Which classification of medications are most commonly used for urinary incontinence management?

Urinary urgency is a symptom where you have a sudden urgent desire to pass urine and you are not able to put off going to the toilet. If you leak urine before you go to the toilet this is called incontinence. For more information see Lower Urinary Tract Symptoms in Men and Lower Urinary Tract Symptoms in Women.

Medicines for urinary urgency and incontinence are used to decrease the number of urine leakages, the number of trips to the toilet and the feeling of urgency. For people with stress incontinence a medicine called duloxetine may be prescribed.

Duloxetine is normally used to treat depression. However, it was found to help with stress incontinence separate to its effect on depression. Duloxetine is thought to work by increasing the activity of chemicals called serotonin and noradrenaline (norepinephrine) in the body. These chemicals are used in transmitting nerve impulses to muscles. Increasing the action of the chemicals stimulates the muscles around the urethra to contract more strongly.

Medicines from a different class to duloxetine, called antimuscarinics (also called anticholinergics), are used to help treat urge incontinence. There are several different types and many different brand names. They include older medicines such as oxybutynin, tolterodine and flavoxate, as well as newer medicines such as darifenacin, fesoterodine, propiverine, solifenacin and trospium.

These medicines work by blocking certain nerve impulses to the bladder which relax the bladder muscle, so increasing the bladder capacity. Other medicines which are used less often are oestrogen gels/creams applied to the vagina, or a medicine called desmopressin.

A medicine called mirabegron is another option sometimes used to treat urge incontinence. It works by stimulating beta3 receptors in the bladder. This has the effect of relaxing the bladder muscles.

In the past other medicines (for example, propantheline and tricyclic antidepressants) were used to treat urge incontinence; however, they are not used any longer because of their side-effects.

Duloxetine is available as oral capsules. Antimuscarinics are available as capsules, tablets or skin patches. Some antimuscarinic tablets are available as slow-release tablets or capsules. This just means that the medicine is released into the body over a longer period of time and you don't have to take the tablets or capsules as often in the day.

When are medicines for urinary urgency and incontinence usually prescribed?

For people with stress incontinence, duloxetine may be advised if pelvic floor exercises alone are not helping to treat their stress incontinence. It is usually advised in women who do not want to undergo surgery, or in women who have health problems that may mean that surgery is unsuitable.

For people with urge incontinence, lifestyle measures (for example, cutting down on caffeine and alcohol) and bladder retraining are normally tried first. If there is not enough improvement with bladder training alone, medicines may then be considered.

Which medicine is usually prescribed?

As discussed above, duloxetine is prescribed for stress incontinence.

For people with urge incontinence, oxybutinin (an antimuscarinic) is normally prescribed first. If you have too many side-effects with this medicine, your doctor may choose a different antimuscarinic such as darifenacin, fesoterodine, propiverine, solifenacin, tolterodine, or trospium. Your doctor may also choose a slow-release preparation of oxybutinin or an oxybutinin skin patch to help lessen side-effects.

Propiverine is sometimes chosen if you have urinary urgency but you do not have urinary incontinence.

You may be prescribed mirabegron if you are unable to take an antimuscarinic.

Other medicines that are used less often are oestrogen applied to the vagina and desmopressin. These medicines are usually prescribed on the advice of a specialist doctor. Oestrogen applied to the vagina may be chosen for women who have gone through the menopause and desmopressin is considered if you are passing urine frequently at night and you are younger than 65 years of age.

How well do medicines for urinary urgency and incontinence work?

For duloxetine, one study showed that in about 6 in 10 women who took duloxetine, the number of urine leakages halved compared to the time before they took the medication. Therefore, on its own, duloxetine is not likely to cure the incontinence but may help to make it less of a problem. However, duloxetine in addition to pelvic floor exercises may give a better chance of curing the incontinence than either treatment alone.

Antimuscarinic medicines are all thought to be as effective as each other. They may improve symptoms in some cases but not in all. The level of improvement varies from person to person. You may have fewer toilet trips, fewer urine leaks and less urgency. However, it is uncommon for symptoms to go completely with medication alone.

What is the usual length of treatment?

Duloxetine is usually given for about a month; after this, you are assessed to see if your symptoms have improved. If your symptoms have improved, duloxetine may be continued and you are assessed every few months to see if it is still working. Your doctor may decide to stop treatment if your symptoms do not improve. If your doctor thinks that you should stop taking duloxetine you should do this slowly - for example, over 1-2 weeks. You should never stop taking this medicine suddenly. This is because you can have withdrawal symptoms such as dizziness, feeling sick (nausea) and headaches.

For antimuscarinics, a common plan is to try a course of medication for a month or so. If it is helpful, you may be advised to continue for up to six months or so and then stop the medication to see how symptoms are without the medication. Symptoms may return after you finish a course of medication. If you combine a course of medication with bladder training, the long-term outlook (prognosis) is better and symptoms may be less likely to return when you stop the medication. The need for continuing antimuscarinic medicine therapy should be reviewed every 4-6 weeks until symptoms stabilise and then every 6-12 months.

What about side-effects?

Duloxetine

The most commonly reported side-effects are nausea, dry mouth, fatigue and constipation. These usually happen in the first week of treatment but most people find they go away after a few weeks. If these symptoms persist, your doctor may decrease your dose or consider stopping treatment. Some people who take duloxetine have small increases in blood pressure. If you already have high blood pressure or any other heart problems, your doctor will measure your blood pressure regularly. Your doctor may consider stopping treatment if there are concerns about your blood pressure. 

Antimuscarinics

Side-effects are quite common with these medicines but are often minor and tolerable. The most common side-effect is a dry mouth and simply having frequent sips of water may counter this. Other common side-effects include dry eyes, constipation and blurred vision. However, the medicines have differences and you may find that if one medicine causes troublesome side-effects, a switch to a different one may suit you better.

Mirabegron

The most common side-effects are a rapid pulse and urine infections. Less common side-effects include indigestion, palpitations and raised blood pressure.

For a full list of side-effects see the information leaflet that came with your medicine.

Who cannot take medicines for urinary urgency and incontinence?

In general, most people are able to take these medicines; however, there are some people who are unable to take these medicines.

Duloxetine should not be taken by people who have severe kidney or liver problems, uncontrolled high blood pressure, or are taking certain medicines - for example, antidepressants called monoamine-oxidase inhibitors.

Antimuscarinics should not be taken by people with:

• Myasthenia gravis. This is a condition where muscles become easily tired and weak.
• Severe bladder problems or urinary retention (where the body retains urine).
• Severe inflammation of the gut (ulcerative colitis).
• Blockage of the gut.
• A condition of the eye, known as uncontrolled angle-closure glaucoma.

For a full list of people who cannot take these medicines, see the leaflet that came with your medicines.

Can I buy medicines for urinary urgency and incontinence ?

No - you cannot buy medicines for urinary urgency and incontinence. They are only available from your pharmacist, with a doctor's prescription.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:

• The side-effect.
• The name of the medicine which you think caused it.
• The person who had the side-effect.
• Your contact details as the reporter of the side-effect.

It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill out the report.

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