7.4.1 Drugs for urinary retention
Alpha-blockers relax smooth muscle in benign prostatic hyperplasia producing an increase in urinary flow rate and an improvement in obstructive symptoms. Watchful waiting may be preferable to treatment in men with mild to moderate symptoms. Alpha-blockers are the treatment of choice for benign prostatic obstruction, and are likely to provide symptom relief in men with prostates of any size. The effect should be noticed within several days, with full response after 4-6 weeks. They appear to be equally effective but there are differences in tolerability. All alpha-blockers reduce blood pressure, and first doses may cause drowsiness and dizziness. Modified release preparations may reduce these effects. Patients also receiving antihypertensives may need lower doses and supervision.
Tamsulosin capsules m/r should be used first line, but some patients may experience a higher incidence of adverse sexual dysfunction, so alfuzosin m/r is often preferable for those in whom this is an issue.
|First Line |
| GREEN Tamsulosin capsules m/r 400microgram |
| Second Line |
| GREEN Alfuzosin tablets m/r 5mg, 10mg |
| tablets 2.5mg |
| GREEN Doxazosin tablets 1mg, 2mg, 4mg |
| (Note M/R preps of Doxazosin should NOT be prescribed.) |
|GREEN Terazosin tablets 2mg, 5mg |
|AMBER Tamsulosin 400mcg/dutasteride 500mcg |
|AMBER Bethanechol tablets 10mg, 25mg (rarely used) |
|RED Distigmine tablets 5mg (for post-operative use in gynaecology patients only) |
| Urinary incontinence |
|Bladder training lasting for a minimum of 6 weeks should be offered as first-line treatment to women with urge or mixed |
|Urinary incontinence. A trial of supervised pelvic floor muscle training of at least 3 months’ duration should be offered as first-line treatment to women with stress or mixed Urinary incontinence. |
|Tolterodine or Oxybutynin should be offered to women with OAB or mixed UI as first-line drug treatment if bladder |
|training has been ineffective. When offering antimuscarinic drugs to treat OAB always take account of: |
| > coexisting conditions (for example, poor bladder emptying, constipation, glaucoma) |
| > use of other existing medication affecting the total antimuscarinic load |
| > risk of adverse effects |
|Discuss with patient: |
| > the likelihood of success and associated common adverse effects, and |
| > the frequency and route of administration, and |
| > that some adverse events 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 |
|Oxybutynin immediate release is recommended by NICE but some patients may not tolerate its adverse effects if used |
|on a regular basis. However, some patients prefer to use an immediate release product to enable them to take prior to |
|certain situations, allowing them to use it 'as required'. This can also be helpful in allowing patients to balance the |
|benefits with the side effects, enabling them to retain control of the timing of their treatment. |
|If after a 4 week trial first choice treatment is ineffective or not tolerated then solifenacin, darifenacin or trospium. |
|should be considered as second line alternatives. Women should be counselled about the adverse effects of |
|antimuscarinic drugs. The need for continuing antimuscarinic drug therapy should be reviewed after 6 months. |
|In accordance with NICE TA290 Mirabegron is recommended as an option ONLY for patients in whom antimuscarinic |
|drugs are ineffective, contra-indicated, or not tolerated. |
|If treatment remains ineffective or is not tolerated patients should be referred to secondary care for further |
|investigations. Propiverine and Fesoterodine are available as treatment options as Amber traffic light drugs |
|First Line Choices |
| GREEN Tolterodine capsules (IR) 2mg (twice daily) |
| GREEN Tolterodine capsules (m/r) 4mg (once daily) |
| GREEN Oxybutynin tablets (I/R) 5mg (2-3 times daily) |
| GREEN Oxybutynin tablets m/r 5mg, 10mg (once daily) |
| AMBER Oxybutynin patches 3.9mg/24hrs (Kentera®) |
| Second Line Choices |
| GREEN Solifenacin tablets 5mg, 10mg |
| GREEN Darifenacin tablets m/r 7.5mg, 15mg |
| GREEN Trospium capsules m/r 60mg |
|Other options available to secondary care |
| AMBER Propiverine Hydrochloride tablets 15mg |
| AMBER Propiverine Hydrochloride m/r capsules 30mg |
| AMBER Fesoterodine tablets 4mg, 8mg |
Mirabegron is recommended by NICE TA290 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 dose needs to be reduced in renal/hepatic impairment. Patient’s should be reviewed 4 weeks after initiating.
