Specific treatment guidance is available for:

• Management of lower urinary tract symptoms (LUTS) in men
• Management of urinary incontinence in women

For urinary frequency, urgency, or incontinence in children, refer to the local continence service (South Devon & Torbay and western locality)

Drugs used for urinary frequency, enuresis, and incontinence not listed here:

• Desmopressin (See 6.5.2 Posterior pituitary hormones and antagonists)
• Duloxetine (See section 4.3.4 Other antidepressant drugs)

7.4.2.1 Anticholinergic Medicines

Indicated for primary bladder instability, overactive bladder, urge incontinence and mixed incontinence. Anticholinergic medicines should not be used for stress incontinence.

Use with caution in elderly or frail patients, (increased susceptibility to adverse effects). Consider lower starting dose and slower titrations.

Long-term effects of anticholinergic drugs on cognitive function are uncertain. Consider the potential impact of coexisting conditions (e.g., cognitive impairment or dementia) and the concurrent use of other medicines that affect total anticholinergic load.

Anticholinergic drugs increase the risk of acute angle closure glaucoma.

See SmPC for dosing recommendations/contraindications in hepatic and renal impairment and with concomitant use of certain medications.

Solifenacin succinate

• Tablets 5mg, 10mg (£1.22 = 5mg daily)
• Oral suspension sugar free 1mg/1ml (£27.62 = 150ml)

Indications and dose

• Urinary frequency, urgency and urge incontinence in adults:
  • 5mg once daily, increased if necessary to 10mg once daily.
• Neurogenic detrusor overactivity in children aged 2-17 years, using oral suspension (specialist):
  • Body-weight 9-15kg: initially 2mg once daily, increased if necessary up to 4mg once daily.
  • Body-weight 16-30kg: Initially 3mg once daily, increased if necessary up to 5mg once daily.
  • Body-weight 31-45kg: Initially 3mg once daily, increased if necessary up to 6mg once daily.
  • Body-weight 46-60kg: Initially 4mg once daily, increased if necessary up to 8mg once daily.
  • Body-weight 61kg and above: Initially 5mg once daily, increased if necessary up to 10mg once daily.

Notes

1. Tablets are not licensed for use in children.
2. Oral suspension: Doses should be followed by a glass of water, avoiding ingestion with food or other drinks (See BNF for further details).
3. Neurogenic detrusor overactivity: Review the continued need for therapy at least every 12 months.

Tolterodine tartrate

• Tablets 1mg, 2mg (£2.50 = 2mg twice daily)
• Modified-release capsules 4mg (click here for preferred brand)

Indications and dose

• Urinary frequency, urgency, or incontinence in adults:
  • Immediate-release: 2mg twice daily, reduced to 1mg twice a day if not tolerated.
  • Modified-release: 4mg once daily. Only indicated where tolterodine immediate-release tablets are effective but not tolerated.

Notes

1. Tolterodine should be used with caution in patients with a history of QT-interval prolongation or in those patients also taking drugs that prolong the QT interval.
2. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).

Fesoterodine fumarate

• Modified-release tablets 4mg, 8mg (£3.05 = 4mg daily)

Indications and dose

• Urinary frequency, urgency and urge incontinence in adults where solifenacin and tolterodine are effective but not tolerated:
  • 4mg once daily, increased if necessary to maximum 8mg once daily.

Trospium

• Tablets 20mg (£10.07 = 20mg twice daily)
• Modified-release capsules 60mg (£23.05 = 60mg daily)

Indications and dose

• Urinary frequency, urgency and incontinence in adults at risk of cognitive impairment (e.g., dementia):
  • Immediate-release: 20mg twice daily, before food.
  • Modified-release: 60mg once daily.

Notes

1. Modified-release trospium is not routinely recommended for initiation in primary care without advice and guidance from urology due to high acquisition costs; treatment may be continued in established patients.

Darifenacin

• Modified-release tablets 7.5mg, 15mg (£25.48 = 7.5mg daily)

Indications and dose

• Urinary frequency, urgency and incontinence in adults following specialist advice (where other anticholinergics are ineffective or not tolerated):
  • 7.5mg once daily, increased to 15mg once daily after 2 weeks if necessary.

Notes

1. Darifenacin is not routinely recommended for initiation in primary care without advice and guidance from urology due to high acquisition costs; treatment may be continued in established patients.

