Solifenacin

• Overactive bladder — urgency, frequency, and urge incontinence
• Neurogenic bladder overactivity

It treats the urgency type of incontinence, not the stress type. Leaking on coughing, laughing or exercising is stress incontinence, and antimuscarinics do not help that — pelvic floor training and, sometimes, surgery do.

• 5mg once daily, increased to 10mg if needed and tolerated
• Take it with or without food, swallowed whole, at the same time each day

Give it time

Allow four weeks at a dose before judging it, and expect improvement rather than cure — typically fewer urgent episodes rather than none.

Practical management of side effects

• Dry mouth: sip water, chew sugar-free gum, use a saliva substitute. It is the commonest reason people stop
• Constipation: fluid, fibre, and a laxative if needed — anticipate it rather than react to it

• Other anticholinergic medicines — amitriptyline, older antihistamines, oxybutynin, some antipsychotics. The burden is cumulative
• Ketoconazole and ritonavir — raise levels; lower doses needed
• Medicines that prolong the QT interval

Monitoring

• Whether it is actually helping — reviewed at four weeks, and periodically after that
• Bladder emptying, where retention is a concern
• Cognition in older people, and total anticholinergic burden

Treatment should be reviewed rather than repeated indefinitely. Many people stay on bladder medication for years without anyone asking whether it still helps.

Solifenacin is available as a generic and is inexpensive.

Mirabegron, an alternative working by a different mechanism, costs more but avoids anticholinergic effects entirely — which frequently makes it the better choice in older people despite the price.

Bladder training and pelvic floor physiotherapy are free on the NHS and should be tried first.

It can be stopped without tapering. Symptoms return, so it is worth having tried conservative measures alongside so there is something to fall back on.

If it is not working or not tolerated

• Mirabegron — a beta-3 agonist. Different mechanism, no dry mouth or constipation, the usual choice where anticholinergic burden matters. It can raise blood pressure, so that is monitored
• Oxybutynin — cheaper but higher anticholinergic burden; generally avoided in older people
• Tolterodine, darifenacin, fesoterodine — similar alternatives
• Botulinum toxin into the bladder, or nerve stimulation, under specialist care

What helps regardless

• Supervised pelvic floor muscle training — effective, and effective for stress incontinence too
• Bladder training to gradually extend the interval between visits
• Reducing caffeine, alcohol and fizzy drinks, all of which irritate the bladder directly
• Vaginal oestrogen after the menopause, which helps urgency and recurrent infection and is consistently underused

Why is my mouth so dry?

Because the drug blocks the same receptors in the salivary glands as in the bladder. It is the commonest reason people stop. Sugar-free gum and saliva substitutes help; mirabegron avoids it altogether.

Will it help leaking when I cough?

No — that is stress incontinence, and this drug does not treat it. Pelvic floor training is the treatment for that, and the distinction matters.

Is it linked to dementia?

Anticholinergic medicines as a group have been associated with increased dementia risk in observational studies. The evidence cannot prove cause, but it is a real consideration — and a reason to review the total burden and to prefer mirabegron in older people.

How long before it works?

Up to four weeks. Expect fewer urgent episodes rather than none.

Can I just do the exercises instead?

Often yes, and it is worth trying properly first. Supervised pelvic floor training over at least three months is genuinely effective and has no side effects.