Related guidance:

Urinary incontinence and pelvic organ prolapse in women: management NICE guideline (NG123 April 2019, updated June 2019)

Mirabegron for treating symptoms of overactive bladder Technology appraisal guidance (TA290 June 2013)

See Antidepressants in formulary for duloxetine for stress incontinence.

See Vaginal and vulval conditions in formulary for intravaginal oestrogens to treat overactive bladder symptoms in postmenopausal women with vaginal atrophy.

See Antidiuretic hormone disorders for the use of desmopressin in the treatment of nocturnal enuresis.

See NHS choices What are pelvic floor exercises? 

See NHS Formulary Dementia for Anticholinergic Burden Score

Medicines for overactive bladder

  • Before starting treatment with a medicine for overactive bladder, explain to the woman:
    • the likelihood of the medicine being successful
    • the common adverse effects associated with the medicine
    • that some adverse effects of anticholinergic medicines, such as dry mouth and constipation, may indicate that the medicine is starting to have an effect
    • that she may not see substantial benefits until she has been taking the medicine for at least 4 weeks and that her symptoms may continue to improveover time
    • that the long-term effects of anticholinergic medicines for overactive bladder on cognitive function are uncertain.
  • When offering anticholinergic medicines to treat overactive bladder, take account of the woman’s:
    • coexisting conditions (such as poor bladder emptying, cognitive impairment or dementia)
    • current use of other medicines that affect total anticholinergic load
    • risk of adverse effects, including cognitive impairment.
  • For women who have a diagnosis of dementia and for whom anticholinergic medicines are an option, follow the recommendations on medicines that may cause cognitive impairment in the NICE guideline on dementia:

Medicines that may cause cognitive impairment

  • Be aware that some commonly prescribed medicines are associated with increased anticholinergic burden, and therefore cognitive impairment.

  • Consider minimising the use of medicines associated with increased anticholinergic burden, and if possible look for alternatives:

    • when assessing whether to refer a person with suspected dementia for diagnosis
    • during medication reviews with people living with dementia.

Choosing medicine

  • Do not offer women flavoxate, propantheline or imipramine to treat urinary incontinence or overactive bladder.
  • Do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health.
  • Offer the anticholinergic medicine with the lowest acquisition cost to treat overactive bladder or mixed urinary incontinence in women. If the first medicine for overactive bladder or mixed urinary incontinence is not effective or well-tolerated, offer another medicine with a low acquisition cost.
  • Offer a transdermal overactive bladder treatment to women unable to tolerate oral medicines.
  • 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.
  • The use of desmopressin may be considered specifically to reduce nocturia in women with urinary incontinence or overactive bladder who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension.
  • Do not use duloxetine as a first-line treatment for women with predominant stress urinary incontinence. Do not routinely offer duloxetine as a second-line treatment for women with stress urinary incontinence, although it may be offered as second-line therapy if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, counsel women about its adverse effects.
  • Do not offer systemic hormone replacement therapy to treat urinary incontinence.
  • Offer intravaginal oestrogens to treat overactive bladder symptoms in postmenopausal women with vaginal atrophy.

Reviewing medicine

  • Offer a face-to-face or telephone review 4 weeks after starting a new medicine for overactive bladder. Ask the woman if she is satisfied with the treatment and:
    • if improvement is optimal, continue treatment
    • if there is no or suboptimal improvement, or intolerable adverse effects, change the dose or try an alternative medicine for overactive bladder and review again 4 weeks later.
  • Offer a review before 4 weeks if the adverse events of a medicine for overactive bladder are intolerable.
  • Refer women who have tried taking medicine for overactive bladder, but for whom it has not been successful or tolerated, to secondary care to consider further treatment.
  • Offer a further face-to-face or telephone review if a medicine for overactive bladder or urinary incontinence stops working after an initial successful 4-week review.
  • Offer a review in primary care to women who remain on long-term medicine for overactive bladder or urinary incontinence every 12 months, or every 6 months if they are aged over 75.

Lifestyle interventions

  • Recommend a trial of caffeine reduction to women with overactive bladder.
  • Consider advising women with urinary incontinence or overactive bladder and a high or low fluid intake to modify their fluid intake.
  • Advise women with urinary incontinence or overactive bladder who have a BMI greater than 30 to lose weight.

Pelvic floor muscle training

  • Offer a trial of supervised pelvic floor muscle training of at least 3 months’ duration as first-line treatment to women with stress or mixed urinary incontinence.
  • Pelvic floor muscle training programmes should comprise at least 8 contractions performed 3 times per day.
  • Do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of pelvic floor muscle training.
  • Continue an exercise programme if pelvic floor muscle training is beneficial.

Adherence after 3 years is less than 10% regardless of class of drug use with little to differentiate treatment options. See Benefits and harms of pharmacologic treatment for urinary incontinence in women. A systemic review (Ann Intern Med June 2012)

Bedwetting in under 19s Clinical guideline (CG111 October 2010)

Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)		Rationale for decision / comments
Antimuscarinics
Oxybutynin
2.5mg tablet: £1.67 (56)

Immediate release are first-line for overactive bladder or mixed urinary incontinence.

