Final part of our series on urinary incontinence - Further treatment options

Urinary Incontinence

Part 4

Antimuscarinic medicines used to treat urge incontinence include

• Oxybutynin
• Tolterodine
• Fesoterodine
• Solifenacin
• Flavoxate

Antimuscarinics take up to 4 weeks to see full benefit. Side effects can include blurred vision, flushed and dry skin, dry mouth, fast heart rate, high blood pressure and fever. They are started at the lowest possible dose to minimise side effects and increased only if not working. Some conditions can be exacerbated due to antimuscarinics; for example, antimuscarinics can worsen symptoms of constipation, glaucoma, dry eyes, and poor bladder emptying. Care must be taken when used with other medication that also cause anti-cholinergic side effects including antihistamines, tricyclic antidepressants, drugs for asthma and COPD such as theophylline and cold preparations. For older people, anti-muscarinic drugs should be used in caution and the lowest possible doses because of increased risk of cognitive impairment and falls in older people.

Mirabegron

If antimuscarinics do not work or are causing side effects, mirabegron is another option. Mirabegron is a once-a-day tablet that works as a Beta 3 agonists that causes bladder muscle relaxation meaning the bladder can more easily fill up with and store urine. Mirabegron starts working within a few hours but can take several weeks to see the full benefit. The usual dose is 50mg daily but 25mg daily is recommended if the person has kidney or liver impairment. Side effects of mirabegron can include fast or irregular heart rate, heart palpitations, urinary tract infections and skin rash or itch. Mirabegron has been shown to be used safely in combination with solifenacin (also used for urge incontinence) and tamsulosin which is used for benign prostatic hyperplasia in men commonly known as enlarged prostate. The symptoms of benign prostatic hyperplasia are like OAB symptoms and can include slowness or dribbling when passing urine, frequent urination, hesitancy, or difficulty starting to urinate, feeling of urgency (sudden need to urinate), and having to get up during the night to urinate

Medication for Stress incontinence

If stress incontinence does not improve with changes to lifestyle or exercises such as bladder re-training, then surgery may be considered. For those that surgery is not suitable, the antidepressant duloxetine may be an option. It works by increasing muscle tone in the urethra (tube that urine flow from the bladder) thus helping keep it closed. For Stress incontinence, duloxetine is prescribed twice daily and after 4 weeks is assessed to see if it is working and has minimal side effects. Side effects can include dry mouth, nausea (which usually eases after a few days), tiredness, fatigue, and constipation. It should be discontinued gradually to prevent withdrawal side effects which can include nausea and vomiting, dizziness, irritability, headaches and intense dreams or nightmares

Medication for Nocturia

Nocturia is having to urinate through the night thus disturbing sleep. Low-dose desmopressin is used to treat nocturia. It works by reducing the volume of urine produced by the kidneys. Another option is a loop diuretic. Diuretics are unlicenced for nocturia meaning they have not gone through clinical trials for this indication, but some GPs and specialists prescribe it and find it effective and safe. Diuretics increase the production and flow of urine. When taken late in the afternoon it removes excess fluid from the body in the afternoon, it so may improve symptoms at night. Dehydration is the main risk.

Surgery

Surgery is sometimes needed to treat OAB. Surgery has varying degrees of success and risk.

Surgery options include:

• Botulinum toxin A.
• Sacral nerve stimulation
• Tibial nerve stimulation
• Augmentation cystoplasty
• Urinary diversion

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