Alvi, Tabasum

Reza, Hashim

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eCommons@AKUDepartment of Psychiatry Medical College, PakistanJuly 1997Neuroleptic induced incontinence--case reportTabasum AlviAga Khan UniversityHashim RezaAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_psychiatryPart of the Psychiatry CommonsRecommended CitationAlvi, T., Reza, H. (1997). Neuroleptic induced incontinence--case report. Journal of Pakistan Medical Association, 47(7), 195-196.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_psychiatry/82Neuroleptic Induced Incontinence - Case ReportPages with reference to book, From 195 To 196 Tabasum Alvi, Hashim Reza ( Department of Psychiatry, Aga Khan University Hospital, Karachi. ) Introduction Urinary incontinence is an uncommon complication of neuroleptic treatment. When it occurs itis verydistressing and disabling for the patieni Renshaw1 reported 4 patients over 60 years of age and 2 under7 years who developed urinary incontinence, both day and night, on thioridazine. It stopped 3 daysafter stopping thioridazine and there was no recurrence when other phenothiazines were used. A non-overflow stress incontinence has been described by Van Putten et al2 in 3 patients heated withthioridazinc, chlorpromazine (CPZ) and irifluoperazine. Shaikh3 reported 4 women, all below 35 years,who were enuretic, mostly at night, within 7 days of depot phenothiazines, 3 on fluphenazine, 1 onflupenthixol. This stopped when treatment was withdrawn and reappeared when it was restarted.Nurnberg and Ambrosini4 reported 5 eases, 3 men, 2 women, aged 18-33 years, who developed urinaryincontinence in 3-15 days on variable doses of haloperidol, CPZ and fiuphenazine. The incontinenceoccurred and remitted spontaneously after beginning neuroleptic treatment and the complaint tended tostabilize if drug was continued. No patient experienced feeling of urge, dribbling or stress related loss.Shenoy5 reported cases of two men, 29 and 30 years old, who developed nocturnal enuresis onthioridazine within 1-7 days of starting treatment. It disappeared after the medication was discontinuedand reappeared when medication was given again, upto a year later. Jose6 also reported two men, aged64 and 66, who developed urinary incontinence while taking thioridazine in relatively small doses of50-150 mg daily. Crittenden7 described the case of a 49 years old man on thiorithzine who becameenuretic and incontinent at night and during day naps.Case Report A 32 years old woman with 12 years history of schizophrenia, paranoid type, was admitted from theEmergency room of the Aga Khan University Hospital with exacerbation of delusions of persecutionand grandiosity, agitation and disturbed sleep since 3 days. She had previously been treated withseveral psychotropics including CPZ, haloperidol, trifluoperazine, fluphenazine decanoate,zuclopenthixol decanoate, amitriptyline, lithium carbonate and lorazepam although she had not beenvery compliant with medication and follow-up arrangements. The longest continuous period ofmedication was for two years, 1989-1991, when she was on haloperidol 20mg daily, CPZ 75 mg dailyand fluphenazine decanoate 50 mg fortnightly. She tolerated these medicines well with partial benefit.She had also been given 10 ECTs in 1980 and zuclopenthixol decanoate 200 mg fortnightly foranunknown period in 1987. She had no significant past medical history, in particular there was no historyof genito-urinary problems, enuresis or urinary incontinence. Her physical examination at the time ofadmission was unremarkable. Prior to her admission she had intermittently been taking haloperidol20mg, CPZ 150 mgand diazepam 5 mg daily for a few weeks. She had afew tolerable side effects,namely blurring of vision, constipation and dizziness. On the second day of admission haloperidol anddiazepam were discontinued with the objective of simplifying her prescription and CPZ was increasedto 500 mg daily in divided doses. When this failed to help her insomnia and agitation, CPZ was furtherincreased to 700 mg daily by the fifth day of admission. She also received her depot antipsychotic,fluphenazine decanoate 25 mg, on the third day of admission. After 4 days of increased CPZ dose, 5days after the depot, she developed urinary incontinence. A day earlier she had been given an extradose of CPZ 100 mg taking the total daily dose to 800 mg. She was not receiving any anticholinergicagents during this period except for a single dose of trihexyphenidyl 2 mg given several days before theonset of incontinence. There were 4 episodes of urinary incontinence all occurring during the day. Shepassed a few drops of urine without prior warning or an urge to void. This was extremely distressingfor her. CPZ was discontinued immediately and she was put on diazepam 4 mg daily to control heragitation. The urinary complaint disappeared within 24 hours of its onset. It did not recur despitecontinuing her weekly depot and substituting CPZ with trifluoperazine 20 rug daily. She wasdischarged from hosptial 3 days later to be followed up in the out-patient clinic. She received twofurther weekly doses of the depot antipsychotic without recurrence of side-effects before dropping outof follow-up.Discussion It is generally well recognised that phenothiazines cause classical anticholinergic side effects whichpredominate over their other peripheral side effects of a-adrenergic and cholincrgic