l PRESCRIBING AND DISPENSING INFORMATION The need for
continuing therapy for urinary incontinence should be
reviewed every 4–6 weeks until symptoms stabilise, and
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (July 2008)
that fesoterodine (Toviaz ®) is accepted for restricted use
within NHS Scotland as a second-line treatment for
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 3, 25
Fesoterodine fumarate 4 mg Toviaz 4mg modified-release tablets
| 28 tablet P £25.78 DT = £25.78
Fesoterodine fumarate 8 mg Toviaz 8mg modified-release tablets |
28 tablet P £25.78 DT = £25.78
Urinary frequency |Urinary incontinence |Dysuria |
Urinary urgency | Bladder spasm due to catheterisation,
l CONTRA-INDICATIONS Gastro-intestinal haemorrhage
l INTERACTIONS → Appendix 1: flavoxate
l PREGNANCY Manufacturer advises avoid unless no safer
l BREAST FEEDING Manufacturer advises caution—no
l PRESCRIBING AND DISPENSING INFORMATION The need for
continuing therapy for urinary incontinence should be
reviewed every 4–6 weeks until symptoms stabilise, and
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 3
▶ Urispas (Recordati Pharmaceuticals Ltd)
Flavoxate hydrochloride 200 mg Urispas 200 tablets | 90 tablet P £11.67 DT = £11.67
Urinary frequency | Urinary urgency | Urinary incontinence
| Neurogenic bladder instability
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Child 5–11 years: Initially 2.5–3 mg twice daily,
increased to 5 mg 2–3 times a day
▶ Child 12–17 years: Initially 5 mg 2–3 times a day,
increased if necessary up to 5 mg 4 times a day
▶ Adult: Initially 5 mg 2–3 times a day, increased if
necessary up to 5 mg 4 times a day
▶ Elderly: Initially 2.5–3 mg twice daily, increased if
tolerated to 5 mg twice daily, adjusted according to
▶ BY MOUTH USING MODIFIED-RELEASE TABLETS
▶ Child 5–17 years: Initially 5 mg once daily, adjusted in
steps of 5 mg every week, adjusted according to
response; maximum 15 mg per day
▶ Adult: Initially 5 mg once daily, increased in steps of
5 mg every week, adjusted according to response;
Urinary frequency | Urinary urgency | Urinary incontinence
▶ BY TRANSDERMAL APPLICATION USING PATCHES
▶ Adult: 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
Nocturnal enuresis associated with overactive bladder
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Child 5–17 years: 2.5–3 mg twice daily, increased to
5 mg 2–3 times a day, last dose to be taken before
▶ BY MOUTH USING MODIFIED-RELEASE TABLETS
▶ Child 5–17 years: Initially 5 mg once daily, adjusted in
steps of 5 mg every week, adjusted according to
response; maximum 15 mg per day
DOSE EQUIVALENCE AND CONVERSION
▶ Patients taking immediate-release oxybutynin may be
transferred to the nearest equivalent daily dose of
l CAUTIONS Acute porphyrias p. 1058
l INTERACTIONS → Appendix 1: oxybutynin
▶ Common or very common Diarrhoea
▶ With transdermal use Gastrointestinal discomfort. increased
▶ With oral use Abdominal discomfort. appetite decreased . dysphagia
▶ With transdermal use Back pain . hot flush . injury
778 Bladder and urinary disorders BNF 78
l PREGNANCY Manufacturers advise avoid unless
essential—toxicity in animal studies.
l BREAST FEEDING Manufacturers advise avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution.
l RENAL IMPAIRMENT Manufacturer advises caution.
l DIRECTIONS FOR ADMINISTRATION
▶ With transdermal use in adults Apply patches to clean, dry,
unbroken skin on abdomen, hip or buttock, remove after
every 3–4 days and site replacement patch on a different
area (avoid using same area for 7 days).
l PRESCRIBING AND DISPENSING INFORMATION
▶ In adults The need for continuing therapy for urinary
incontinence should be reviewed every 4–6 weeks until
symptoms stabilise, and then every 6–12 months.