The usual dose is 5 mg two or three times a day. This may be increased up to a maximum of 5 mg four times daily if required to obtain a clinical response, providing that the side effects are tolerated.
5mg tablet: £1.96 (56)
5mg modified-release tablet: £15.63
For overactive bladder or mixed urinary incontinence.

The recommended starting dose is one 5 mg tablet once daily.
After at least one week on 5 mg daily, the dose may be increased to 10 mg once daily, with subsequent incremental increases or decreases of 5 mg/day. There should be an interval of at least one week between dose changes. In patients requiring a higher dose, the total daily dose should not exceed 20 mg.
10mg modified-release tablet: £31.25
3.9mg/24hours transdermal patch: £27.20 (8)For overactive bladder or mixed urinary incontinence for those unable to
tolerate oral medicines. The recommended dose is one 3.9 mg transdermal patch applied twice weekly.
Solifenacin


5mg tablet: £2.37 (30)


First-line for overactive bladder or mixed urinary incontinence.The recommended dose is 5 mg once daily. If needed, the dose may be increased to 10 mg once daily.
10mg tablet: £2.33 ( 30)
as Vesicare®1mg/ml oral suspension sugar free: £27.62 (150ml)For children or patients who have swallowing difficulties as per traffic light guidance (SPF Jan 2019).
Tolterodine

1mg tablet: £2.43 (56)
Second line for overactive bladder or mixed urinary incontinence who are unable to tolerate first line options as per traffic light guidance. The recommended dose is 2 mg twice daily except in patients with impaired liver function or severely impaired renal function (GFR ≤30 ml/min) for whom the recommended dose is 1 mg twice daily. In case of troublesome side effects the dose may be reduced from 2 mg to 1 mg twice daily.
2mg tablet: £2.81 (56)
as Neditol XL®2mg modified-release capsule: £11.60




The recommended dose is 4 mg once daily except in patients with impaired liver function or severely impaired renal function (GFR ≤30 ml/min) for whom the recommended dose is 2 mg once daily. In case of troublesome adverse reactions the dose may be reduced from 4 mg to 2 mg once daily.
4mg modified-release capsule: £12.89
as Mariosea XL®2mg modified-release capsule: £11.59
4mg modified-release capsule: £12.89
as Tolthen XL®2mg modified-release capsule: £6.99
4mg modified-release capsule: £6.99
Trospium 20mg tablet: £10.91 (60)Third line option for overactive bladder or mixed urinary incontinence as per traffic light guidance in women where first- and second-line
choices are not effective or well tolerated.

One tablet twice daily.

In patients with severe renal impairment (creatinine clearance between 10 and 30 mL/min/1.73 m2) the recommended dosage is one tablet per day or every second day.
as Regurin XL®60mg modified-release tablet: £23.05 One capsule once daily, not recommended for use in renally impaired patients.
Propiverine 15mg tablet: £69.02 (56)For overactive bladder or mixed urinary incontinence. One tablet, once or twice daily increased if necessary up to 15mg three times a day. Maximum daily dose of 30mg if eGFR <30mL/min/1.73 m2).
as Detrunorm XL®30mg modified-release capsule: £24.45 One capsule once daily.
Darifenacin7.5mg modified-release tablet: £25.48 For overactive bladder or mixed urinary incontinence. The recommended starting dose is 7.5 mg daily. After 2 weeks of starting therapy, patients should be reassessed. For those patients requiring greater symptom relief, the dose may be increased to 15 mg daily, based on individual response.
15mg modified-release tablet: £25.48
Fesoterodine4mg modified-release tablet: £25.78
Third line for overactive bladder or mixed urinary incontinence as per traffic light guidance (Fesoterodine is a prodrug for tolterodine).

The recommended starting dose is 4 mg once daily. Based upon individual response, the dose may be increased to 8 mg once daily. Dose may need to be reduced with renal or hepatic impairment in the absence and presence of moderate and potent CYP3A4 inhibitors.
8mg modified-release tablet: £25.78
Beta3-adrenoceptor agonist
Mirabegron25mg modified-release tablet: £29.00 (30)

For overactive bladder or mixed urinary incontinence only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects as per traffic lights guidance. (SPF March 2013)

The recommended dose is 50 mg once daily.

Dose may need to be reduced with renal or hepatic impairment in the absence and presence of strong CYP3A inhibitors.

Mirabegron is contraindicated in severe uncontrolled hypertension defined as systolic blood pressure ≥ 180 mm Hg and/or diastolic blood pressure ≥ 110 mm Hg. Blood pressure should be measured at baseline and periodically during treatment with mirabegron.
50mg modified-release tablet: £29.00 (30)
Mirabegron is now contraindicated in patients with severe uncontrolled hypertension; advice about regular monitoring is being introduced because of cases of severe hypertension. See MHRA Drug Safety Update (October 2015) for Mirabegron (Betmiga▼): risk of severe hypertension and associated cerebrovascular and cardiac events