A 70-Year-Old Man Seeks Advice for Continuing Bladder Problems

A 70-year-old man seeks advice for continuing bladder problems.  Over the last several years, the patient has had a slow decrease in the volume and force of his urinary stream associated with nocturia and urinary frequency.  When seen in the office 12 months ago, his American Urological Association symptom score was 18 (indicating significant symptoms) .  Digital rectal examination showed a slightly enlarged, smooth, nontender prostate.  Urinalysis and prostate-specific antigen were normal.  The patient was prescribed a long-acting alpha adrenergic blocker and his symptoms improved.  However, he now has intermittent urinary incontinence associated with a strong urge to void.  This usually occurs when he senses a full bladder, but it is also triggered by the sound of running water or with exposure to cold.  Limiting his fluid intake and scheduling himself to void frequently have not helped.  The patient has had no associated dysuria and has not added any new medications in the past year.
Genitourinary examination including prostate examination is unchanged from a year ago.  Urinalysis is normal.  Ultrasound bladder scan estimates a residual urine volume of 60 mL.
Which of the following is the best next step in management of this patient's urinary symptoms?

A) Add a 5-alpha reductase inhibitor
B) Add an antimuscarinic agent
C) Change to another alpha-adrenergic blocking agent
D) Sacral nerve stimulation
E) Urodynamic testing

Correct Answer:

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