• The patient may have been prescribed the medicine in the past but not wanted to take it.
  This question gives an opportunity for concerns to be aired and answered
• Some patients may have tried an antimuscarinic already and not been able to tolerate the side-effects. Reassurance that the ‘new’ treatment is intended to reduce these effects is helpful
• This is also an opportunity to check that a contraindication to the medication has not been overlooked at the prescribing stage.

• This is good time to find out the patient’s interpretation of the dosing instructions
• Patients are usually advised to start on a low dose to minimise possible side-effects. The dose can then be increased until the medicine is effective.

It is worthwhile helping the patient to identify when they are going to take the medication and how they will set up systems to ensure they don’t forget – perhaps writing it on a calendar, setting an audible reminder on a smart speaker, digital watch or smart phone, or involving carers or family members. Alongside other medicines,
a compliance aid may help.

Show the patient the relevant section of the patient information leaflet.

• This teases out whether the patient understands the long-term nature of the medication
• Antimuscarinics are likely to take two to four weeks to exert their full effect
• NICE recommends that the need for continuing therapy for urinary incontinence should be reviewed every four to six weeks until symptoms stabilise, then every six to 12 months.

• Draw attention to the patient information leaflet to highlight common side-effects, ensuring the definition of “common” is explained in this context
• The main complaint about antimuscarinics is that they cause a dry mouth and constipation. Other common/very common side-effects for antimuscarinics were listed earlier in this module. There are some differences between antimuscarinics, so using the patient information leaflet is helpful, both at the start of treatment and in subsequent conversations with patients about side-effects
• Antimuscarinics can affect the performance of skilled tasks (e.g. driving)
• Experiencing side-effects such as dry mouth and constipation shows that the medicine is actually having an effect. Advice about managing these adverse effects in advance, as well as when they become troublesome, may be helpful. Frequent small sips of water may help a dry mouth, particularly at night. For patients who have a tendency to constipation, suggest actions to take if and when it occurs
• From the PMR, pharmacists can have an idea of the patient’s existing antimuscarinic load and can explore any current side-effects
• A substantial minority of patients discontinue antimuscarinics because of common side-effects. Ultimately the trade-off between side-effects and clinical benefit has to be an individual decision for each patient. Keeping a diary of frequency/urgency/leakage, together with symptoms of possible side-effects at the outset, can help in making this decision
• Common adverse effects of mirabegron include: urinary tract infection; headache and dizziness; tachycardia; nausea; constipation or diarrhoea
• Common adverse effects of duloxetine include: insomnia; headache; constipation or diarrhoea; dry mouth; sweating; loss of appetite; and sexual dysfunction
• Some of the more common side-effects of drug treatment are more likely to occur soon after starting therapy and some may actually subside in due course.

• This is an opportunity to highlight interactions, and how they might occur with other prescribed medicines and OTC products
• Medicines associated with urinary incontinence include diuretics, ACE inhibitors and ARBs, and SSRIs. If the onset of incontinence symptoms has coincided with starting one of these medicines, the patient can be referred back to the prescriber
• HRT (oral oestrogen) and vaginal oestrogen products may have been prescribed for vaginal atrophy or other menopause symptoms. If any incontinence related to these conditions has not been discussed with the prescriber, the patient should be advised to raise this with them.

Alongside bladder training for mixed or urge incontinence and pelvic floor muscle training for mixed or stress incontinence, recommended lifestyle interventions are:

• Weight loss (if BMI over 30)
• Caffeine reduction – this includes restricting coffee, tea and cola drinks
• Fluid management including timing of intake in relation to bedtime. Restrict fluids in the evening (especially caffeinated drinks; alcohol)
• Adjust timing of medicines taking. Time intake of diuretics (take mid-to-late afternoon, six hours before bedtime)
• Reduce physical exertion (e.g. lifting)
• Stop smoking
• Resolve chronic constipation and prevent recurrence.

It is difficult to advise on ‘normal’ fluid intake as there is no professional consensus on this, and evidence is sparse, but altering how much fluid is drunk each day may be helpful. However, drinking too much or too little can make incontinence worse.

Age UK recommends having six to eight drinks per day (200ml each – a normal cup or small glass size). All hot and cold drinks count (including tea and coffee), so keeping a chart on the fridge to keep track can be useful. Remind the patient that foods can be high in fluid (e.g. jelly, creamy sauces, custard and milk on cereal) and need to be counted in the total.

Perhaps counterintuitively, cutting down too much on fluids will usually not help incontinence and could contribute to constipation, which in turn is likely to make incontinence worse, creating a vicious circle. It may also lead to urinary tract infections.

If needing to urinate during the night is a problem, drinking less in the hours before going to bed can help. Different sources give conflicting advice about this, ranging from not drinking after 6pm to not drinking more than one hour before bedtime. There is no hard and fast rule here and patients can experiment to find what works for them, remembering to avoid caffeine later in the day. Alcohol may also aggravate incontinence, particularly at night.

At two weeks the patient should start to experience both beneficial effects on their bladder symptoms alongside the almost ubiquitous side-effects from treatment. Patients can be asked about common side-effects and how troublesome these are. If the side-effects are very troublesome or intolerable at this stage, the patient should be referred back to the prescriber.

At four weeks they are likely to be experiencing maximum clinical benefit and can consider whether the side-effects can be tolerated in the longer term, or if these outweigh the benefits of treatment. Questions like: “Do you think the quality of your life has improved overall” may help this decision-making.

Some patients may feel they ‘have a duty’ to continue a medicine if prescribed by the doctor and may be prepared to endure unpleasant side-effects unnecessarily – or get given a prescription but not take the medication. Non-judgmental questions about adherence may help – e.g. “Are you still happy to take the tablet(s) every day?”

It is also worth pointing out to the patient that each person experiences side-effects differently and that trying other treatment options may be more acceptable than persevering with something that is unpleasant for them. If the patient is unsure about continuing, they can be referred back to the prescriber to discuss this further.