5-5 mg twice or three times a day; long-acting oxybutynin, 5-15 mg daily; and oxybutynin transdermal patch, 3.9 mg per day applied twice weekly. All of these agents can produce delirium, dry mouth, or urinary retention; long-acting preparations may be better tolerated. Agents such as fesoterodine (4-8 mg orally once daily), trospium chloride (20 mg orally once or twice daily), darifenacin (7.5-15 mg orally daily), and solifenacin (5-10 mg orally daily)
appear to have similar efficacy and have not been clearly demonstrated to be better tolerated than the older agents in long-acting form.
The combination of behavioral therapy and antimusca- rinics appears to be more effective than either alone although one study in a group of younger women showed that adding behavioral therapy to individually titrated doses of extended-release oxybutynin was no better than drug treatment alone.
In men with both benign prostatic hyperplasia and detrusor overactivity and who have postvoid residual volumes of 150 mL or less, an antimuscarinic agent added to an a-blocker may provide additional relief of lower urinary tract symptoms.
2. Urethral incompetence (stress incontinence)—
Lifestyle modifications, including limiting caffeine intake and timed voiding, may be helpful for some women, particularly women with mixed stress/urge incontinence. Pelvic floor muscle exercises are effective for women with mild to moderate stress incontinence; the exercises can be combined, if necessary, with biofeedback, electrical stimulation, or vaginal cones. Instruct the patient to pull in the pelvic floor muscles and hold for 6-10 seconds and to perform three sets of 8-12 contractions daily. Benefits may not be seen for 6 weeks. Pessaries or vaginal cones may be helpful in some women but should be prescribed by providers who are experienced with using these modalities.
Although a last resort, surgery is the most effective treatment for stress incontinence, resulting in a cure rate as high as 96% even in older women. Drug therapy is limited. Clinical trials have shown that duloxetine, a serotonin and norepinephrine reuptake inhibitor, reduces stress incontinence episodes in women but efficacy in older women remains unknown. It is approved for use for this indication in some countries but not the United States. Side effects, including nausea, are common.
3. Urethral obstruction—Surgical decompression is the most effective treatment for obstruction, especially in the setting of urinary retention due to benign prostatic hyperplasia.