Tricyclic anti – depressants have been used widely for symptoms of frequency, urgency, urge incontinence and especially nocturia for many years. Although grade 1 evidence justifying their use is lacking, many patients are satisfied with the results. Ethipramine is inexpensive and widely available, with a multitude of effects – and side effects.
Its actions are anticholinergic in nature, with an adrenergic effect on the bladder neck. Theoretically at least, this makes it ideal for mixed incontinence, but its side – effects are often troublesome. It causes cardiac conduction defects and this has caused the WHO to warn against its use. Dry mouth and drowsiness are the most bothersome side effects, limiting its use. The drug is available in 10mg and 25mg tablets, and the usual starting dose is 10mg in the mornings, with 25mg or 50mg at night. The soporific effect of ethipramine may be used to advantage, allowing increased evening dosage. Contra – indications are as for other anti – cholinergics. If clinicians prescribe ethipramine, they must be aware of its cardiac effects especially in elderly women.
The use of imipramine is parallel to that of ethipramine – with the proviso that it remains untested as a pure anticholinergic for use in incontinence. Imipramine is primarily, with amytriptyline, an antidepressant, and its useful anticholinergic effects are purely fortuitous. Clinicians must be aware that these agents are of limited use as niche agents, and that ethipramine is perhaps more clinically useful.
Pharmcotherapy remains the mainstay of therapy for the treatment of OAB, and the contemporary literature shows that antimuscarinic agents are used as a first line therapy for OAB. To gain a better understanding of the overall benefits of OAB treatment, it is critical that RCTs use validated instruments to assess HRQL and to relate these changes to changes in OAB symptoms. The International Continence Society advocates the use of HRQL measures in clinical research has provided increasing evidence for the HRQL benefits conferred by effective OAB treatments.
The future emphasis of work in this field must also incorporate patient – perceived outcomes using existing tools to assess bother and QOL.