7.4.2 Drugs for urinary frequency, enuresis, and incontinence

Urinary Frequency Due to Overactive Bladder (symptoms)

ChoiceDrugDosage
1st choiceTolterodine 1mg, 2mg tablets (immediate release)Dose: 2mg twice a day; reduce to 1mg twice a day if necessary to minimise side-effects
Or

Tolterodine m/r 2mg, 4mg capsules
(Neditol® XL is the cost-effective choice)

Dose:
Usual dose 4mg once daily; reduce to 2mg once daily if troublesome adverse reactions
Or
Trospium immediate release (generic) tabletsDose:
20mg twice daily, to be taken before food

2nd choice
(reserve for when first choice not effective or well tolerated)

Fesoterodine See BNF Chapter 7
Or
SolifenacinSee BNF Chapter 7

Prescribing Notes

  • Refer to NICE CG97 Lower Urinary Tract Symptoms.
  • Refer to NICE NG123 Urinary Incontinence in Women.
  • For urinary incontinence, NICE recommend conservative management as first line treatment, including bladder training, supervised pelvic floor muscle training and lifestyle advice. Drug treatment should only be considered when the condition has not improved with conservative management alone.
  • Refer to community continence service for lifestyle advice before offering treatment.
  • Before overactive bladder (OAB) drug treatment starts, discuss with patients the likelihood of success and associated common adverse effects and that they may not see the full benefits until they have been taking the treatment for 4 weeks.
  • Prescribe the lowest dose when starting a new OAB drug treatment.
  • Offer a review 4 weeks after the start of each new OAB drug treatment. Ask the patient if they are satisfied with the therapy: if improvement is optimal, continue treatment; if there is no, or suboptimal improvement, or intolerable adverse effects, change the dose, or try an alternative OAB drug and review again 4 weeks later.
  • Offer a review before 4 weeks if the adverse effects of the OAB drug treatment are intolerable.
  • Patient review is important to minimise the number of anticholinergic drugs where possible. Some patients may be suitable for a ‘drug holiday’. Resources to support this can be found here.
  • NICE NG123 states:
    • do not use duloxetine as a first-line treatment for women with predominant stress urinary incontinence
    • do not use flavoxate, propantheline and imipramine for the treatment of urinary incontinence or OAB in women
    • do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health
  • The long-term effects of anticholinergic medicines for overactive bladder on cognitive function are uncertain. When offering anticholinergic medicines to treat overactive bladder, take account of the woman’s:
    • coexisting conditions (such as poor bladder emptying, cognitive impairment or dementia). For women with a diagnosis of dementia and for whom anticholinergic medicines are an option, refer to Medicines that may cause cognitive impairment in NICE guideline on dementia
    • current use of other medicines that affect total anticholinergic load
    • risk of adverse effects, including cognitive impairment
  • Mirabegron is recommended as an option for treating the symptoms of overactive bladder only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects. See NICE TA 290.
  • Mirabegron should normally be prescribed at a dose of 50mg daily (25mg daily is suboptimal for most patients unless e.g. renal or hepatic impairment – refer to BNF for full details.
  • Do not offer systemic hormone replacement therapy for the treatment of urinary incontinence.
  • Offer intravaginal oestrogens for the treatment of overactive bladder symptoms in post-menopausal women with vaginal atrophy.

Cautions

  • Anticholinergic drugs can cause a broad range of adverse effects, including constipation, dry mouth, dry eyes, urinary retention, confusion, falls and agitation. The increased risks from anticholinergic drugs are cumulative, based on the number of anticholinergic drugs taken and the strength of each drug’s anticholinergic effect.  Older people are particularly susceptible to adverse effects, even at therapeutic doses. For further information see here.
  • There is risk of severe hypertension and associated cerebrovascular and cardiac events with mirabegron (Betmiga®). For further details see MHRA Drug Safety Update October 2015.