Urinary incontinence
Patient > 65 years consider anticholinergic load (see polypharmacy guidance). If initial trial of 1st choice antimuscarinic is ineffective try the alternative first choice option or see 2nd choice options.
5mg once daily, increased if necessary to 10mg once daily.
5mg once daily, increased if necessary to 10mg once daily.
2mg twice daily, reduced if not tolerated to 1mg twice daily.
2mg twice daily, reduced if not tolerated to 1mg twice daily.
4mg once daily.
Mirabegron may be used in patients who have not responded to treatment with two different antimuscarinics or in whom antimuscarinics are not tolerated or contraindicated. It may also be considered as a first line option where there is concern that patients have a high anticholinergic load (see polypharmacy guidance).
50mg once daily.
50mg once daily.
Patient > 65 years consider anticholinergic load (see polypharmacy guidance).
4mg once daily, increased if necessary up to 8mg once daily.
4mg once daily, increased if necessary up to 8mg once daily.
3rd line agents may be initiated on the advice of a specialist when tolerability issues or contra-indications to first or second line agents. Patient > 65 years consider anticholinergic load (see polypharmacy guidance).
One tablet daily.
Patient > 65 years consider anticholinergic load (see polypharmacy guidance). Oxybutynin patches are reserved for use in patients if side effects have occurred with tablets.
Apply 1 patch twice weekly.
As per specialist.
As per specialist.
As per specialist.
Prescribing Notes:
- Please see individual board referral pathways for Male Lower Urinary Tract Symptoms and Urinary Symptoms in the Female. For NHS Lothian see RefHelp.
- Drugs used to treat urinary frequency and incontinence should be used along with non-drug measures, including pelvic floor muscle exercises, bladder retraining, monitoring fluid intake and lifestyle changes.
- Antimuscarinic therapy should be reviewed after 6 months and if symptoms are well-controlled therapy may be reduced or discontinued as symptoms may not recur.
- Patients’ response to drugs within this class is idiosyncratic. It may be necessary to try different drugs before a response occurs. A number of therapeutic formulary options are available – patients can have a trial of 3 different anticholinergics before treatment failure.
- There is no evidence that oestrogens cause subjective or objective improvement of symptoms of urgency and urge incontinence.
- Anticholinergics (including oxybutynin, tolterodine, fesoterodine, solifenacin) have long been linked to impaired cognition and falls risk, and more recently have also been linked to increased morbidity and mortality. Further information about anticholinergic load can be read in the Scottish Government Polypharmacy Guidance.
- Baseline blood pressure monitoring should be completed prior to initiation of mirabegron and regular monitoring is advised. Do not initiate mirabegron if blood pressure is out with normal parameters.
- Mirabegron has been shown to be less likely to cause dry mouth than tolterodine, overall discontinuation rates with mirabegron are similar to tolterodine. There is no trial evidence to suggest mirabegron is more effective than antimuscarinics.
- Most patients will respond to solifenacin 5mg, which should be trialled for at least 4 weeks before considering a dose increase to 10mg.
- Botulinum toxin type A (Botox) is approved for use in the management of urinary incontinence in adult patients with neurogenic detrusor overactivity due to subcervical spinal cord injury (traumatic or non-traumatic) or MS, who are not adequately managed with anticholinergics; patients should be already catheterising or willing and able to catheterise if required.
- Botulinum toxin type A (Botox) is approved for restricted use for the management of bladder dysfunctions in adult patients who are not adequately managed with anticholinergics: overactive bladder with symptoms of urinary incontinence, urgency and frequency. Restricted to use in patients who have failed appropriate oral treatment options.
History Notes
18/05/2022
East Region Formulary content agreed.
Pelvic floor muscle exercises.
Specialist Referral and consider physiotherapy for pelvic floor muscle exercises and support.
Duloxetine AND pelvic floor muscle exercises.
For moderate to severe stress urinary incontinence, 40mg twice daily, assessed after 2-4 weeks and reduced to 20mg twice daily if side-effects are troublesome.
For moderate to severe stress urinary incontinence, 40mg twice daily, assessed after 2-4 weeks and reduced to 20mg twice daily if side-effects are troublesome.
Prescribing Notes:
- Duloxetine is rarely used; the prescribing of duloxetine should only be initiated in secondary care by a gynaecologist or urologist.
- Patients should be reviewed after 4 weeks and 12 weeks of therapy to assess progress and the treatment discontinued if no improvement is demonstrated.
- Duloxetine is restricted to use, by the Scottish Medicines Consortium (SMC), in moderate to severe stress incontinence in women as part of an overall management strategy in addition to pelvic floor muscle exercises.
- NICE NG123 states that duloxetine should not be used as a first line treatment for stress urinary incontinence. It should not be routinely used as a 2nd line treatment but may be offered as an alternative to surgical treatment.
History Notes
18/05/2022
East Region Formulary content agreed.