▶ In children The need for therapy for urinary indications
should be reviewed soon after it has been commenced and
then at regular intervals; a response usually occurs within
▶ With transdermal use in adults Patients or carers should be
given advice on how to administer oxybutynin transdermal
Medicines for Children leaflet: Oxybutynin for daytime urinary
symptoms www.medicinesforchildren.org.uk/oxybutynindaytime-urinary-symptoms
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
▶ With transdermal use in adults The Scottish Medicines
Consortium has advised (July 2005) that Kentera ® should be
restricted for use in patients who benefit from oral
oxybutynin but cannot tolerate its side-effects.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 3, 25
▶ Lyrinel XL (Janssen-Cilag Ltd)
Oxybutynin hydrochloride 5 mg Lyrinel XL 5mg tablets |
30 tablet P £13.77 DT = £13.77
Oxybutynin hydrochloride 10 mg Lyrinel XL 10mg tablets | 30 tablet P £27.54 DT = £27.54
CAUTIONARY AND ADVISORY LABELS 3
▶ Oxybutynin hydrochloride (Non-proprietary)
Oxybutynin hydrochloride 3 mg Oxybutynin 3mg tablets | 56 tablet P £15.23 DT = £14.44
Oxybutynin hydrochloride 5 mg Cystrin 5mg tablets | 84 tablet P £21.99
Oxybutynin hydrochloride 2.5 mg Ditropan 2.5mg tablets |
Oxybutynin hydrochloride 5 mg Ditropan 5mg tablets | 84 tablet P £2.90
CAUTIONARY AND ADVISORY LABELS 3
▶ Oxybutynin hydrochloride (Non-proprietary)
Oxybutynin hydrochloride 500 microgram per 1 ml Oxybutynin
2.5mg/5ml oral solution sugar free sugar-free | 150 ml P £154.50–£214.85 DT = £194.26
Oxybutynin hydrochloride 1 mg per 1 ml Oxybutynin 5mg/5ml oral
solution sugar free sugar-free | 150 ml P £199.20–£235.53 DT =
CAUTIONARY AND ADVISORY LABELS 3
▶ Kentera (Orion Pharma (UK) Ltd)
Oxybutynin 3.9 mg per 24 hour Kentera 3.9mg/24hours patches | 8 patch P £27.20 DT = £27.20
Urinary frequency, urgency and incontinence associated
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Adult: 15 mg 1–2 times a day, increased if necessary up
▶ BY MOUTH USING MODIFIED-RELEASE CAPSULES
Urinary frequency, urgency and incontinence associated
with neurogenic bladder instability
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
l INTERACTIONS → Appendix 1: propiverine
▶ Common or very common Abdominal pain . fatigue
▶ Uncommon Taste altered .tremor
▶ Rare or very rare Restlessness
▶ Frequency not known Hallucination
l PREGNANCY Manufacturer advises avoid (restriction of
skeletal development in animals).
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution in
mild impairment; avoid in moderate to severe impairment
l RENAL IMPAIRMENT Manufacturer advises caution in mild
Dose adjustments Max. daily dose 30 mg if eGFR less than
l PRESCRIBING AND DISPENSING INFORMATION The need for
continuing therapy for urinary incontinence should be
reviewed every 4–6 weeks until symptoms stabilise, and
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 3, 25
▶ Detrunorm XL (Advanz Pharma)
Propiverine hydrochloride 30 mg Detrunorm XL 30mg capsules | 28 capsule P £24.45 DT = £24.45
Propiverine hydrochloride 45 mg Detrunorm XL 45mg capsules | 28 capsule P £27.90 DT = £27.90
CAUTIONARY AND ADVISORY LABELS 3
▶ Propiverine hydrochloride (Non-proprietary)
Propiverine hydrochloride 15 mg Propiverine 15mg tablets | 56 tablet P £18.00 DT = £18.00
Propiverine hydrochloride 15 mg Detrunorm 15mg tablets | 56 tablet P £18.00 DT = £18.00
Urinary frequency | Urinary urgency | Urinary incontinence
▶ Adult: 5 mg once daily, increased if necessary to 10 mg
BNF 78 Urinary frequency, enuresis, and incontinence 779
DOSE ADJUSTMENTS DUE TO INTERACTIONS
▶ Manufacturer advises max. dose 5 mg daily with
concurrent use of potent inhibitors of CYP3A4; avoid
concurrent use in patients who also have moderate
hepatic impairment or severe renal impairment.
l CONTRA-INDICATIONS Narrow-angle glaucoma
l CAUTIONS Neurogenic bladder disorder. susceptibility to
l INTERACTIONS → Appendix 1: solifenacin
▶ Common or very common Gastrointestinal discomfort
oedema .taste altered . urinary tract infection
▶ Rare or very rare Hallucination
▶ Frequency not known Anaphylactic reaction . appetite
interval prolongation .renal impairment
l PREGNANCY Manufacturer advises caution—no
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution in
moderate impairment (risk of increased half-life); avoid in
severe impairment (no information available).
