Normal micturition requires normal bladder muscle and sphincter function and an intact neural connection between the cerebral cortex and brainstem. Any disruption of bladder contraction, relaxation, or outlet function can result in incontinence.

Incontinence is classified into stress, urge, and overflow incontinence depending on the actual mechanism. The overflow incontinence results from incomplete bladder emptying.

Medications with anticholinergic , antihistaminic, analgesic effects may affect bladder function. The exact mechanism depends on the agent.

In women, the likelihood of urinary incontinence increases with age and postmenopausal status due to changes in estrogen levels, detrusor activity, and urethral pressure. In men, with increasing age and prostate hypertrophy, risk for both urinary retention and incontinence increases.

In both women and men, obesity, neurologic disease, peripheral neuropathy, pelvic, or prostate surgery may cause or contribute to urinary problems. Urinary tract infections (UTIs) and severe constipation with fecal impaction are temporary causes of incontinence, the former more common in women. Cognitive impairment and physical disability may limit capacity to use the bathroom appropriately and in time.

Caffeine and alcohol contribute to incontinence due to a diuretic effect and effect on bladder muscle contractility.

The etiology determines the type of incontinence and whether there is coexisting urinary retention. See appendix for common etiologies associated with urinary incontinence and urinary retention.

Overall incidence of psychotropic-induced urinary problems is low. The mechanism of urinary incontinence is mostly by alpha 1 adrenergic blockade causing decreased resistance of the urethral sphincter. Agents with alpha-adrenergic agonist activity also can experience incontinence due to increased urethral sphincter resistance and bladder overflow. Another important mechanism is anticholinergic action leading to decreased bladder activity and urinary retention with resultant overflow incontinence . Central dopaminergic blockade (causing detrusor muscle hyperactivity) and serotonergic inhibition (affecting parasympathetic bladder innervation) are also thought to play a role. Detrusor hyperactivity has been shown in urodynamic testing in people on atypical antipsychotics [1].

Among antipsychotics, clozapine is commonly implicated in urinary incontinence. It is also associated with enuresis . The two often occur together and while the mechanisms may be different for each, pharmacologic agents used for treatment are the same. Ephedrine has proved effective, postulated to be from an alpha-agonist effect [2]. There are case reports for successful resolution of incontinence with pseudoephedrine [3], oxybutynin , intranasal desmopressin [4], and aripiprazole [5]. However, aripiprazole itself is associated with enuresis , especially in children. Clozapine may also cause predominant symptoms of urinary retention with incomplete voiding.

Urinary incontinence can also occur with other antipsychotics [6]. Many typical antipsychotics including chlorpromazine, fluphenazine, and haloperidol also can cause urinary incontinence. The incontinence develops soon after the medication is initiated. It is dose related and the symptom resolves on stopping the medication.

Among antidepressants, tricyclic antidepressants can cause urinary retention due to their anticholinergic action. Selective serotonin reuptake inhibitors (SSRIs) also cause urinary incontinence in a small proportion of patients with sertraline carrying the highest risk [7]. It is thought to be due to potentiation of cholinergic neurotransmission and some dopamine blockade with sertraline. Venlafaxine may also cause this effect while duloxetine actually may improve incontinence. Benzodiazepines may contribute to urinary problems mainly due to sedative effect.

The table lists psychotropic medications commonly associated with urinary incontinence and retention.

Patients with urge incontinence have an urge to void during bladder filling and experience some leakage before they can reach a bathroom. Patients with stress incontinence have some bladder leakage during activities that increase intra-abdominal pressure such as coughing, sneezing, and straining during bowel movements. Among younger women, stress incontinence is the more common type. In a majority of women, the incontinence is typically mixed type. Patients with overflow incontinence complain of incomplete voiding and leakage.

Patients on psychotropic medications usually present with mixed incontinence and possibly nocturnal enuresis . They may also present with more predominant features of urinary retention with anticholinergic side effects—weak urinary stream, intermittency, hesitancy, incomplete emptying, straining, and urgency. Men with BPH have similar symptoms, sometimes collectively called Lower Urinary Tract Symptoms (LUTS) .

If patients complain of new-onset urinary incontinence , the type of incontinence should be determined by history. Clinicians should also assess for other symptoms such as urinary frequency and in men, LUTS. Voiding diaries may be helpful in determining if urinary frequency is related to intake of fluids including caffeine and alcohol. Easily treatable causes such as urinary tract infections and constipation can be usually ruled out by history. Specialists may consider postvoid residual measurement (<50 mL is adequate voiding and >200 mL is inadequate voiding) or other urodynamic measurements but these are neither necessary nor feasible in a psychiatric treatment setting.