Tablets, f/c, alfuzosin hydrochloride 2.5 mg, net price 60-tab pack = £3.88. Counselling, initial dose, driving, see above
Xatral® (Sanofi-Aventis) 
Tablets, f/c, alfuzosin hydrochloride 2.5 mg, net price 60-tab pack = £20.37. Counselling, initial dose, driving, see above
Modified release
Besavar® XL (Zentiva) 
Tablets, m/r, yellow/white, alfuzosin hydrochloride 10 mg, net price 30-tab pack = £12.51. Label: 21, 25, counselling, initial dose, driving, see above
Dose benign prostatic hyperplasia 10 mg once daily
Acute urinary retention associated with benign prostatic hyperplasia in men over 65 years, 10 mg once daily for 2–3 days during catheterisation and for one day after removal; max. 4 days
Vasran® XL (Ranbaxy) 
Tablets, m/r, alfuzosin hydrochloride 10 mg, net price 30-tab pack = £11.48. Label: 21, 25, counselling, initial dose, driving, see above
Dose benign prostatic hyperplasia 10 mg once daily
Xatral® XL (Sanofi-Aventis) 
Tablets, m/r, yellow/white, alfuzosin hydrochloride 10 mg, net price 10-tab pack = £4.17, 30-tab pack = £12.51. Label: 21, 25, counselling, initial dose, driving, see above
Dose benign prostatic hyperplasia 10 mg once daily
Acute urinary retention associated with benign prostatic hyperplasia in men over 65 years, 10 mg once daily for 2–3 days during catheterisation and for one day after removal; max. 4 days
DOXAZOSIN
Indications benign prostatic hyperplasia; hypertension (section 2.5.4)
Cautions see notes above and section 2.5.4
Contra-indications see notes above
Hepatic impairment section 2.5.4
Side-effects see notes above and section 2.5.4
Dose
Initially 1 mg daily; dose may be doubled at intervals of 1–2 weeks according to response, up to max. 8 mg daily; usual maintenance 2–4 mg daily
INDORAMIN
Indications benign prostatic hyperplasia; hypertension (section 2.5.4)
Cautions see notes above and section 2.5.4
Contra-indications see notes above and section 2.5.4
Hepatic impairment section 2.5.4
Renal impairment section 2.5.4
Side-effects see notes above and section 2.5.4
Dose
20 mg twice daily; increased if necessary by 20 mg every 2 weeks to max. 100 mg daily in divided doses; ELDERLY, 20 mg at night may be adequate
PRAZOSIN
Indications benign prostatic hyperplasia; hypertension, congestive heart failure and Raynaud’s syndrome (section 2.5.4)
Cautions see notes above and section 2.5.4
Contra-indications see notes above and section 2.5.4
Hepatic impairment section 2.5.4
Renal impairment section 2.5.4
Side-effects see notes above and section 2.5.4
Dose
Initially 500 micrograms twice daily for 3–7 days, subsequently adjusted according to response; usual maintenance (and max.) 2 mg twice daily; ELDERLY initiate with lowest possible dose
First dose effect 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 abate completely
TAMSULOSIN HYDROCHLORIDE
Indications benign prostatic hyperplasia
Contra-indications see notes above
Hepatic impairment avoid in severe impairment
Renal impairment use with caution if eGFR less than 10 mL/minute/1.73 m2
Side-effects see notes above
Dose
400 micrograms daily
154Tamsulosin hydrochloride (Non-proprietary) 
Capsules, m/r, tamsulosin hydrochloride 400 micrograms, net price 30-cap pack = £4.64. Label: 25, counselling, driving
Brands include Bazetham® MR, Contiflo® XL, Diffundox® XL, Losinate ® MR, Pinexel® PR, Prosurin® XL, Stronazon® MR, Tabphyn® MR
Flomaxtra® XL (Astellas) 
Tablets, m/r, tamsulosin hydrochloride 400 micrograms, net price 30-tab pack = £10.47. Label: 25, counselling, driving
With solifenacin
For prescribing information on solifenacin, see section 7.4.2
Vesomni® (Astellas) 
Tablets, m/r, f/c, red, tamsulosin hydrochloride 400 micrograms, solifenacin succinate 6 mg, net price 30-tab pack = £27.62. Label: 3, 25
Dose ADULT over 18 years, moderate to severe urinary frequency, urgency, and obstructive symptoms associated with benign prostatic hyperplasia when monotherapy ineffective, 1 tablet daily
TERAZOSIN
Indications benign prostatic hyperplasia; hypertension (section 2.5.4)
Cautions see notes above and section 2.5.4
Driving May affect performance of skilled tasks e.g. driving
Contra-indications see notes above
Side-effects see notes above and section 2.5.4
Dose
