1. Pre-consultation

Medicines for urge incontinence

After six weeks of bladder training, NICE advises trying drug treatment if the woman has not experienced satisfactory improvement. Antimuscarinics (anticholinergics) are commonly used. The recommended first-line drugs are oxybutynin immediate release, tolterodine immediate release, or darifenacin. Second-line alternative antimuscarinics are: oxybutynin extended release or patches; tolterodine extended release; fesoterodine; darifenacin; solifenacin; trospium; or propiverine preparations.

When dispensing one of these medicines, NICE recommends that it should be explained to patients that side-effects of dry mouth and constipation indicate that the medicine is working. However, dry mouth can be distressing and lead to discontinuation of treatment. And constipation can contribute to, or worsen, urinary incontinence – so patients need a strategy to deal with it if it turns out to be a problem.

The prescriber is responsible for taking into account the recommendations made by NICE in its 2019 guidance on ‘Urinary incontinence and pelvic organ prolapse in women: management’ (Guideline NG123).

NICE says: “When offering anticholinergic medicines to treat overactive bladder, take account of the woman’s:

• Co-existing conditions (such as poor bladder emptying, cognitive impairment or dementia)
• Current use of other medicines that affect total anticholinergic load
• Risk of adverse effects, including cognitive impairment.”

The following side-effects are seen with many antimuscarinic treatments: constipation; dizziness; drowsiness; dry mouth; dyspepsia; flushing; headache; nausea; palpitations; skin reactions; tachycardia; urinary disorders; vision disorders; and vomiting.

The BNF advises: “Immediate release oxybutynin hydrochloride, immediate release tolterodine tartrate, or darifenacin can be used first-line. Immediate release oxybutynin should not be used in frail, older women at risk of sudden deterioration in their physical or mental health. The lowest dose should be used and titrated upwards if necessary.

“Transdermal oxybutynin hydrochloride may be used in those unable to tolerate oral treatment. Mirabegron may be used if treatment with an anticholinergic is contraindicated, ineffective, or not tolerated.”

Duloxetine is sometimes used in stress incontinence where lifestyle changes have not resulted in adequate improvement and the patient does not want surgical intervention.