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.

Chevron osteotomy for the treatment of hallux valgus

Seventy-six chevron osteotomies with follow-up periods ranging from six months to eight years were reviewed. The majority of patients had pain over the bunion prior to operation, and 27 also presented with second metatarsalgia. After surgery there was a marked decrease of pain in the first metatarsophalangeal joint, and in 18 feet the second metatarsalgia was either eliminated or markedly decreased. Most patients were pleased with the appearance of the feet after surgery, but almost one-third of the women complained of difficulty in wearing high heels. The surgical technique is straightforward, but careful attention to detail is necessary to obtain a consistent and satisfactory result.

Studies of dynamic ligamentous instability of the knee by electrogoniometric means

Ligamentous injuries to a knee joint increase the risk of post-traumatic degenerative changes. Successful early diagnosis and treatment of such injuries remains a challenging and controversial task. There are a variety of clinical tests available and some of these are difficult to perform and interpret. These clinical tests are really static in nature and may not reveal the presence of what is essentially a dynamic event. A complete assessment would need to be "dynamic" and by its application during ambulation, incorporate the effects of ground-foot forces, joint motions and muscle activities. At the Ontario Crippled Children's Centre (OCCC) a triaxial electrogoniometer system (extensively modified CARS-UBC) has been used, together with complementary gait laboratory instrumentation, in order to study the knees of 16 male subjects. Ten subjects had knees without evidence of injury and six had a variety of cruciate and menisceal tears. The purpose of the study was to investigate if a subject's knee could be classified as "normal" or "unstable" by using just the data provided by the electrogoniometer during walking trials. These data are difficult to interpret in their time series form because they are multidimensional and in all subjects likely to exhibit subtle stride to stride variations. The method described allows the mapping of this data into an abstract two dimensional co-ordinate system, resulting in a set of trajectories which cluster together for data belonging to the "normal" group. Only two subjects, with grossly unstable knees, were judged different from normal using a level walking test protocol. Some potential reasons for this are discussed.