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

Exclude or manage treatable causes of nocturnal polyuria.

Advise the patient to limit fluid intake in the late afternoon and evening.

If limiting fluid intake in the late afternoon or evening is ineffective:

Low dose oral desmopressin (50micrograms oral lyophilisate) (6.5.2. Posterior pituitary hormones and antagonists) may be considered as a licensed option to reduce nocturia in men with LUTS experiencing idiopathic nocturnal polyuria. In line with NICE guidance, low dose desmopressin (25micrograms oral lyophilisate) may also be used as a licensed option by the specialist services to reduce nocturia in women who find it a troublesome symptom.

Elderly patients, aged 65 years and over, are at an increased risk of developing hyponatremia with desmopressin treatment and may also have impaired renal function. Caution should therefore be exercised in this age group and daily doses should not be increased beyond the licensed dose.

In line with NICE, loop diuretics (2.2.2 Loop diuretics) administered in the late afternoon may also be considered as an option in men and women, in reducing nocturia associated with nocturnal polyuria (unlicensed).

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 tartrate

• Tablets 1mg, 2mg (£2.90 = 2mg twice daily)
• Modified-release capsules 4mg (click here for preferred brand)

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.
2. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Oxybutynin hydrochloride

• Tablets 2.5mg, 5mg (£1.92 = 5mg three times daily)
• Modified-release tablets 5mg, 10mg (£29.13 = 10mg daily)

Indications and dose

• Urinary frequency, urinary urgency, urinary incontinence, neurogenic bladder instability:
  • Immediate-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
• Hyperhidrosis which has not responded to a topical aluminium antiperspirant and self-care management strategies (second line) (off-label):
  • Immediate-release: Initially 2.5mg once daily, adjusted according to response and tolerability; maximum 10mg daily given in two to four divided doses.
  • Modified-release: Where immediate release products are not tolerated. Initially 5mg once daily, increased if required to a maximum dose of 10mg once daily.
    

Notes

1. Medicine Supply Notification MSN/2023/116 (18 December 2023): Oxybutynin 5mg modified-release tablets
   1. Oxybutynin 5mg modified-release tablets are out of stock until mid-July 2024.
      
   2. Oxybutynin immediate-release formulations (tablets and liquids) remain available and can support increased demand, as can alternative anticholinergic agents.
   3. Refer to the MSN for advice on prescribing.
2. Do not offer oxybutynin immediate-release to frail older patients.
3. 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.
4. Although it is an off-label use, specialists advise that for patients with hyperhidrosis, oxybutynin is considered ahead of the licensed alternative (propantheline bromide) owing to greater evidence of efficacy and lower cost.
   

Darifenacin

• Modified-release tablets 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

• Modified-release tablets 25mg, 50mg (£27.07 = 50mg daily)

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 succinate

• Tablets 5mg, 10mg (£1.36 = 5mg daily)
• Oral suspension sugar free 1mg/1ml (£27.62 = 150ml)

Indications and dose

• Urinary frequency, urgency and urge incontinence in adults
  • 5mg once daily, increased if necessary to 10mg once daily
• Neurogenic detrusor overactivity in children aged 2-17 years, using oral suspension (specialist)
  • Body-weight 9-15kg: initially 2mg once daily, increased if necessary up to 4mg once daily
  • Body-weight 16-30kg: Initially 3mg once daily, increased if necessary up to 5mg once daily
  • Body-weight 31-45kg: Initially 3mg once daily, increased if necessary up to 6mg once daily
  • Body-weight 46-60kg: Initially 4mg once daily, increased if necessary up to 8mg once daily
  • Body-weight 61kg and above: Initially 5mg once daily, increased if necessary up to 10mg once daily

Notes

1. Tablets are not licensed for use in children
2. See SPC for dosing recommendations/contraindications in hepatic and renal impairment and with concomitant use of certain medications
3. Oral suspension should be taken orally followed by a glass of water
4. The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months
5. The need for continuing therapy for neurogenic detrusor overactivity should be reviewed at least every 12 months

Trospium chloride

• Modified-release capsules 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 fumarate

• Modified-release tablets 4mg, 8mg (£2.89 = 4mg daily)

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.