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7.4 Drugs for genito-urinary disorders

NICE CG 97: Lower urinary tract symptoms in men: assessment and management

Derbyshire Overactive bladder guideline

7.4.1    Drugs for Urinary Retention

Indoramin tablets
Alfuzosin tablets (1st line); XL tablets (3rd line option)
Tamsulosin capsules (2nd line)
Carbachol tablets
Distigmine tablets

 

7.4.2    Drugs for Urinary Frequency, Enuresis and Incontinence

Oxybutynin tablets (1st line)
Tolterodine tablets (2nd line), XL capsules
Trospium Chloride tablets (3rd line)
Solifenacin tablets (3rd line) used for non-responders or those with contraindications
Mirabegron tablets (3rd line option for over-active bladder) - See NICE TA290 and DSU (risk of severe hypertension)
Fesoterodine tablets
Propiverine Hydrochloride tablets (for neurogenic bladder)
Duloxetine capsules - for moderate-to-severe stress urinary incontinence (to be initiated by specialists only: urology, gynaecology) after pelvic floor muscle training.
Desmopressin tablets (available for primary nocturnal enuresis)

Notes:

1. Objective assessment of urinary frequency by frequency volume chart should be obtained before starting drug therapy. Metabolic disorders, such as diabetes or bladder obstruction should be excluded.

2. Simple bladder training will be sufficient for many patients with urinary frequency. There are self-help booklets, which will help many patients understand the importance of fluid intake and caffeine intake in frequency, which may avoid needless medication.

3. Solifenacin should always be initiated at 5mg od as >50% of patients should respond well to this dose and there is no evidence to suggest severe symptoms respond any better to higher doses. However, those with an inadequate response at 1 month may titrate to 10mg (except those with eGFR <30ml/min or moderate hepatic impairment where the dose is limited to 5mg).

4. Mirabegron is a beta-3 adrenoreceptor agonist. It is associated with a lower incidence of dry mouth compared to tolterodine MR. However, it is contraindicated in patients with severe uncontrolled hypertension, and BP should be monitored before starting and regularly during treatment. 

5. Desmopressin nasal spray is not now indicated for primary nocturnal enuresis due to a high percentage of adverse drug reactions compared to tablets.

6. Desmopressin tablets are expensive and should be reserved for those patients who have problems with nasal preparations.

 

7.4.3    Drugs used in urological pain

Potassium citrate effervescent tablets ("effercitrate")
Ascorbic acid effervescent tablets

Note:

One Potassium citrate effervescent  tablet is equivalent to 5ml of the traditional mixture of potassium citrate. It should be noted that each tablet contains 13.9 mmol K+.

 

7.4.4    Bladder instillations and urological surgery

Sodium chloride 0.9%
Uro-Tainer Solution G - citric acid 3.23%
Uro-Tainer Solution R  - citric acid 6%
Glycine 1.5%
Hexaminolevulinate (Hexvix) - Photodynamic diagnostic aid in the detection of superficial bladder cancer (in particular highly malignant carcinoma-in-situ).

 

Prophylactic use

The prophylactic use of topical antiseptics e.g. chlorhexidine to prevent bacteriuria is of doubtful value in preventing infection of the urinary tract; infection with resistant organisms has been reported. Therefore, prophylactic bladder irrigations are not recommended.

Therapeutic use

For established bladder infection in catheterised patients appropriate systemic therapy may be necessary if the patient shows systemic signs of infection such as raised temperature.

Sodium chloride 0.9% washouts may be helpful as an adjunct. Chlorhexidine 1 in 5000 solution (0.02%) is not recommendedas it may irritate the mucosa and cause burning and haematuria.

For established endcrustation Solution G (citric acid 3.2%) should be used daily. If neccessary this can be changed to Solution R which is a more concentrated citrate solution.

Smaller volumes (e.g. 30-50ml) of bladder instillations are being used more frequently nowadays.

 

7.4.5    Drugs for Erectile Dysfunction

Alprostadil injection, urethral application (MUSE)
Papaverine injection
Phentolamine injection
Sildenafil tablets
Tadalafil tablets

Note:

Apomorphine Sublinqual - For Patients where Sildenafil has not been effective or has caused side effects

Tadalafil is for 2nd line use only.

 

For link to BNF section: 7.4 Drugs for genito-urinary disorders