| 7.4.1 Drugs for urinary retention | Alpha-blockers relax smooth muscle in benign prostatic hyperplasia producing an increase in urinary
| flow rate and improvement in obstructive symptoms. Watchful waiting may be preferable to treatment
| in men with mild to moderate symptoms. Alpha-blockers are the treatment of choice for benign
| prostatic obstruction, and are likely to provide symptom relief in men with prostates of any size.
| The effect should be noticed within several days, with full response after 4-6 weeks. They appear
| to be equally effective but there are differences in tolerability. All alpha-blockers reduce blood
| | pressure, and first doses may cause drowsiness and dizziness. Modified release preparations may | | reduce these effects. Patients also receiving anti-hypertensives may need lower doses and supervision. | Tamsulosin capsules m/r should be used first line, but some patients may experience a higher
| incidence of adverse sexual dysfunction, so alfuzosin m/r is often preferable for those in whom this is
| an issue.
| First Line
| GREEN Tamsulosin capsules m/r 400microgram
| | | Second Line
| GREEN Alfuzosin tablets m/r 5mg, 10mg
| | tablets 2.5mg | GREEN Doxazosin tablets 1mg, 2mg, 4mg
| | (Note M/R preps of Doxazosin should NOT be prescribed.) | GREEN Terazosin tablets 2mg, 5mg
| AMBER Tamsulosin 400mcg/dutasteride 500mcg
| | | Parasympathomimetics
| AMBER Bethanechol tablets 10mg, 25mg (rarely used)
| RED Distigmine tablets 5mg (for post-operative use in gynaecology patients only)
| | | | Back to Main Chapter |
| | 7.4.2 Drugs for urinary frequency, enuresis and incontinence | | See Overactive Bladder Syndrome Guidelines | Urinary incontinence
| Bladder training lasting for a minimum of 6 weeks should be offered as first-line treatment to women
| with urge or mixed urinary incontinence. A trial of supervised pelvic floor muscle training of at least 3 months’ duration should be offered as first-line treatment to women with stress or mixed Urinary
| | incontinence. Tolterodine or Oxybutynin should be offered to women with Over Active Bladder (OAB) | | or mixed Urinary Incontinence as first-line drug treatment if bladder training has been ineffective. | When offering antimuscarinic drugs to treat OAB always take account of:
|
> coexisting conditions (for example, poor bladder emptying, constipation, glaucoma)
|
> use of other existing medication affecting the total antimuscarinic load
|
> risk of adverse effects
|
| |
Discuss with patient:
|
| > the likelihood of success and associated common adverse effects, and |
| > the frequency and route of administration, and |
| > that some adverse events such as dry mouth and constipation may indicate that treatment is |
starting to have an effect, and that they may not see the full benefits until they have been taking
|
| the treatment for 4 weeks. |
Oxybutynin immediate release is recommended by NICE but some patients may not tolerate its adverse
|
effects if used on a regular basis. However, some patients prefer to use an immediate release product
|
to enable them to take prior to certain situations, allowing them to use it 'as required'. This can also be
|
helpful in allowing patients to balance the benefits with the side effects, enabling them to retain control
|
of the timing of their treatment. If after a 4 week trial first choice treatment is ineffective or not tolerated then solifenacin, darifenacin or trospium should be considered as second line alternatives. Women
|
should be counselled about the adverse effects of antimuscarinic drugs.
|
The need for continuing antimuscarinic drug therapy should be reviewed after 6 months.
|
In accordance with NICE TA290 Mirabegron is recommended as an option ONLY for patients in whom
|
antimuscarinic drugs are ineffective, contra-indicated, or not tolerated.
|
If treatment remains ineffective or is not tolerated patients should be referred to secondary care for further investigations.
|
Propiverine and Fesoterodine are available as treatment options as AMBER traffic light drugs.
|
| |
| |
GREEN Tolterodine capsules (IR) 2mg (twice daily)
|
GREEN Tolterodine capsules (m/r) 4mg (once daily)
|
GREEN Oxybutynin tablets (I/R) 5mg (2-3 times daily
|
GREEN Oxybutynin tablets m/r 5mg, 10mg (once daily)
|
AMBER Oxybutynin patches 3.9mg/24hrs (Kentera®)
|
| |
Second Line Choices
|
GREEN Solifenacin tablets 5mg, 10mg
|
GREEN Darifenacin tablets m/r 7.5mg, 15mg
|
GREEN Trospium capsules m/r 60mg
|
| |
Other options available to secondary care
|
AMBER Propiverine Hydrochloride tablets 15mg
|
AMBER Propiverine Hydrochloride m/r capsules 30mg
|
AMBER Fesoterodine MR tablets 4mg, 8mg
|
| |
Mirabegron is recommended by NICE TA290 as an option for treating the symptoms of overactive bladder only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective,
|
or have unacceptable side effects. The dose needs to be reduced in renal/hepatic impairment. Patient’s
|
| should be reviewed 4 weeks after initiating. |
| |
Following a review by the European Medicines Agency and the Medicines and Healthcare products
|
Regulatory Agency (MHRA), there are now new recommendations for the use of Betmiga▼
|
| (mirabegron). |
The new recommendations follow a review by the European Medicines Agency of cumulative data
|
associated with mirabegron and increased blood pressure. Serious cases of hypertension and increased blood pressure have been reported in patients on mirabegron treatment.
|
|
In addition, there have been some reports of hypertensive crisis and cerebrovascular and cardiac
|
events associated with hypertension with a clear temporal relationship with the use of mirabegron.
|
Its use in patients with severe uncontrolled high blood pressure is now contraindicated. Blood
|
pressure should be measured at the start of treatment and monitored regularly, especially in
|
| patients with hypertension. |
| |
GREEN Mirabegron tablets 25mg, 50mg
|
| |
Oxybutyin patches are not routinely recommended and should be reserved only for individuals who are
|
| unable to tolerate oral medication. |
| A guideline for the management of the condition can be found here |
| Back to Main Chapter |