Initially 1 mg at bedtime; if necessary dose may be doubled at intervals of 1–2 weeks according to response, up to max. 10 mg once daily; usual maintenance 5–10 mg daily
First dose effect 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 abate completely
Terazosin (Non-proprietary) 
Tablets, terazosin (as hydrochloride) 2 mg, net price 28-tab pack = £2.44; 5 mg, 28-tab pack = £2.76; 10 mg, 28-tab pack = £8.04. Counselling, initial dose, driving
Hytrin® (AMCo) 
Tablets, terazosin (as hydrochloride) 2 mg (yellow) net price, 28-tab pack = £2.20; 5 mg (tan), 28-tab pack = £4.13; 10 mg (blue), 28-tab pack = £8.24; starter pack (for benign prostatic hyperplasia) of 7 × 1-mg tab with 14 × 2-mg tab and 7 × 5-mg tab = £10.97. Counselling, initial dose, driving
Parasympathomimetics
The parasympathomimetic bethanechol increases detrusor muscle contraction. However, it has only a limited role in the relief of urinary retention; its use has been superseded by catheterisation.
BETHANECHOL CHLORIDE 
Indications urinary retention, but see notes above
Cautions autonomic neuropathy (use lower initial dose); interactions: Appendix 1 (parasympathomimetics)
Contra-indications peptic ulcer; intestinal or urinary obstruction; conditions where increased motility of the urinary or gastro-intestinal tract could be harmful; cardiovascular disorders (including recent myocardial infarction, bradycardia, and heart block); hypotension; obstructive airways disease; epilepsy; parkinsonism; hyperthyroidism
Pregnancy manufacturer advises avoid — no information available
Breast-feeding manufacturer advises avoid; gastro-intestinal disturbances in infant reported
Side-effects nausea, vomiting, diarrhoea, abdominal pain, increased salivation, eructation; flushing, hypotension, bradycardia; bronchoconstriction, rhinorrhoea; headache; increased lacrimation; increased sweating
Dose
10–25 mg 3–4 times daily half an hour before food
7.4.2 Drugs for urinary frequency, enuresis, and incontinence
Urinary incontinence
Incontinence in adults which arises from detrusor instability is managed by combining drug therapy with conservative methods for managing urge incontinence such as pelvic floor exercises and bladder training; stress incontinence is generally managed by non-drug methods. Duloxetine, an inhibitor of serotonin and noradrenaline re-uptake can be added and is licensed for the treatment of moderate to severe stress incontinence in women; it may be more effective when used as an adjunct to pelvic floor exercises.
Antimuscarinic drugs reduce symptoms of urgency and urge incontinence and increase bladder capacity. Oxybutynin also has a direct relaxant effect on urinary smooth muscle. Side-effects limit the use of oxybutynin, but they may be reduced by starting at a lower dose. A modified-release preparation of oxybutynin is effective and has fewer side-effects; a transdermal patch is also available. The efficacy and side-effects of tolterodine are comparable to those of modified-release oxybutynin. Flavoxate has less marked side-effects but it is also less effective. Darifenacin, fesoterodine, propiverine, solifenacin, and trospium are newer antimuscarinic drugs licensed for urinary frequency, urgency, and incontinence. The need for continuing antimuscarinic drug therapy should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months.
The Scottish Medicines Consortium has advised (June 2008) that fesoterodine (Toviaz®) is accepted for restricted use within NHS Scotland as a second-line treatment for overactive bladder syndrome.
Propantheline and tricyclic antidepressants were used for urge incontinence but they are little used now because of their side-effects. The use of imipramine is limited by its potential to cause cardiac side-effects.
Mirabegron, a selective beta3 agonist, is licensed for the treatment of urinary frequency, urgency, and urge incontinence associated with overactive bladder syndrome.
NICE guidance
Mirabegron for treating symptoms of overactive bladder (June 2013)
Mirabegron is recommended as an option only for patients in whom antimuscarinic drugs are ineffective, contra-indicated, or not tolerated; patients currently receiving mirabegron who do not meet these criteria should have the option to continue until they and their clinician consider it appropriate to stop.
