Use of aripiprazole in clozapine induced enuresis: report of two cases

The association of lower urinary tract symptoms with schizophrenia and its treatments: A narrative review

BACKGROUND

A higher incidence of lower urinary tract symptoms (LUTS) in people with schizophrenia compared to the general population is often suggested. However, it is not clear whether this is a genuine association, and whether it is a direct result of schizophrenia itself, or a side-effect of certain antipsychotics.

METHODS

We undertook a narrative review evaluating how the published literature reports the relationship between LUTS and schizophrenia and its treatments. We searched Embase, Ovid Emcare, and Ovid MEDLINE(R) ALL to August 2022, limited to the English language. We selected the following search terms: schizophrenia, schizophrenic, LUTS, overactive bladder, urinary urgency, urinary incontinence, overactive bladder, enuresis, nocturnal enuresis, and voiding dysregulation. We identified seven domains for assessment in advance of commencing the review. These were the categorization, description, and treatment status of schizophrenia; evaluation of LUTS; categorization of LUTS confounders; recapturing of the disease states of both schizophrenia and LUTS after therapies; assessment of the association between LUTS and schizophrenia and/or antipsychotics.

RESULTS

The association between LUTS and schizophrenia was poorly described. The evidence was low quality and focused predominantly on urinary incontinence as an antipsychotic side effect, neglecting other LUTS. The status of schizophrenia was often incompletely characterized, and no papers made use of a bladder diary or LUTS-specific questionnaires to assess symptoms. No papers collected information about LUTS in patients not on antipsychotics, nor did any thoroughly evaluate the influence of confounding variables. Despite the tendency of symptoms and severity of both conditions to fluctuate over time, no studies fully assessed the status of both schizophrenia and LUTS at baseline, therapy initiation, and follow-up.

CONCLUSIONS

It is not possible to state whether there is an association between LUTS and schizophrenia or its treatments. This review highlights the need to improve research and clinical management of the urinary tract in schizophrenia, with meticulously designed longitudinal studies.

Treatment strategies for clozapine-induced nocturnal enuresis and urinary incontinence: a systematic review

BACKGROUND

Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug reactions, including nocturnal enuresis and urinary incontinence. This side effect can be burdensome and lead to medication nonadherence and psychotic relapse. Evidence to guide treatment of clozapine-induced nocturnal enuresis and urinary incontinence is sparse. We therefore aimed to synthesize the evidence base to guide management for clinicians, patients, and their carers.

METHODS

We systematically searched PubMed, Embase, PsycInfo, CINAHL, and the Cochrane Trial Registry databases from inception to May 2021 for publications on management of clozapine-induced nocturnal enuresis and urinary incontinence using a PROSPERO preregistered search strategy.

RESULTS

We identified 22 case reports and case series describing 74 patients. Interventions included clozapine dose reduction, nonpharmacological treatment, and pharmacological treatments. Among pharmacological treatments, desmopressin, oxybutynin, trihexyphenidyl, tolterodine, imipramine, amitriptyline, ephedrine, pseudoephedrine, aripiprazole, and verapamil were associated with complete resolution of nocturnal enuresis and urinary incontinence. Balancing evidence for effectiveness against risk of adverse effects, we developed a management framework for clozapine-induced nocturnal enuresis and urinary incontinence.

CONCLUSIONS

Following assessment of urological, psychiatric, pharmacological, and common comorbid medical issues, first-line treatments should be nonpharmacological, including bathroom alarms, voiding before bedtime, and nocturnal fluid restriction. If these interventions do not provide adequate relief, aripiprazole should be trialed. Desmopressin may be considered for severe refractory cases, but monitoring for hyponatremia is essential.

Risperidone-associated enuresis—a case report

Background

Risperidone has been reported to be effective in treating both the positive and negative symptoms of schizophrenia, aggression, and behavioral disorders. While the metabolic side effect profile of this medication has been broadly studied, studies related to this medication’s bladder effects are relatively rare. We present a case of risperidone-induced enuresis in an adult male with schizophrenia that resolved upon discontinuation of the offending medication.

Case presentation

We describe a case of a 32-year-old man with a primary psychotic disorder who developed debilitating enuresis secondary to taking risperidone. Enuresis resolved upon switching to Seroquel.

Conclusion

Enuresis secondary to risperidone is not commonly discussed prior to initiation by the treating psychiatrist however can be debilitating. Discussing this potential side effect is critical to informed decision making on the patient’s part.

