What is Sanctura (trospium chloride) used for in adults, possibly middle-aged or older, with symptoms of urinary urgency, frequency, and incontinence?

What is Sanctura Used For?

Sanctura (trospium chloride) is an antimuscarinic medication used to treat overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and urinary frequency. 1

Indication and Clinical Context

Sanctura is FDA-approved specifically for treating overactive bladder syndrome characterized by:

• Urinary urgency - a sudden, compelling desire to urinate that is difficult to defer 2
• Urinary frequency - typically more than 7 voids during waking hours 2
• Urge urinary incontinence - involuntary urine leakage associated with urgency 2
• Nocturia - waking one or more times at night to void 2

Treatment Algorithm Position

Sanctura is recommended as second-line therapy for OAB, after behavioral interventions have been attempted. 3

The AUA/SUFU guidelines specify that trospium (along with other oral antimuscarinics including darifenacin, fesoterodine, oxybutynin, solifenacin, and tolterodine) should be offered as second-line treatment, with no hierarchy implied among these agents. 3

First-Line Treatment Must Precede Sanctura

Before prescribing Sanctura, patients should receive:

• Behavioral therapies including bladder training, delayed voiding, and pelvic floor muscle exercises 3
• Fluid management with appropriate reduction in intake 3
• Weight loss if obese (8% weight loss reduces urgency incontinence episodes by 42%) 3
• Caffeine reduction to decrease voiding frequency 3

Behavioral therapies are as effective as antimuscarinics in reducing symptoms and are risk-free, making them mandatory first-line interventions. 3

Clinical Efficacy

Trospium chloride demonstrates:

• Rapid onset - significant symptom improvement by week 1 that is sustained through 12 weeks 4, 5
• Reduced toilet voids - decreases daily voids by approximately 2.7 episodes compared to 1.9 with placebo 6
• Reduced incontinence episodes - decreases urge incontinence by 2.4 episodes/day compared to 1.8 with placebo 6
• Increased bladder capacity - increases volume per void 4, 5
• Improved quality of life - measured by Incontinence Impact Questionnaire scores 4

Critical Safety Considerations and Contraindications

Sanctura must NOT be used in patients with narrow-angle glaucoma unless approved by their ophthalmologist. 3

Sanctura must be used with extreme caution or avoided entirely in patients with:

• Impaired gastric emptying - requires gastroenterologist clearance before initiation 3
• History of urinary retention - requires urologist clearance and post-void residual (PVR) measurement 3, 7
• Elevated PVR >250-300 mL - antimuscarinics may worsen retention and should be avoided 7
• Concurrent use of solid oral potassium chloride - reduced gastric emptying may increase potassium absorption to dangerous levels 3

Common Adverse Effects

The most frequent side effects are:

• Dry mouth (10.7% vs 3.7% placebo) 6
• Constipation (8.5% vs 1.5% placebo) 6
• Headache 8

Notably, trospium has favorable CNS side effect profile with lower rates of dizziness (0.2% vs 1.0% placebo) and headache (1.4% vs 2.4% placebo) compared to placebo, likely due to its quaternary amine structure limiting CNS penetration. 6, 8

Unique Pharmacologic Advantages

Trospium chloride offers specific benefits:

• No cytochrome P450 metabolism - minimizes drug-drug interactions, advantageous for patients on multiple medications 8, 9
• Predominantly renal excretion - approximately 80% excreted unchanged via active tubular secretion 9
• Minimal CNS penetration - quaternary amine structure limits blood-brain barrier crossing 8, 9
• Low oral bioavailability (9.6%) but sufficient for therapeutic effect 9

When to Escalate Beyond Sanctura

If patients fail to respond adequately to behavioral therapy plus Sanctura (or other antimuscarinics), they should be referred to a specialist for third-line therapies. 3

Third-line options include:

• Sacral neuromodulation (SNS) 3
• Posterior tibial nerve stimulation (PTNS) 3
• Intradetrusor onabotulinumtoxinA 3

These advanced therapies carry greater risks and require careful patient selection. 3

Common Pitfall to Avoid

The most critical error is prescribing Sanctura to patients with unrecognized urinary retention or overflow incontinence. 7 Always measure post-void residual in patients with obstructive symptoms, history of incontinence surgery, prostatic enlargement, or neurologic diagnoses before initiating antimuscarinic therapy. 2, 7 Misdiagnosing overflow incontinence as OAB and treating with antimuscarinics will worsen urinary retention. 7