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Incontinence, Urinary Retention, Polyuria & Urinary Retention

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Lifestyle Advice

  • Reduce caffeine - may improve symptoms of urgency and frequency but not incontinence.
  • Fluid intake — avoid drinking either excessive amounts, or reduced amounts, of fluid each day
  • BMI > 30 kg/m
  • Smoking  

Incontinence In Women

First-Line

  • Oxybutynin (immediate release) 
    • Not in older women who may have an increased risk of sudden physical or mental health deterioration
    • Oxybutyinin patch
      • Apply 1 patch twice weekly, patch is to be applied to clean, dry unbroken skin on abdomen, hip or buttock. Patch should be removed every 3–4 days and site replacement patch on a different area. The same area should be avoided for 7 days.
      • When oral medication nt tolerated
  • tolterodine (immediate release)
  • darifenacin (once daily preparation)
  • Do not offer flavoxate, propantheline, or imipramine
  • Side effects dry mouth and constipation may indicate that anticholinergic medicine is starting to work
  • The long-term effects of anticholinergic drugs on cognitive function are uncertain for women using them for overactive bladder

Second-Line 

  • Oxybutynin extended release.
  • Propiverine or propiverine (extended release)
  • Solifenacin
  • Trospium (extended release)

Third-Line

  • Mirabegron

Vaginal atrophy in post-menopausal women

Troublesome Nocturia in Women

  •  desmopressin (off-label indication)
    • Avoid in women aged 65 years or over with cardiovascular disease or hypertension.

Nocturnal Polyuria in Men

  • If limiting fluid intake in the late afternoon and evening is ineffective, consider offering a loop diuretic to be taken in the late afternoon, for example furosemide 40 mg (off-label use). For detailed prescribing information, see the section on Furosemide.
  • If nocturnal polyuria remains bothersome, consider one of the following two options:
    • Refer the man to a urologist for assessment and further management. 
    • Seek specialist advice about switching to oral desmopressin to be taken at bedtime.
      • Be aware that elderly people (age 65 years and older) are at increased risk of hyponatraemia and renal impairment with oral desmopressin.
      • For detailed prescribing information, see the section on Desmopressin.
  • Provide advice on sources of additional information and support. 
    • The Bladder and Bowel Foundation has a helpline (telephone 01536 533 255) and provides a range of resources on their website www.bladderandbowelfoundation.org).

Overractive Bladder in Men

  • Prudent fluid intake, especially that fluid intake should not be limited excessively in an attempt to control symptoms, as doing this could increase the risk of complications (such as urinary tract infection).
    • Lifestyle measures, such as avoiding constipation (or treating it if present); maintaining a healthy lifestyle (with respect to body weight, exercise, diet, smoking, and alcohol consumption); and limiting intake of caffeine, artificial sweeteners, and fizzy drinks.
  • If necessary, offer a choice of temporary urine containment products (such as sheath and leg bags, absorbent pads, and absorbent pants) to achieve social continence, and refer the man to the local continence service.
    • To find the local continence service, telephone the Bladder and Bowel Foundation on 01536 533 255 or contact the local district nursing team.
    • Be aware that only products listed within the Appliances section of the Drug tariff can be prescribed on the FP10.
  • Offer referral for supervised bladder training — this may be available from the local continence nurse, continence physiotherapist, or urology clinic.
  • If symptoms persist, offer an antimuscarinic (anticholinergic) drug.
    • Oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation) can be used first line.
      • Do not offer oxybutynin (immediate release) to frail older men due to the risk of impairment of daily functioning, chronic confusion, or acute delirium (less common).
      • If the first-line drug treatment is not effective or tolerated, offer an alternative drug.
    • Review the man every 4–6 weeks until symptoms are stable, then every 6–12 months. During the review, re-assess symptoms and quality of life (for example using the International Prostate Symptom Score [IPSS] questionnaire) and assess for adverse effects and the need to continue treatment.
    • For detailed prescribing information, see the section on Antimuscarinics.
  • If an antimuscarinic drug is contraindicated, not tolerated, or not effective, offer mirabegron (depending on local prescribing policy).
    • Review at 4–6 weeks to assess tolerability and efficacy.
    • For detailed prescribing information, see the section on Mirabegron.

Urinary Retention in Men

  • If the man has recurrent acute retention or acute-on-chronic urinary retention, admit the man, or insert a urethral catheter. Discuss and decide on treatment to prevent or manage recurrent urine retention. Options include:

    • An alpha-blocker (modified-release alfuzosin 10 mg a day) — in men over 65 years of age.
      • Start at least 24 hours before attempting to remove the catheter.
      • After removing the catheter, confirm over several hours that the man can void freely.
      • The licensed duration of use is for 2–3 days during catheterization, and for 1 day after removal (maximum 4 days). However, some experts recommend that the alpha-blocker should be continued until the man has been fully investigated to determine the cause and to assess renal function.
      • For detailed prescribing information, see the section on Alpha-blockers.

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