From the Guidelines
For nocturnal incontinence not responding to Myrbetriq (mirabegron), I recommend trying desmopressin (DDAVP) as an alternative treatment, as suggested by the most recent guidance from the European Urology journal in 2022 1. Desmopressin is typically started at 0.1-0.2 mg orally at bedtime, with the dose potentially adjusted based on response. Another option would be an anticholinergic medication such as solifenacin (Vesicare) 5-10 mg daily or oxybutynin 5 mg at bedtime, as recommended by the American College of Physicians guideline in 2014 1. Before starting any new medication, the patient should have a thorough evaluation to determine the specific type of incontinence (overflow, stress, or urge) as this affects treatment choices. Lifestyle modifications should also be implemented, including fluid restriction 2-3 hours before bedtime, avoiding caffeine and alcohol in the evening, and scheduled voiding before sleep. Desmopressin works by reducing urine production overnight by mimicking antidiuretic hormone, while anticholinergics reduce bladder muscle contractions. Side effects of desmopressin include hyponatremia (particularly in older adults), so sodium levels should be monitored. Anticholinergics may cause dry mouth, constipation, and blurred vision. A urologist or urogynecologist consultation would be beneficial for persistent symptoms. Key considerations in managing nocturnal incontinence include:
- Evaluating and treating underlying medical conditions that may be contributing to nocturia, as emphasized in the 2022 European Urology guidance 1
- Assessing the patient's overall health and prioritizing the management of underlying conditions over nocturia treatment, if necessary
- Implementing lifestyle modifications to reduce nocturia symptoms, such as fluid restriction and avoiding caffeine and alcohol in the evening
- Monitoring for potential side effects of medications and adjusting treatment plans accordingly.
From the Research
Treatment Options for Nocturnal Incontinence
The patient is already taking Myrbetriq (mirabegron) but reports that it does not help with nocturnal incontinence. Considering this, the following treatment options can be explored:
- Desmopressin: Studies have shown that desmopressin can improve nocturia symptoms in women 2.
- Antimuscarinics: Antimuscarinics, such as oxybutynin, have been found to reduce the number of nocturia episodes in women 2.
- Behavioral treatment: Although the evidence is limited and controversial, behavioral treatment may be beneficial for some patients with nocturnal incontinence 2.
- Other medications: OnabotulinumtoxinA and sacral nerve stimulators have been shown to improve symptoms of urge incontinence, but their effectiveness for nocturnal incontinence is not well established 3.
Considerations for Treatment
When selecting a treatment option, it is essential to consider the patient's individual needs and medical history. For example:
- Anticholinergic medications may not be suitable for older adults due to adverse effects 3.
- Mirabegron has been shown to improve sleep measures, nocturia, and lower urinary tract symptoms in patients with disordered sleep 4, but its effectiveness for this patient is unclear.
- A stepped-care approach, advancing from least invasive to more invasive interventions, is recommended for managing urinary incontinence in women 3.