Should I start a short‑term antidepressant to improve adherence to pelvic‑floor biofeedback therapy, and which medication would be best (e.g., bupropion) without worsening urinary, bowel, or sexual function?

Should You Start an Antidepressant to Support Pelvic-Floor Biofeedback Therapy?

Yes, starting bupropion is a reasonable strategy to address your depression while supporting your pelvic-floor biofeedback therapy, as it is the only antidepressant specifically mentioned in guidelines for managing psychological distress during pelvic-floor treatment and has minimal adverse effects on urinary, bowel, or sexual function. 1

Why Bupropion Is the Optimal Choice

Guideline-Supported for Pelvic-Floor Dysfunction Context

• The NCCN explicitly lists bupropion among medications to discuss when patients present with "global symptoms of distress, anxiety (generalized or about sex), depression, or other psychological concerns" during treatment for pelvic-floor and sexual dysfunction 1
• This recommendation appears in the context of comprehensive pelvic-floor therapy, making it directly applicable to your situation 1

Favorable Side-Effect Profile for Your Therapy

Bupropion uniquely avoids the side effects that would sabotage your pelvic-floor work:

• Sexual function: Bupropion causes the least sexual dysfunction of any antidepressant and may actually improve sexual desire and arousal—critical since pelvic-floor therapy often addresses sexual symptoms 2, 3, 4
• Urinary function: Unlike anticholinergic antidepressants, bupropion does not impair bladder sensation or mask urgency symptoms that you need to perceive during biofeedback training 5
• Weight: Bupropion is more likely to cause weight loss than gain, avoiding the metabolic burden that could interfere with therapy adherence 3, 4
• Bowel function: Bupropion does not cause the constipation common with other antidepressants, which is essential since constipation management is a cornerstone of pelvic-floor dysfunction treatment 5

Proven Antidepressant Efficacy

• Bupropion demonstrates equivalent effectiveness to SSRIs and tricyclic antidepressants in treating major depressive disorder 3, 4
• It works through dopamine-norepinephrine reuptake inhibition rather than serotonin mechanisms, providing a different neurochemical approach 2, 4
• Meta-analyses support its use as both a sole antidepressant and as augmentation to other medications 4

Practical Prescribing Strategy

Formulation and Dosing

• Start with bupropion SR (sustained-release) 150 mg once daily in the morning to minimize insomnia risk 3, 6
• After 3–4 days, increase to 150 mg twice daily (morning and early afternoon) if tolerated 3
• The SR formulation has fewer side effects and lower seizure risk than immediate-release bupropion 6

Timeline Aligned with Biofeedback

• Begin bupropion at the same time you start your biofeedback program 5, 7
• Commit to at least 3 months of both interventions together, as this is the minimum duration for pelvic-floor therapy to achieve optimal benefit 5, 7
• Depression itself is an independent negative predictor of biofeedback success, so treating it improves your therapy outcomes 7

Monitoring for Success

• Track your mood weekly using a simple scale (0–10) alongside your voiding/bowel diary that your pelvic-floor therapist will have you maintain 5, 7
• Expect mood improvement within 2–4 weeks, though full antidepressant effect may take 6–8 weeks 3
• Your biofeedback therapist should see improved engagement and adherence as your mood stabilizes 7

Critical Warnings and Pitfalls

Seizure Risk

• Bupropion lowers seizure threshold—avoid doses above 400 mg/day total and never exceed 200 mg in a single dose 2, 6
• Do not use bupropion if you have a history of seizures, eating disorders (anorexia/bulimia), or abrupt alcohol/benzodiazepine withdrawal 2

Common Side Effects to Anticipate

• Nervousness and insomnia are the most frequent complaints, occurring in 10–20% of patients 2, 6
• Taking the second dose no later than mid-afternoon minimizes sleep disruption 6
• These side effects typically diminish after 1–2 weeks 6

What NOT to Do

• Do not combine bupropion with MAO inhibitors (at least 14 days must separate these medications) 2
• Do not use anticholinergic antidepressants (tricyclics, paroxetine) as alternatives, since they impair bladder sensation needed for biofeedback and cause constipation 1, 5
• Do not skip your home pelvic-floor exercises even if your mood improves—the medication supports therapy adherence but does not replace the exercises themselves 5, 7

Why This Approach Addresses Your Specific Concern

You worry about "psyching yourself out" if progress is slow. This is a legitimate concern because behavioral/psychiatric comorbidities directly impair biofeedback outcomes 5, 7. By treating your depression proactively:

• You remove a documented barrier to therapy success 7
• You maintain the motivation needed for daily home exercises over the required 3-month minimum 5
• You avoid the 15% discontinuation rate seen with other antidepressants that cause sexual or urinary side effects 1

The combination of supervised biofeedback with home exercises achieves 90–100% success rates when patients remain engaged 5—bupropion helps ensure you stay in that successful cohort rather than becoming a dropout statistic.

Duration of Antidepressant Treatment

While you mentioned wanting "temporary" medication, the evidence suggests:

• Continue bupropion for at least 6–9 months after achieving both mood stability and pelvic-floor symptom improvement 3
• Premature discontinuation (before 6 months) increases depression relapse risk 4
• Once your pelvic-floor therapy is complete and your mood has been stable for 6+ months, taper bupropion gradually over 2–4 weeks under physician supervision 3