Dose adjustments Manufacturer advises maximum 5 mg
Dose adjustments Max. 5 mg daily if eGFR less than
l PRESCRIBING AND DISPENSING INFORMATION The need for
continuing therapy for urinary incontinence should be
reviewed every 4–6 weeks until symptoms stabilise, and
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
▶ Vesicare (Astellas Pharma Ltd)
Solifenacin succinate 1 mg per 1 ml Vesicare 1mg/ml oral
suspension sugar-free | 150 ml P £27.62
CAUTIONARY AND ADVISORY LABELS 3
▶ Vesicare (Astellas Pharma Ltd)
Solifenacin succinate 5 mg Vesicare 5mg tablets | 30 tablet P £27.62 DT = £27.62
Solifenacin succinate 10 mg Vesicare 10mg tablets | 30 tablet P £35.91 DT = £35.91
Urinary frequency |Urinary urgency | Urinary incontinence
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Adult: 2 mg twice daily, reduced if not tolerated to 1 mg
▶ BY MOUTH USING MODIFIED-RELEASE CAPSULES
DOSE EQUIVALENCE AND CONVERSION
▶ Children stabilised on immediate-release tolterodine
tartrate 2 mg twice daily may be transferred to
modified-release tolterodine tartrate 4 mg once daily.
l CAUTIONS History of QT-interval prolongation
l INTERACTIONS → Appendix 1: tolterodine
disorders . paraesthesia . peripheral oedema . vertigo . weight increased
▶ Uncommon Arrhythmia . heart failure . memory loss . nervousness
▶ Frequency not known Hallucination
l PREGNANCY Manufacturer advises avoid—toxicity in
l BREAST FEEDING Manufacturer advises avoid—no
l HEPATIC IMPAIRMENT Manufacturer advises caution (risk
Dose adjustments For immediate-release medicines,
manufacturer advises dose reduction to 1 mg twice daily.
For modified-release capsules, manufacturer advises dose
l RENAL IMPAIRMENT Avoid modified-release preparations
if eGFR less than 30 mL/minute/1.73m2
Dose adjustments Reduce dose to 1 mg twice daily if eGFR
l PRESCRIBING AND DISPENSING INFORMATION The need for
continuing therapy for urinary incontinence should be
reviewed every 4–6 weeks until symptoms stabilise, and
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 3
▶ Tolterodine tartrate (Non-proprietary)
Tolterodine tartrate 1 mg Tolterodine 1mg tablets | 56 tablet P £29.03 DT = £2.21
Tolterodine tartrate 2 mg Tolterodine 2mg tablets | 56 tablet P £30.56 DT = £2.34
Tolterodine tartrate 1 mg Detrusitol 1mg tablets | 56 tablet P £29.03 DT = £2.21
Tolterodine tartrate 2 mg Detrusitol 2mg tablets | 56 tablet P £30.56 DT = £2.34
CAUTIONARY AND ADVISORY LABELS 3, 25
Tolterodine tartrate 4 mg Blerone XL 4mg capsules |
28 capsule P £25.78 DT = £25.78
Tolterodine tartrate 4 mg Detrusitol XL 4mg capsules | 28 capsule P £25.78 DT = £25.78
Tolterodine tartrate 4 mg Efflosomyl XL 4mg capsules | 28 capsule P £20.62 DT = £25.78
Tolterodine tartrate 4 mg Inconex XL 4mg capsules | 28 capsule P £21.91 DT = £25.78
Tolterodine tartrate 2 mg Mariosea XL 2mg capsules |
28 capsule P £11.59 DT = £11.60
Tolterodine tartrate 4 mg Mariosea XL 4mg capsules | 28 capsule P £12.88 DT = £25.78
▶ Neditol XL (Aspire Pharma Ltd)
Tolterodine tartrate 2 mg Neditol XL 2mg capsules | 28 capsule P £11.60 DT = £11.60
Tolterodine tartrate 4 mg Neditol XL 4mg capsules | 28 capsule P £12.89 DT = £25.78
▶ Preblacon XL (Actavis UK Ltd)
Tolterodine tartrate 4 mg Preblacon XL 4mg capsules |
28 capsule P £25.78 DT = £25.78
Tolterodine tartrate 4 mg Santizor XL 4mg capsules | 28 capsule P £25.78 DT = £25.78
780 Bladder and urinary disorders BNF 78
Urinary frequency | Urinary urgency | Urge incontinence
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Adult: 20 mg twice daily, to be taken before food
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
l INTERACTIONS → Appendix 1: trospium
▶ Common or very common Abdominal pain
▶ Uncommon Chest pain . diarrhoea . flatulence
▶ Rare or very rare Arthralgia . asthenia . dyspnoea . myalgia
l PREGNANCY Manufacturer advises caution.