Purified bovine collagen implant (Contigen®, Bard) is indicated for urinary incontinence caused by intrinsic sphincter deficiency (poor or non-functioning bladder outlet mechanism). The implant should be inserted only by surgeons or physicians trained in the technique for injection of the implant.
Cautions Antimuscarinic drugs should be used with caution in the elderly (especially if frail), in those with autonomic neuropathy, and in those susceptible to angle-closure glaucoma. They should also be used with caution in hiatus hernia with reflux oesophagitis. Antimuscarinics can worsen hyperthyroidism, coronary artery disease, congestive heart failure, hypertension, prostatic hyperplasia, arrhythmias, and tachycardia. For interactions, see Appendix 1 (antimuscarinics).
Contra-indications Antimuscarinic drugs should be avoided in patients with myasthenia gravis, significant bladder outflow obstruction or urinary retention, severe ulcerative colitis, toxic megacolon, and in gastro-intestinal obstruction or intestinal atony.
Side-effects Side-effects of antimuscarinic drugs include dry mouth, gastro-intestinal disturbances including constipation, flatulence, taste disturbances, blurred vision, dry eyes, drowsiness, dizziness, fatigue, difficulty in micturition (less commonly urinary retention), palpitation, and skin reactions (including dry skin, rash, and photosensitivity); also headache, diarrhoea, angioedema, arrhythmias, and tachycardia. Central nervous system stimulation, such as restlessness, disorientation, hallucination, and convulsion may occur; children are at higher risk of these effects. Antimuscarinic drugs can reduce sweating, leading to heat sensations and fainting in hot environments or in patients with fever, and very rarely may precipitate angle-closure glaucoma.
DARIFENACIN
Indications urinary frequency, urgency, and incontinence
Cautions see notes above
Contra-indications see notes above
Hepatic impairment max. 7.5 mg daily in moderate impairment; avoid in severe impairment
Pregnancy manufacturer advises avoid — toxicity in animal studies
Breast-feeding present in milk in animal studies — manufacturer advises caution
Side-effects see notes above; also less commonly ulcerative stomatitis, oedema, hypertension, dyspnoea, cough, rhinitis, weakness, insomnia, impotence, and vaginitis
Dose
ADULT over 18 years, 7.5 mg once daily, increased if necessary after 2 weeks to 15 mg once daily
DULOXETINE
Indications moderate to severe stress urinary incontinence in women; major depressive disorder (section 4.3.4); diabetic neuropathy (section 4.3.4); generalised anxiety disorder (section 4.3.4)
Cautions elderly; cardiac disease; hypertension (avoid if uncontrolled); history of mania; history of seizures; raised intra-ocular pressure, susceptibility to angle-closure glaucoma; bleeding disorders or concomitant use of drugs that increase risk of bleeding; interactions: Appendix 1 (duloxetine)
Withdrawal Nausea, vomiting, headache, anxiety, dizziness, paraesthesia, sleep disturbances, and tremor are the most common features of abrupt withdrawal or marked reduction of the dose; dose should be reduced over at least 1–2 weeks
Hepatic impairment manufacturer advises avoid
Renal impairment avoid if eGFR less than 30 mL/minute/1.73 m2
Pregnancy toxicity in animal studies — avoid in patients with stress urinary incontinence; risk of neonatal withdrawal symptoms if used near term
Breast-feeding present in milk — manufacturer advises avoid
Side-effects nausea, vomiting, dyspepsia, constipation, diarrhoea, abdominal pain, weight changes, decreased appetite, flatulence, dry mouth; palpitation, hot flush; insomnia, abnormal dreams, paraesthesia, drowsiness, anxiety, headache, dizziness, fatigue, weakness, tremor, nervousness, anorexia; sexual dysfunction; visual disturbances; sweating, pruritus; less commonly gastritis, halitosis, hepatitis, bruxism, dysphagia, tachycardia, hypertension, postural hypotension, syncope, raised cholesterol, vertigo, taste disturbance, cold extremities, impaired temperature regulation, impaired attention, movement disorders, muscle twitching, musculoskeletal pain, thirst, stomatitis, hypothyroidism, urinary disorders, and photosensitivity; rarely mania; very rarely angle-closure glaucoma; also reported supraventricular arrhythmia, chest pain, hallucinations, suicidal behaviour (see Suicidal Behaviour and Antidepressant Therapy), seizures, hypersensitivity reactions including urticaria, angioedema, rash (including Stevens-Johnson syndrome) and anaphylaxis, hyponatraemia (see Hyponatraemia and Antidepressant Therapy)
