MUR Tips incontinence

Drug treatments for urinary incontinence depend on the type of incontinence the individual experiences. Duloxetine is a serotonin and noradrenaline reuptake inhibitor licensed for moderate to severe stress incontinence in women. Antimuscarinic agents (oxybutynin, tolterodine, flavoxate, darifenacin, propiverine, solifenacin, trospium) are used for urge incontinence because of their ability to reduce involuntary detrusor muscle contractions and increase bladder capacity. All the above should be used with care in the elderly.

Dosage regimen
* Duloxetine: 40mg twice daily, assessed after two to four weeks and reduced to 20mg twice daily if side effects prove troublesome.
•    Flavoxate: 200mg three times daily.
•    Oxybutynin: Initially 5mg two to three times daily, increased if necessary to maximum 5mg four times daily. Elderly patients should start on 2.5-3mg twice daily, increasing to 5mg twice daily according to response and tolerance.
•    Propiverine: 15mg one to three times daily, increased if necessary to a maximum 15mg four times daily.
•    Solifenacin: 5mg daily, increased if necessary to 10mg once daily.
•    Tolterodine: 2mg twice daily, reducing to 1mg twice daily if necessary to minimise side effects.
•    Trospium: 20mg twice daily before food.

Patient's knowledge of the medicines use
•    Duloxetine tightens the urethra and should be used in combination with pelvic floor exercises.
•    Antimuscarinics reduce the contractions that cause urgency and increase capacity.
•    Trospium needs to be taken an hour before food or on an empty stomach.

Is the medicine working?
•    Does the patient still need to pass urine more than eight times during the day or more than once or twice at night? If so, refer back to the GP.
•    Monitor frequency of micturition, volume voided and the number of urge incontinence episodes.

Side effects
•    Duloxetine: nausea, vomiting, dyspepsia, dry mouth, constipation and diarrhoea.
•    Antimuscarinics: dry mouth, gastro-intestinal disturbances, dry eyes, blurred vision, palpitations and skin reactions.

Monitoring
•    Antimuscarinic treatment should be reviewed after three to six months.
•    Duloxetine should not be used in liver disease.
•    Oxybutynin requires referral if vision becomes cloudy. If side effects of oral oxybutynin are intolerable and patient has shown benefits from the drug, transdermal patches may be tried.
•    Liver enzymes need checking for those on long-term propiverine.
•    Check any other drug therapy is not exacerbating incontinence (eg timing of any diuretic doses may need altering).

Lifestyle
•    Pelvic floor exercises may benefit patients with stress incontinence).
•    Bladder re-training to enable the patient's bladder to tolerate normal stretching as it fills. This can be beneficial to patients with urge incontinence.
•    Many patients benefit from using incontinence devices, either temporarily or longer-term. Make sure they know aboutpads, pants and catheters.
•    Reduce caffeine and fluid intake.
•    Stop smoking. Nicotine is a bladder irritant and smoking may cause coughing, which can trigger incontinence.
•    Lose weight: excess weight can put pressure on the bladder.