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 antihypertensives
| 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)
| | | | | 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 |
| |
