How to manage worsening urinary incontinence in patients taking Risperidone (risperidone)?

Managing Worsening Urinary Incontinence in Patients Taking Risperidone

For patients experiencing worsening urinary incontinence while taking risperidone, the most effective approach is to consider adding an anticholinergic medication such as oxybutynin while maintaining the antipsychotic therapy if it is providing significant clinical benefit. 1

Understanding the Connection

Risperidone-induced urinary incontinence is a documented but underreported adverse effect that can significantly impact quality of life and medication adherence:

• Mechanism: Risperidone can affect neural pathways controlling continence by binding to receptors for neurotransmitters including serotonin, dopamine, acetylcholine, and adrenaline 2
• Prevalence: Higher than reported in literature, with one study finding 14 out of 35 patients (40%) developing urinary incontinence after starting risperidone 3
• Risk factors: Female patients appear to be at higher risk 3

Management Algorithm

Step 1: Rule Out Other Causes

Before attributing incontinence to risperidone, exclude other common causes:

• Urinary tract infection
• Prostatic hyperplasia (in men)
• Neurological conditions
• Medication interactions

Step 2: Consider Clinical Response to Risperidone

Evaluate the therapeutic benefit of risperidone:

If risperidone is providing significant clinical benefit:

• Add pharmacological management for incontinence
• Oxybutynin has shown effectiveness in managing risperidone-induced urinary incontinence 1
• Other options include:
  • Trihexyphenidyl
  • Amitriptyline
  • Ephedrine
  • Desmopressin 2
  • Reboxetine (has shown success in treating risperidone-induced nocturnal enuresis) 4

If risperidone's clinical benefit is modest or alternatives are available:

• Consider dose reduction of risperidone (has shown improvement in urinary incontinence) 3
• Consider switching to another antipsychotic with lower risk of urinary side effects

Step 3: Non-Pharmacological Interventions

Implement alongside medication management:

• Pelvic floor muscle training (PFMT): Recommended as first-line treatment for urinary incontinence with high-quality evidence 5

  • Protocol: 3 sets of 8-12 contractions daily, holding each for 6-8 seconds

• Bladder training: Scheduled voiding with gradual extension of time between voids 5

• Fluid management: Consider 25% reduction in fluid intake 5

Important Considerations

1. Medication Selection for Incontinence Management:

   • Solifenacin has the lowest risk for discontinuation due to adverse effects among antimuscarinics (NNTB of 9 for achieving continence) 5
   • Mirabegron is recommended as a first-choice therapy for urge incontinence due to superior side effect profile 5

2. Monitoring and Follow-up:

   • Schedule follow-up at 4-6 weeks to assess technique and compliance
   • Evaluate treatment response at 8-12 weeks 5
   • Allow sufficient time (8-12 weeks) for behavioral therapies to show benefit 5

3. Caution with Anticholinergic Burden:

   • Be aware of potential additive anticholinergic effects when combining risperidone with anticholinergic medications
   • Monitor for dry mouth, constipation, blurred vision, and cognitive effects

4. Formulation Considerations:

   • Switching from oral to injectable risperidone has been associated with new onset or worsening of urinary incontinence in some cases 6
   • This may be due to more consistent blood levels with injectable formulations

By following this structured approach, clinicians can effectively manage risperidone-induced urinary incontinence while maintaining the therapeutic benefits of antipsychotic treatment, ultimately improving patient quality of life and medication adherence.