Oxybutynin hydrochloride

• Tablets 2.5mg, 5mg (£1.89 = 5mg three times daily)
• Modified-release tablets 5mg, 10mg (£32.72 = 10mg daily)
• Patches 36mg (3.9mg oxybutynin/24 hours) (£27.20 = 8 patches)

Indications and dose

• Urinary frequency, urinary urgency, urinary incontinence, neurogenic bladder instability following specialist advice (See note 2):
  • Immediate-release: Initially 5mg 2–3 times daily, increased if necessary to maximum 5mg 4 times daily; elderly initially 2.5mg twice daily, increased to 5mg twice daily according to response and tolerability.
  • Modified-release: Initially 5mg once daily, adjusted according to response in steps of 5mg at weekly intervals; maximum 20mg once daily.
• Urinary frequency, urinary urgency, urinary incontinence for adults who are unable to take oral medicines following specialist advice (See note 2):
  • Transdermal patch: 1 patch twice a week. Applied to abdomen, hip, or buttock. Site replacement patch on a different area, avoiding the same area for 7 days.
• Hyperhidrosis which has not responded to a topical aluminium antiperspirant and self-care management strategies (second line) (off-label):
  • Immediate-release: Initially 2.5mg once daily, adjusted according to response and tolerability; maximum 10mg daily given in two to four divided doses.
  • Modified-release: Where immediate-release products are not tolerated. Initially 5mg once daily, increased if required to a maximum dose of 10mg once daily.

Notes

1. Medicine Supply Notification MSN/2023/116 (18 December 2023): Oxybutynin 5mg modified-release tablets
   1. Oxybutynin 5mg modified-release tablets are out of stock until mid-July 2024.
   2. Oxybutynin immediate-release formulations (tablets and liquids) remain available and can support increased demand, as can alternative anticholinergic agents.
   3. Refer to the MSN for advice on prescribing.
2. Oxybutynin for urinary incontinence in adults is not routinely recommended for initiation in primary care without advice and guidance from urology due to tolerability (including potential for cognitive impairment); treatment may be continued in established patients.
3. Although it is an off-label use, specialists advise that for patients with hyperhidrosis, oxybutynin is considered ahead of the licensed alternative (propantheline bromide) owing to greater evidence of efficacy and lower cost.

7.4.2.2 Beta-3 adrenoreceptor agonists

Vibegron

• Tablets 75mg (£24.90)
  

Indications and dose

• Symptoms of overactive bladder syndrome in adults if antimuscarinic medicines are not suitable, do not work well enough or have unacceptable side effects
  • 75mg once daily
  • Hepatic impairment: no dose adjustment required in mild to moderate impairment. Not recommended in severe impairment due to lack of data
  • Renal impairment: no dose adjustment required in mild, moderate or severe impairment. Not recommended in end stage renal disease (eGFR <15ml/min/1.73m²) due to lack of data

Notes

1. Patients with uncontrolled hypertension (systolic BP ≥180 mmHg and/or diastolic BP ≥100 mmHg) were excluded from the pivotal phase 3 trial of vibegron.
2. Vibegron is not recommended in women of childbearing potential not using contraception. Avoid in pregnancy and breastfeeding. Refer to SmPC for further information.
3. Vibegron tablets may be crushed, mixed with a tablespoon (approximately 15 mL) of soft food (e.g. apple sauce) and taken immediately with a glass of water.
4. NICE TA999 (September 2024): Vibegron is recommended as an option for treating the symptoms of overactive bladder syndrome in adults. It is only recommended if antimuscarinic medicines are not suitable, do not work well enough or have unacceptable side effects.

Mirabegron

• Modified-release tablets 25mg, 50mg (£27.07 = 50mg daily)

Indications and dose

• Urinary frequency, urgency or incontinence in adults where anticholinergic drugs are contraindicated, ineffective, or not tolerated: 
  • 50mg once daily.
  • Hepatic impairment: Reduce dose to 25mg once daily in moderate impairment. Not recommended in severe hepatic impairment due to lack of data
    • Concurrent use of strong CYP3A inhibitors and hepatic impairment: reduce dose to 25mg once daily in mild impairment; avoid in moderate and severe impairment
  • Renal impairment: Reduce dose to 25mg once daily in severe impairment (eGFR 15-29mL/min/1.73m²). Not recommended in end stage renal disease (eGFR < 15mL/min/1.73m²) due to lack of data
    • Concurrent use of strong CYP3A inhibitors and renal impairment: reduce dose to 25 mg once daily if eGFR 30–89 mL/minute/1.73m²; avoid if eGFR less than 30 mL/minute/1.73m²

Notes

1. Mirabegron is not recommended in women of childbearing potential not using contraception. Avoid in pregnancy and breastfeeding. Refer to SmPC for further information.
2. NICE TA290 (June 2013): Mirabegron is recommended 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.
3. MHRA Drug Safety Update (October 2015): Mirabegron: risk of severe hypertension and associated cerebrovascular and cardiac events
   1. Mirabegron is contraindicated in patients with severe uncontrolled hypertension (systolic blood pressure ≥180 mm Hg or diastolic blood pressure ≥110 mm Hg, or both)
   2. Blood pressure should be measured before starting treatment and monitored regularly during treatment, especially in patients with hypertension