Dose
ADULT over 18 years, 40 mg twice daily, assess for benefit and tolerability after 2–4 weeks
Note Initial dose of 20 mg twice daily for 2 weeks can minimise side-effects
Yentreve® (Lilly) 
Capsules, duloxetine (as hydrochloride) 20 mg (blue), net price 28-cap pack = £18.48, 56-cap pack = £30.80; 40 mg (orange/blue), 56-cap pack = £36.96. Label: 2
Cymbalta® (Lilly) 
Section 4.3.4 (major depressive episode, generalised anxiety disorder, and diabetic neuropathy)
FESOTERODINE FUMARATE
Indications urinary frequency, urgency, and urge incontinence
Cautions see notes above; gastro-oesophageal reflux
Contra-indications see notes above
Hepatic impairment manufacturer advises increase dose cautiously; max. 4 mg daily in moderate impairment; avoid in severe impairment; consult product literature before concomitant use of cytochrome P450 enzyme inhibitors
Renal impairment increase dose cautiously if eGFR 30–80 mL/minute/1.73 m2; max. 4 mg daily if eGFR less than 30 mL/minute/1.73 m2; consult product literature before concomitant use of cytochrome P450 enzyme inhibitors
Pregnancy manufacturer advises avoid — toxicity in animal studies
Breast-feeding manufacturer advises avoid — no information available
Side-effects see notes above; also insomnia; less commonly nasal dryness, pharyngolaryngeal pain, cough, and vertigo
Dose
ADULT over 18 years, 4 mg once daily, increased if necessary to max. 8 mg once daily
Note Max. 4 mg daily with concomitant atazanavir, clarithromycin, indinavir, itraconazole, ritonavir, saquinavir, or telithromycin; in patients with hepatic or renal impairment, consult product literature before concomitant use with amprenavir, aprepitant, atazanavir, clarithromycin, diltiazem, erythromycin, fluconazole, fosamprenavir, indinavir, itraconazole, ritonavir, saquinavir, telithromycin, verapamil, or grapefruit juice
FLAVOXATE HYDROCHLORIDE
Indications urinary frequency and incontinence, dysuria, urgency; bladder spasms due to catheterisation, cytoscopy, or surgery
Cautions see notes above
Contra-indications see notes above; gastro-intestinal haemorrhage
Pregnancy manufacturer advises avoid unless no safer alternative
Breast-feeding manufacturer advises caution — no information available
Side-effects see notes above; also vertigo, eosinophilia, leucopenia, urticaria, erythema, and pruritus
Dose
ADULT and CHILD over 12 years, 200 mg 3 times daily
MIRABEGRON
Indications urinary frequency, urgency, and urge incontinence
Cautions history of QT-interval prolongation; concomitant use with drugs that prolong the QT interval; interactions: Appendix 1 (mirabegron)
Contra-indications severe hypertension
Hepatic impairment avoid in severe impairment — no information available; reduce dose to 25 mg once daily in moderate impairment; with concomitant use of strong cytochrome P450 inhibitors such as itraconazole, ritonavir, or clarithromycin reduce dose to 25 mg once daily in mild impairment and avoid in moderate impairment
Renal impairment avoid if eGFR less than 15 mL/minute/1.73 m2 — no information available; reduce dose to 25 mg once daily if eGFR 15–29 mL/minute/1.73m2; with concomitant use of strong cytochrome P450 inhibitors such as itraconazole, ritonavir, or clarithromycin reduce dose to 25 mg once daily if eGFR 30–89 mL/minute/1.73 m2 and avoid if eGFR less than 30 mL/minute/1.73 m2
Pregnancy avoid — toxicity in animal studies; contraception advised in women of child-bearing potential
Breast-feeding avoid — present in milk in animal studies
Side-effects tachycardia, urinary-tract infection; less commonly dyspepsia, gastritis, palpitation, atrial fibrillation, hypertension, vulvovaginal infection and pruritus, joint swelling, rash, pruritus
Dose
ADULT over 18 years, 50 mg once daily
NICE Technology Appraisal
NICE recommended. See Mirabegron for treating symptoms of overactive bladder (July 2013)
OXYBUTYNIN HYDROCHLORIDE
Indications urinary frequency, urgency and incontinence, neurogenic bladder instability, and nocturnal enuresis associated with overactive bladder
