesoteridine fumarate or darifenacin hydrobromide, but we didn’t get a cost discussion. The risk of acute retention is minimal, but pre-existing urinary retention is one of the contraindications (others include closed-angle glaucoma, ileus/bowel stenosis/severe IBD/toxic megacolon, myasthenia gravis, and tachyarrhythmias. People can respond differently to different formulations, so it’s worth trying a different one if no response to the first.
As an alternative, beta-3 agonists (e.g. mirabegron) are well tolerated, but the cost-effectiveness is currently unknown.
Follow-up is recommended 4 – 6 weeks after starting or adjusting therapy.
Failure of medical therapy generally warrants specialist referral.