l BREAST FEEDING Manufacturer advises caution.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
mild to moderate impairment; avoid in severe impairment
l RENAL IMPAIRMENT Use with caution. Avoid Regurin ® XL.
Dose adjustments Reduce dose to 20 mg once daily or
20 mg on alternate days if eGFR 10–30 mL/minute/1.73m2
l PRESCRIBING AND DISPENSING INFORMATION The need for
continuing therapy for urinary incontinence should be
reviewed every 4–6 weeks until symptoms stabilise, and
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral solution
CAUTIONARY AND ADVISORY LABELS 23, 25
Trospium chloride 60 mg Regurin XL 60mg capsules |
28 capsule P £23.05 DT = £23.05
CAUTIONARY AND ADVISORY LABELS 23
▶ Trospium chloride (Non-proprietary)
Trospium chloride 20 mg Trospium chloride 20mg tablets | 60 tablet P £9.00 DT = £5.42
Trospium chloride 20 mg Flotros 20mg tablets | 60 tablet P £18.20 DT = £5.42
Trospium chloride 20 mg Regurin 20mg tablets | 60 tablet P £26.00 DT = £5.42
Trospium chloride 20 mg Uraplex 20mg tablets | 60 tablet P £26.00 DT = £5.42
Urinary frequency, urgency, and urge incontinence
DOSE ADJUSTMENTS DUE TO INTERACTIONS
▶ Manufacturer advises reduce dose to 25 mg once daily
in patients with mild hepatic impairment with
concurrent use of potent inhibitors of CYP3A4; avoid
▶ Manufacturer advises reduce dose to 25 mg once daily
if eGFR 30–89 mL/minute/1.73 m2 with concurrent use
of potent inhibitors of CYP3A4; avoid if eGFR less than
l CONTRA-INDICATIONS Severe uncontrolled hypertension
(systolic blood pressure 180 mmHg or diastolic blood
l CAUTIONS History of QT-interval prolongation . stage 2
l INTERACTIONS → Appendix 1: mirabegron
▶ Frequency not known Insomnia
l CONCEPTION AND CONTRACEPTION Contraception advised
in women of child-bearing potential.
l PREGNANCY Avoid—toxicity in animal studies.
l BREAST FEEDING Avoid—present in milk in animal studies.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
moderate impairment (risk of increased exposure); avoid
in severe impairment (no information available).
Dose adjustments Manufacturer advises dose reduction to
25 mg once daily in moderate impairment.
l RENAL IMPAIRMENT Avoid if eGFR less than
Dose adjustments Reduce dose to 25 mg once daily if eGFR
l MONITORING REQUIREMENTS Blood pressure should be
monitored before starting treatment and regularly during
treatment, especially in patients with pre-existing
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Mirabegron for treating symptoms of overactive bladder (June
Mirabegron is recommended as an option only for patients
mirabegron who do not meet these criteria should have the
option to continue until they and their clinician consider it
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 25
▶ Betmiga (Astellas Pharma Ltd)
Mirabegron 25 mg Betmiga 25mg modified-release tablets | 30 tablet P £29.00 DT = £29.00
Mirabegron 50 mg Betmiga 50mg modified-release tablets | 30 tablet P £29.00 DT = £29.00
Urinary retention is the inability to voluntarily urinate. It
may be secondary to urethral blockage, drug treatment (such
as use of antimuscarinic drugs, sympathomimetics, tricyclic
antidepressants), conditions that reduce detrusor
contractions or interfere with relaxation of the urethra,
neurogenic causes, or it may occur postpartum or
Acute urinary retention is a medical emergency characterised
by the abrupt development of the inability to pass urine
Chronic urinary retention is the gradual (over months or
years) development of the inability to empty the bladder
completely, characterised by a residual volume greater than
one litre or associated with the presence of a distended or
Urinary retention due to benign prostatic hyperplasia
The most common cause of urinary retention in men is
benign prostatic hyperplasia. Men with an enlarged prostate
can have lower urinary tract symptoms associated with
obstruction, such as urinary retention (acute or chronic),
frequency, urgency or nocturia.
