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Management of Overactive Bladder
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     To the Editor: In his review of the management of overactive bladder (Feb. 19 issue),1 Dr. Ouslander states in Table 1 that cholinesterase inhibitors could theoretically contribute to detrusor overactivity, but he suggests that there is no evidence to support this association. Cholinesterase inhibitors are widely used to manage the symptoms of dementia.2

    Two case series have identified patients in whom urinary incontinence developed after the initiation of treatment with cholinesterase inhibitors. In one report, among three adults with Alzheimer's disease associated with Down's syndrome, two had incontinence after starting donepezil.3 A second report documents the emergence of transient, dose-dependent incontinence in 7 of 94 patients with probable Alzheimer's disease who were started on donepezil.4 In both reports, urinary incontinence was temporally associated with the introduction of the drug, and it resolved after discontinuation of the drug. Although these case series cannot establish causality, they support the association.

    It is important to highlight urinary incontinence as a potential adverse drug event. Since dementias themselves can cause neurogenic detrusor overactivity,1 clinicians may misattribute the development of cholinesterase inhibitor–associated incontinence to the underlying dementia.

    Sudeep S. Gill, M.D.

    Muhammad Mamdani, Pharm.D., M.P.H.

    Paula A. Rochon, M.D., M.P.H.

    Institute for Clinical Evaluative Sciences

    Toronto, ON M4N 3M5, Canada

    sudeep.gill@ices.on.ca

    References

    Ouslander JG. Management of overactive bladder. N Engl J Med 2004;350:786-799.

    Kawas CH. Early Alzheimer's disease. N Engl J Med 2003;349:1056-1063.

    Hemingway-Eltomey JM, Lerner AJ. Adverse effects of donepezil in treating Alzheimer's disease associated with Down's syndrome. Am J Psychiatry 1999;156:1470-1470.

    Hashimoto M, Imamura T, Tanimukai S, Kazui H, Mori E. Urinary incontinence: an unrecognised adverse effect with donepezil. Lancet 2000;356:568-568.