Urological adverse drug reactions of psychotropic medication in psychiatric inpatients - A drug surveillance report from German-speaking countries

Urological adverse drug reactions (UADR) are common during treatment with psychotropic medication. The aim of this study was to provide a systematic description of the differential profile of UADR of psychotropic drugs in a large naturalistic population. Data stems from psychiatric hospitals collected by AMSP (Arzneimittelsicherheit in der Psychiatrie), a continuous multi-center pharmacovigilance program in Austria, Germany, and Switzerland. 171 cases of severe UADR (0.037%) among a total population of 462 661 inpatients treated with psychotropic drugs in 99 psychiatric hospitals between 1993 and 2016 were examined. Urinary retention (129 cases, 0.028%) was the most common UADR followed by incontinence (23 cases, 0.005%) and nocturnal enuresis (16 cases, 0.003%). Risk of UADR was higher in patients with mania than in other diagnostic groups. Promethazine and haloperidol were the antipsychotics with the highest rate of UADR. Tricyclic antidepressants had a higher and selective serotonin reuptake inhibitors a lower risk for UADR than the respective other antidepressants. Amitriptyline and clomipramine were the most common causes of urinary retention and clozapine of urinary incontinence. This research improves our knowledge of the urological risk profiles of psychotropic drugs in inpatients and highlights compounds associated with higher or lower risk.

An association between incontinence and antipsychotic drugs: A systematic review

To date, due to the increasing prevalence of psychiatric diseases, the use of antipsychotic drugs has expanded. One of the proven side effects of these drugs is incontinence. Treatment of this complication improves the quality of life in these patients, increases self-confidence, and betters cope with their psychiatric illness. The exact mechanism of this side effect is not fully understood, but various methods have been used experimentally to deal with it. Strategies such as behavior therapy, discontinuation or change of drugs, reducing the dose of drugs, and adding drugs with less incontinence have been used. Each of these methods and studies has different results that need to be summarized to make optimal use of them. Since most of these reports are case reports with a low statistical population, our study has systematically reviewed these studies to find a comprehensive model to deal with this complication.

Resolution of enuresis with aripiprazole in children with psychiatric disorders: two case reports

BACKGROUND

Aripiprazole is a third-generation atypical antipsychotic drug that acts as a stabilizer of the dopaminergic and serotonergic system. As partial agonist of the dopamine (D2) and serotonin (5-HT1A) receptors, it appears to be effective in reducing mania in patients with bipolar disorder, tics in Tourette Syndrome, aggression in schizophrenia and autism spectrum disorder. Enuresis has been reported among its side effects. Only a few studies, with conflicting results, have investigated the relationship between aripiprazole and enuresis.

CASE PRESENTATION

We report the disappearance of enuresis in a Caucasian girl with intellectual disability and oppositional defiant disorder and in a Caucasian boy with intellectual disability and early-onset psychosis, both following initiation of treatment with aripiprazole.

CONCLUSION

The aim of this study was to contribute to the literature on the use of aripripazole in subjects with enuresis. Our findings lead us to suggest that aripiprazole is less burdened with side effects, including bedwetting, than other antipsychotic drugs.

Second generation antipsychotics & nocturnal enuresis in children

Nocturnal enuresis, or involuntary wetting during sleep, is an adverse drug reaction that may occur with numerous second generation antipsychotics (SGAs) and currently is underreported. This article reviews SGA-induced enuresis and its management.

Urinary incontinence and diarrhoea associated with the switch from oral to injectable risperidone

OBJECTIVE

Urgency, urinary incontinence and bowel disturbances are distressing side effects that have been observed during treatment with risperidone and other antipsychotics probably due to the receptor affinity profile. This occurrence can lead to poor compliance and therefore impair clinical outcome.

METHOD

We report the case of a 50 year-old lady, who experienced urinary incontinence and diarrhoea, when switching from oral to injectable risperidone, which ceased when discontinuing the drug. Results and conclusions It should be taken into account that some side effects can be revealed when switching from oral to depot formulations due to non-compliance to orals; nevertheless dose-dependent mechanisms and individual metabolic variability must be considered when observing idiosyncratic reactions to drugs.

Olanzapine as a cause of urinary incontinence: a case report

Olanzapine, an atypical antipsychotic, is one of the most commonly used antipsychotics. Though olanzapine is commonly associated with endocrine side effects, it is generally well tolerated by most patients and is rarely associated with urinary incontinence. This report highlights the case of a 23 -year old male patient with schizophrenia who developed severe urinary incontinence following the use of olanzapine. No medications were given to relieve the incontinence contrary to some other studies where ephedrine was used. Olanzapine was changed to trifluoperazine, and the patient's condition improved within two days. Urinary incontinence, though uncommon, is an embarrassing side effect of olanzapine which could negatively affect drug compliance. As such, clinicians should enquire about it in order to improve the patient's health.