Following a review by the European Medicines Agency and the Medicines and Healthcare products Regulatory Agency (MHRA), there are now new recommendations for the use of Betmiga▼ (mirabegron).
The new recommendations follow a review by the European Medicines Agency of cumulative data associated with mirabegron and increased blood pressure. Serious cases of hypertension and increased blood pressure have been reported in patients on mirabegron treatment.
In addition, there have been some reports of hypertensive crisis and cerebrovascular and cardiac events associated with hypertension with a clear temporal relationship with the use of mirabegron.
Its use in patients with severe uncontrolled high blood pressure is now contraindicated. Blood pressure should be measured at the start of treatment and monitored regularly, especially in patients with hypertension.
GREEN Mirabegron tablets 25mg, 50mg
Oxybutyin patches are not routinely recommended and should be reserved only for individuals who are unable to tolerate oral medication.
A guideline for the management of the condition can be found here
7.4.3 Drugs used in urological pain
| Alkalinisation of urine |
| GREEN Potassium citrate (30%) mixture BP |
| RED Potassium citrate matrix tablets (Urocit-K®) 5mEq, 10mEq (unlicensed) |
| For use in specific group of patients only |
| GREEN Sodium bicarbonate capsules 500mg |
| GREEN Sodium bicarbonate tablets 600mg |
| Acidification of urine |
| GREEN Ascorbic acid (Vitamin C) tablets 500mg |
| Pentosan polysulfate sodium may be used for bladder pain or discomfort associated with interstitial cystitis. |
| RED Pentosan polysulfate sodium (Elmiron®) 100mg tablets -(Unlicensed) |
| Pentosan polysulfate sodium is recommended as an option for treating bladder pain syndrome with glomerulations |
| or Hunner's lesions in adults with urinary urgency and frequency, and moderate to severe pain as per NICE TA610 |
| RED Pentosan polysulfate sodium (Elmiron®) 100mg tablets CCG Commissioned |
7.4.4 Bladder instillations and urological surgery
| Irrigation for infected bladder or dissolution of blood clots |
| GREEN Sodium chloride solution 0.9% |
| Interstitial cystitis |
|Dimethyl sulphoxide may be used for symptomatic relief in patients with interstitial cystitis. Treatment may be repeated |
|every two weeks but long term use requires ophthalmic, renal and hepatic assessment every 6 months. |
| RED Dimethyl sulphoxide (DMSO) bladder instillation 50% (50mL) – (unlicensed) |
| Sodium hyaluronate may be used as a bladder coating therapy to treat the symptoms of interstitial cycstitis. |
| RED Sodium hyaluronate (Cystistat®) intravesical instillation (40 mg in 50 mL) -(Unlicensed) |
| Urological surgery |
| RED Purisole® irrigation solution |
| Catheter Patency Solutions |
| GREEN Sodium chloride 0.9% (OptiFlo S® solution 50ml) |
| GREEN Solution G (OptiFlo G® solution 50mL) |
| GREEN Solution R (OptiFlo R® solution 50mL) |
| Bladder Cancer Installations see section 8.2.4 (BCG) and 8.1.2 (Mitomycin) |
An amendment to the SLS regulations, effective from the 1 August 2014 means that prescribers will no longer be required to annotate prescriptions for the generic erectile dysfunction tablet sildenafil with the letters "SLS".