Cautions see notes above; acute porphyria (section 9.8.2)
Contra-indications see notes above
Hepatic impairment manufacturer advises caution
Renal impairment manufacturer advises caution
Pregnancy manufacturers advise avoid unless essential — toxicity in animal studies
Breast-feeding manufacturers advise avoid — present in milk
Side-effects see notes above; also less commonly anorexia, facial flushing; rarely night terrors; application site reactions with patches; also reported cognitive impairment
Dose
ADULT and CHILD over 12 years, initially 5 mg 2–3 times daily, increased if necessary to max. 5 mg 4 times daily; ELDERLY initially 2.5–3 mg twice daily, increased to 5 mg twice daily according to response and tolerance; CHILD 5–12 years, neurogenic bladder instability, 2.5–3 mg twice daily, increased to 5 mg 2–3 times daily; CHILD under 5 years see BNF for Children; CHILD 5–18 years, nocturnal enuresis associated with overactive bladder, 2.5–3 mg twice daily increased to 5 mg 2–3 times daily (last dose before bedtime)
Oxybutynin Hydrochloride (Non-proprietary) 
Tablets, oxybutynin hydrochloride 2.5 mg, net price 56-tab pack = £2.03; 3 mg, 56-tab pack = £16.10; 5 mg, 56-tab pack = £2.89, 84-tab pack = £4.07. Label: 3
Cystrin® (Zentiva) 
Tablets, oxybutynin hydrochloride 5 mg (scored), net price 84-tab pack = £21.99. Label: 3
Ditropan® (Sanofi-Aventis) 
Tablets, both blue, scored, oxybutynin hydrochloride 2.5 mg, net price 84-tab pack = £1.60; 5 mg, 84-tab pack = £2.90. Label: 3
Elixir, oxybutynin hydrochloride 2.5 mg/5 mL, net price 150-mL pack = £6.88. Label: 3
Modified release
Lyrinel® XL (Janssen) 
Tablets, m/r, oxybutynin hydrochloride 5 mg (yellow), net price 30-tab pack = £13.77; 10 mg (pink), 30-tab pack = £27.54. Label: 3, 25
Dose ADULT over 18 years, initially 5 mg once daily, adjusted according to response in steps of 5 mg at weekly intervals; max. 20 mg once daily; CHILD 5–18 years see BNF for Children
Note Patients taking immediate-release oxybutynin may be transferred to the nearest equivalent daily dose of Lyrinel® XL
Transdermal preparations
Kentera® (Orion) 
Patches, self-adhesive, oxybutynin 36 mg (releasing oxybutynin approx. 3.9 mg/24 hours), net price 8-patch pack = £27.20. Label: 3, counselling, administration
Dose ADULT over 18 years, urinary frequency, urgency and incontinence, apply 1 patch twice weekly 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)
Note 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
PROPANTHELINE BROMIDE
Indications adult enuresis
Cautions see notes above; ulcerative colitis
Contra-indications see notes above
Hepatic impairment manufacturer advises caution
Renal impairment manufacturer advises caution
Pregnancy manufacturer advises avoid — no information available
Breast-feeding may suppress lactation
Side-effects see notes above; also facial flushing
Dose
Initially 15 mg 3 times daily at least one hour before food and 30 mg at bedtime, subsequently adjusted according to response (max. 120 mg daily)
PROPIVERINE HYDROCHLORIDE
Indications urinary frequency, urgency and incontinence associated with overactive bladder or neurogenic bladder instability
Cautions see notes above
Contra-indications see notes above
Hepatic impairment avoid in moderate to severe impairment
Renal impairment manfacturer advises caution in mild or moderate impairment; max. daily dose 30 mg if eGFR less than 30 mL/minute/1.73 m2
Pregnancy manufacturer advises avoid (restriction of skeletal development in animals)
Breast-feeding manufacturer advises avoid — present in milk in animal studies
Side-effects see notes above
Dose
Overactive bladder, ADULT over 18 years, 15 mg 1–2 times daily, increased if necessary to max. 15 mg 3 times daily
Neurogenic bladder instability, ADULT over 18 years, 15 mg 3 times daily
Detrunorm® (AMCo) 
Tablets, pink, s/c, propiverine hydrochloride 15 mg, net price 56-tab pack = £18.00. Label: 3
Modified release
Detrunorm® XL (AMCo) 
Capsules, orange/white, m/r, propiverine hydrochloride 30 mg, net price 28-cap pack = £24.45. Label: 3, 25
Dose overactive bladder, ADULT over 18 years, urinary frequency, urgency, and incontinence, 30 mg once daily
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