General principles when using overactive bladder drugs
When offering antimuscarinic drugs to treat overactive bladder always take account of:
the woman's coexisting conditions (for example, poor bladder emptying) use of other existing medication affecting the total anticholinergic load risk of adverse effects
Before overactive bladder drug treatment starts, discuss with women:
the likelihood of success and associated common adverse effects, and the frequency and route of administration, and that some adverse effects 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
Prescribe the lowest recommended dose when starting a new overactive bladder drug treatment If a woman's overactive bladder drug treatment is effective and well-tolerated, do not change the dose or drug
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Choosing overactive bladder drugs
Do not use flavoxate, propantheline and imipramine for the treatment of urinary incontinence or overactive bladder in women Do not offer oxybutynin (immediate release) to frail older women (with multiple comorbidities, functional impairments such as walking or dressing difficulties and any degree of cognitive impairment) Offer one of the following choices first to women with overactive bladder or mixed urinary incontinence:
oxybutynin (immediate release), or tolterodine (immediate release), or darifenacin (once daily preparation)
If the first treatment for overactive bladder or mixed urinary incontinence is not effective or well-tolerated, offer another drug with the lowest acquisition cost (solifenacin, fesoterodine, oxybutynin (extended release), oxybutynin (transdermal), oxybutynin (topical gel), propiverine, propiverine (extended release), tolterodine (extended release), trospium and trospium (extended release) Offer a transdermal overactive bladder drug to women unable to tolerate oral medication For guidance on mirabegron for treating symptoms of overactive bladder, refer to Mirabegron for treating symptoms of overactive bladder (NICE technology appraisal guidance 290)
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Reviewing overactive bladder drug treatment
Offer a face-to-face or telephone review 4 weeks after the start of each new overactive bladder drug treatment. Ask the woman if she is satisfied with the therapy:
If improvement is optimal, continue treatment If there is no or suboptimal improvement or intolerable adverse effects, change the dose, or try an alternative overactive bladder drug, and review again 4 weeks later
Offer review before 4 weeks if the adverse events of overactive bladder drug treatment are intolerable Offer referral to secondary care if the woman does not want to try another drug, but would like to consider further treatment Offer a further face-to-face or telephone review if a woman's condition stops responding optimally to treatment after an initial successful 4-week review Review women who remain on long-term drug treatment for urinary incontinence or overactive bladder annually in primary care (or every 6 months for women over 75) Offer referral to secondary care if overactive bladder drug treatment is not successful If the woman wishes to discuss the options for further management (non-therapeutic interventions and invasive therapy) refer to the MDT and arrange urodynamic investigation to determine whether detrusor overactivity is present and responsible for her overactive bladder symptoms:
If detrusor overactivity is present and responsible for the overactive bladder symptoms, offer invasive therapy If detrusor overactivity is present but the woman does not wish to have invasive therapy, offer her advice about managing urinary symptoms, and explain that if she changes her mind at a later date she can book a review appointment to discuss past tests and interventions and reconsider her treatment options If detrusor overactivity is not present, refer back to the MDT for further discussion concerning future management
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