Treatment of urinary retention depends on the underlying
condition. Catheterisation is used to relieve acute painful
urinary retention or when no cause can be found. Surgical
procedures or dilatation are often used to correct mechanical
g Acute retention is painful and requires immediate
treatment by catheterisation. Before the catheter is removed
an alpha-adrenoceptor blocker (such as alfuzosin
hydrochloride below, doxazosin p. 783, tamsulosin
hydrochloride p. 785, prazosin p. 784, indoramin p. 784 or
terazosin p. 786) should be given for at least two days to
manage acute urinary retention h.
g In patients with chronic urinary retention, intermittent
bladder catheterisation should be offered before an
indwelling catheter. Catheters may be used as a long-term
solution where persistent urinary retention is causing
incontinence, infection, or renal dysfunction and a surgical
solution is not feasible. hTheir use is associated with an
increased risk of adverse events including recurrent urinary
infections, trauma to the urethra, pain, and stone formation.
g In men who have symptoms that are bothersome,
drug treatment should only be offered when other
conservative management options have failed. Men with
tamsulosin hydrochloride or terazosin). Treatment should
initially be reviewed after 4–6 weeks and then every
The parasympathomimetic bethanechol chloride p. 786
increases detrusor muscle contraction. It is licensed for acute
postoperative, postpartum and neurogenic urinary retention
but its use has largely been superseded by catheterisation.
Urinary retention due to benign prostatic hyperplasia
In patients with benign prostatic hyperplasia, treatment is
influenced by the severity of symptoms and their effect on
the patient’s quality of life.g Watchful waiting is suitable
for men with symptoms that are not troublesome and in
those who have not yet developed complications of benign
prostatic hyperplasia such as renal impairment, urinary
retention or recurrent infection.
The recommended treatment of benign prostatic
hyperplasia is usually an alpha-adrenoceptor blocker. The
alpha1-selective adrenoceptor blockers relax smooth muscle
in benign prostatic hyperplasia producing an increase in
urinary flow-rate and an improvement in obstructive
In patients with an enlarged prostate, a raised prostate
specific antigen concentration, and who are considered to be
offered if symptoms remain a problem.
Surgery is recommended for men with more severe
symptoms that do not respond to drug therapy, or who have
complications such as acute urinary retention, haematuria,
renal failure, bladder calculi or recurrent urinary-tract
Other drugs used for urinary retention: neostigmine p. 1125,
pyridostigmine bromide p. 1126.
Lower urinary tract symptoms in men. National Institute for
Health and Care Excellence. Clinical guideline CG97. May
Alfuzosin hydrochloride 21-Jul-2018
▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES
▶ Adult: 2.5 mg 3 times a day; maximum 10 mg per day
▶ Elderly: Initially 2.5 mg twice daily, adjusted according
to response; maximum 10 mg per day
▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES
Acute urinary retention associated with benign prostatic
▶ BY MOUTH USING MODIFIED-RELEASE TABLETS
▶ Elderly: 10 mg once daily for 2–3 days during
catheterisation and for one day after removal; max.
l CONTRA-INDICATIONS Avoid if history micturition syncope . avoid if history of postural hypotension
l CAUTIONS Acute heart failure . concomitant
antihypertensives (reduced dosage and specialist
supervision may be required). discontinue if angina
l INTERACTIONS → Appendix 1: alpha blockers
hypotension . vertigo . vomiting
reactions . syncope . visual impairment
▶ Rare or very rare Angina pectoris . angioedema
▶ Frequency not known Cerebral ischaemia . floppy iris
syndrome . hepatic disorders . neutropenia . priapism . thrombocytopenia
SIDE-EFFECTS, FURTHER INFORMATION First dose may
cause collapse due to hypotensive effect (therefore should
be taken on retiring to bed). Patient should be warned to
lie down if symptoms such as dizziness, fatigue or
sweating develop, and to remain lying down until they
l HEPATIC IMPAIRMENT For immediate-release preparations
manufacturer advises caution in mild to moderate hepatic
failure; avoid in severe hepatic failure (risk of increased
half-life). For modified-release preparations manufacturer
advises avoid in hepatic failure.
Dose adjustments For immediate-release preparations
manufacturer advises initial dose of 2.5 mg once daily,
increased to 2.5 mg twice daily according to response in
mild to moderate hepatic failure.
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