Following consultation the Department of Health (DH) selected to remove sildenafil from the list of medicines that may only be prescribed where they meet the selected list scheme requirements.
Whilst generically written prescriptions for sildenafil no longer require the prescriber to annotate the prescription with the letters “SLS” the branded version of the drug - Viagra s should be annotated “SLS” in order to be valid for NHS prescribing. Viagra is black lighted in East Lancashire.
The regulation amendment applies only to generic sildenafil. Other oral PDE5 for erectile dysfunction remain subject to the “SLS” requirements.
Prescribers should make clear to any patients prescribed sildenafil outside the selected list scheme that they will not be eligible for other treatment options for erectile dysfunction on NHS prescription, unless they met the appropriate “SLS” criteria. If treatment with sildenafil proves unsuccessful and patients do not meet SLS criteria then any alternative treatment for erectile dysfunction should be offered on a private prescription.
Prescribing of other PDE5 preparations should be in line with the Health Service Circular Guidelines (HSC 1999/115). NHS prescriptions (endorsed "SLS") can be issued for alprostadil, tadalafil, vardenafil and certain vacuum tumescence devices to men suffering from erectile dysfunction who have these medical conditions: diabetes, prostate cancer or prostatectomy, spinal cord injury, radical pelvic surgery or severe pelvic injury, parkinson's disease, renal failure requiring dialysis or following transplant, multiple sclerosis, spina bifida, poliomyelitis, single gene neurological disease, plus men who were receiving treatment for erectile dysfunction who was a member of the EU before 14th september 1998. GPs can issue private prescriptions for the above drugs and devices for patients on their list who do not meet these criteria, but cannot charge patients for issuing a private prescription.
In cases where erectile dysfunction is causing severe distress ALL prescribing should only be carried out from specialist services.
| Sildenafil |
|When used for any unlicensed indication e.g. Raynaud's all prescribing must be retained by the specialists. GP's are |
|unable to prescribe due to the restrictions for all PDE-5 inhibitors. The PPD will not re-imburse prescriptions for any |
| unlicensed use. |
| First Line |
| GREEN Generic Sildenafil tablets 25mg, 50mg, 100mg |
|Trial lowest effective dose. Consider moving to second line choice only when maximum strength dose has been tried on eight occasions. |
| Second line |
| GREEN Tadalafil tablets 10mg, 20mg* |
| * GREEN - More than one treatment a week may be considered in younger patients such as those suffering from |
| severe distress. Prescribing and supply for this group of patients should either be retained by the psychosexual |
| service or a maximum of 3 month’s supply can be issued by a GP at the request of the psychosexual service whilst |
| under specialist care. Treatment beyond 3 months is not recommended. |
|AMBER Alprostadil (Caverject® or Viridal Duo®) Injection: 10microgram, 20microgram |
|AMBER Papaverine injection (unlicensed) |
Vardenafil remains available on formulary for any patients started on this drug prior to July 2012
| AMBER Alprostadil (Vitraos®) Cream |
| treatment option in line with Erectile Dysfunction Guidelines if resistant to PDE5 inhibitors |
| GREEN Alprostadil (Vitraos®) Cream |
| treatment option in line with Erectile Dysfunction Guidelines if PDE5 inhibitors not tolerated or contra-indicated |
| AMBER Alprostadil (Muse®) urethral sticks |
| treatment option in line with Erectile Dysfunction Guidelines - SPECIALIST INITIATION |
| Please refer to the Erectile Dysfunction Guideline - click here |
| Aviptadil (VIP) 25micrograms / Phentolamine Mesilate 2mg (Invicorp) (solution for injection) |
Specilaist initiation only, Reserved for patients not responding or intolerant to Alprostadil, as an option before referral for surgical procedure.
| AMBER Aviptidil with Phentolamine Mesilate 25mcg/2mg/0.35ml (Invicorp®) |
| solution for injection |