blockade whichcould lead to urinar incontinence through different mechanisms: bladder sphincter relaxation orparalysis. retention and overflow. Almost all antipsvchotics. including CPZ. chiorprothixine,fluphenazine. haloperidol. pimozide. thiothixine and trifluoperazinc, have been reported to causeurinary incontinence or nocturnal enuresis. Thioridazine alone has been implicated in atlcast 12 casesalthough high doses of this antipsychotic have also been used to treat urinary incontinence8. Typically,the incontinence isa nocturnal event, not of the overflow or stress variety and limited in its duration. Itcan however occur at any time of the day or night. It tends to occur within hours or sporadically overthe first several weeks regardless of the patient’s previous genitourinary condition. It tends to diminishwith continued neuroleptic administration or follows an on-off pattern when the drug is discontinued9.Most authors have reported successfully substituting the incriminated antipsychotic with another.Crittenden2 substituted diazepam for thioridazine with equally successful outcome. Our case wasatypical in that the episodes of incontinence occurred during the waking hours and lasted for less than aday. Otherwise, it had all the other usual features, it was not of overflow or stress variety and occurredwhile the patient was on the same drugs. She had previoush’ been given several times without anadverse event. She had never been given CPZ at such a high dose before which made it the likelyculprit. Sudden improvement was seen alter its discontinuation and no recurrence occurred after twofurther doses of fluphenazine decanoate. In view of the severe distress caused to the patient, it wasdecided not to rechallenge her with CPZ.Various hypotheses have been proposed to explain this uncommon side effect. Renshaw1 proposed thatphenothiazinc induced incontinence may be due to an overflow incontinence secondary to theanticholinergic effect of reduced bladder tone, which allows for increased bladder volume andincreased urinary retention. This observation was based on all her patients having developed this sideeffect on thioridazine which is the most anticholinergic of all phenothiazines. Contrary to this, Jose6and Dainow10suggested use of anticholinergics to control urinary incontinence. Van Putten et al2 postulated that a-adrenergic blocking properties of the phenothiazines induce internal urinary sphincter relaxation inanatomically predisposed women. This mechanism occasionally causes retrograde ejaculation in mentaking the drug. Shenoy’s case report5 of young men with adequate sexual function refutes thisexplanation as does the observation that thiothixine, an antipsy choic with low a-adrenergic blockingactivity, causes enuresis. He argued that psychotropics cause fragmentation of REM sleep and a relativeprolongation of non-REM sleep which increased the chances of developing enuresis. He also proposedthat psychotropic induced dryness of mouth resulting in increased fluid intake might give rise ofphysiologic çpolvuria and nocturnal enurcsis. Nurnberg and Ambrosini5-9. ,ernphasizing the effects ofbutyrophenones and phenothiazines related compounds on dynamics of central biogenic amineneurotransmitter SV stems. have argued for centrally mediated bladder disturbance. They quotedreports of incontinence in disturbances of the brain stern, basal ganglia and frontal lobes in support ofthis hypothesis. Anticholinergic compounds did not seem to influence directly the incontinence in thoseof their cases in wiuch they were used for control of mild extrapy ramidal side effects. However,incontinence as a variant of an extrapy ramidal syndrome was not ruled out. In our opinion, the exactmechanism of urinary incontinence caused by antipsychotic use remains poorly understood. In view ofits distressing nature it should be recognised early with discontinuation or reduction in dose of thesuspected medicine. Adding diazepam or anticholinergic agents could also be helpful. In some casesthe problem tends to stabilise despite continuing the incriminated medicine.Acknowledgements We sincerely thank the librarian, Royal College of Psychiatrists and Dr. Ali Sajjad for their help in theliterature search.References 1. Renshaw,D,C Thioridazine and incontinence. JAMA.. 1971 ;21 8:738.2. Van-Putten, T., Malkin, M.D. and Weiss. MS. Phen othiathie- induced stress Incontinence. J. UroL,1973,109:625-626.3. Shaikh, A. Urinary incontinence during treatment with depot phenothiazines Br Med 5, 1978;1:1698.4. Numberg. H.G. and Ambrosini, P.J. Urinary incontinence in patients receiving neuroleptics. J. ClinPsychiatry. 1979:40:271-2745. Shenoy, R.S. Nocturnal enuresis caused by psychotropic drugs. Am J. Psychiatry. 1980;137:739-740.6. Jose. C.J. Nocturnal enuresis caused by psychotropic drugs. Am. J. Psychiatry. 1981;138: 15 )9.1520.7. Crittenden, F.M- Thioridazine incontinence JAMA., 1972:219- 27.8. Bey. DR. Urinary incontinence treated with thioridazine. JAMA., 1972:220:126.9. Ambrosini, P.J and Nurnberg, H.G Enuresis and incontinence occurring with neuroleptics Am. J.Psychiatry, 1980,137:1278-79..10. Dainow. I.I. Urinary incontinence during treatment with depot phenothiazines. Br Med. J,,1978:ii:282.

Neuroleptic induced incontinence--case report

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Neuroleptic induced incontinence--case report

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