7.4.2 Drugs for urinary frequency, enuresis, and incontinence

The Bladder and Bowel Care Service (North Devon: 01769 575182; Exeter: 01392 208465) will often prove a useful resource in assisting in the management of these conditions. In hospitals initiation of these drugs would usually be appropriate by urology, gynaecology and elderly care. Others may wish to seek advice from these primary and secondary care resources before initiating treatment.

For children, discussion with a paediatrician is strongly recommended.

Patients with neurological problems such as MS and confused elderly may be more appropriately assessed by the Bladder and Bowel Care Service.

Urological symptoms may result from oestrogen deficiency in post-menopausal women and treatment of atrophic vaginitis with local topical oestrogens may bring about improvement. (see 7.6 Vaginal and vulval conditions)

Urinary incontinence and overactive bladder

Bladder training for 6 weeks is the first line treatment (this may be accessed via the Bladder and Bowel Care Service).

Patients with uncomplicated symptoms who fail to respond to two months of conservative measures should be referred to the Bladder and Bowel Care Service.

Chronic retention can present with frequency in the elderly. If there is doubt, arrange a bladder scan locally prior to treatment.

There is no evidence that men taking anticholinergics are more likely to progress to acute urinary retention.

Whilst successful treatment may be evident in 1-2 weeks, the elderly may take up to 6 weeks before benefit becomes apparent. It is important that patients realise that freedom from incontinence is not likely with any form of drug therapy but that a reduction in frequency and incontinence episodes is a realistic expectation of treatment.

Stress incontinence

Supervised pelvic floor muscle training for at least 3 months is the first line treatment for stress or mixed incontinence. This may be accessed through the Bladder and Bowel Care Service (North Devon: 01769 575182; Exeter: 01392 208465). NICE Clinical Guideline 171 offers further detailed advice on management options for stress incontinence. Drug therapy is an option if surgery is not possible or is refused.

Anticholinergics should not be used for stress incontinence.

Nocturia

Consider giving a loop diuretic (2.2 Diuretics) in the late afternoon to men and women with nocturnal polyuria (unlicensed).

In line with NICE guidance, desmopressin (6.5 Hypothalamic and pituitary hormones and anti-oestrogens) may be used by the specialist services to reduce nocturia in women who find it a troublesome symptom. Oral desmopressin may be considered for men with LUTS experiencing nocturnal polyuria if treatment with a loop diuretic fails (unlicensed). A reduction in serum sodium is a common (more than 10%) adverse effect of such treatment and patients require pre-treatment and early post-treatment (72 hours) serum sodium monitoring. Where there are new symptoms or a change in medication, further monitoring of serum sodium is recommended. Patient electrolyte levels should be measured 3 days after starting therapy with desmopressin.

Drug treatments

Anticholinergics are used for the management of primary bladder instability, overactive bladder, urge incontinence and mixed incontinence but should not be used for stress incontinence.

Tolterodine
  • Tablets 1mg, 2mg (£1.80 = 2mg twice daily)
  • Neditol® XL tolterodine capsules modified release 4mg (£12.89 = 4mg daily)

Dose

  • Urinary frequency, urgency, and incontinence, 2mg twice daily; reduce to 1mg twice daily if necessary to minimise side-effects
  • Modified release: 4mg once daily

Notes

  1. See SPC for dose reduction in patients with hepatic or renal impairment. Concomitant administration with certain medications should be avoided.
Oxybutynin
  • Tablets 2.5mg, 5mg (£2.22 = 5mg three times daily)
  • Oxybutynin tablets modified release 5mg, 10mg (£25.70 = 10mg daily)

Dose

  • Imediate release: Initially 5mg 2–3 times daily, increased if necessary to maximum 5mg 4 times daily; elderly initially 2.5mg twice daily, increased to 5mg twice daily according to response and tolerance
  • Modified release: Initially 5mg once daily, adjusted according to response in steps of 5mg at weekly intervals; maximum 20mg once daily

Notes

  1. Do not offer oxybutynin immediate release to frail older patients.
  2. Oxybutynin immediate release tablets may be particularly suitable for those who wish to take medication on an occasional basis or to titrate doses themselves. If these have failed, there is little benefit trying tolterodine or MR preparations.
Darifenacin
  • Tablets m/r 7.5mg, 15mg (£25.48=7.5mg daily)
Dose
  • 7.5mg once daily, increased to 15mg once daily after 2 weeks if necessary
Notes
  1. See SPC for dosing recommendations/contraindications in hepatic impairment and with concomitant use of certain medications.
Mirabegron
  • Tablets modified release 25mg, 50mg (£27.07)

Dose

  • 50mg once daily

Notes

  1. Mirabegron is recommended for patients in whom antimuscarinic drugs are contraindicated, clinically ineffective, or have unacceptable side effects. It is expected that the majority of patients would have tried and failed on at least one formulary choice antimuscarinic drug before being prescribed mirabegron
  2. Mirabegron should be used with caution in patients with a history of QT-interval prolongation or in those patients also taking drugs that prolong the QT interval
  3. Mirabegron is contraindicated for use in patients with severe uncontrolled hypertensive patients (systolic blood pressure 180 mm Hg or greater and/or diastolic blood pressure 110 mm Hg or greater). Blood pressure should be measured before and during treatment, especially in patients with hypertension.
  4. Renal impairment: avoid if eGFR is less than 15mL/min/1.73m2. If eGFR is 15-29mL/min/1.73m2 reduce dose to 25mg daily. See SPC for further dosing recommendations in renal impairment and concomitant use of certain medications.
  5. Hepatic impairment: avoid in severe impairment. Reduce dose to 25mg once daily in moderate hepatic impairment. See SPC for further dosing recommendations in renal impairment and concomitant use of certain medications.
  6. Please refer to NICE TA290 Overactive bladder (June 2013)
Solifenacin
  • Tablets 5mg, 10mg (£25.78 = 5mg daily)

Dose

  • 5mg daily, increased if necessary to 10mg once daily

Notes

  1. See SPC for dosing recommendations/contraindications in hepatic and renal impairment and with concomitant use of certain medications.
Trospium
  • Capsules modified release 60mg (£23.05 = 60mg daily)

Dose

  • 60mg once daily

Notes

  1. Modified release capsules are not recommended for patients with renal impairment and patients with severe hepatic impairment.
Fesoterodine
  • Tablets m/r 4mg, 8mg (£25.78)

Dose

  • 4mg once daily, increased if necessary to maximum 8mg once daily

Notes

  1. See SPC for dosing recommendations/contraindications in hepatic and renal impairment and with concomitant use of certain medication.

 

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