A case report of double incontinence associated with clozapine.

Abstract

Sir: Clozapine is known to be an effective agent in the treatment of refractory psychotic disorders. Although clozapine causes minimal extrapyramidal symptoms, adverse effects such as agranulocytosis, weight gain, hypersalivation, seizures, and urinary incontinence form obstacles to patients' compliance. Clozapine-induced urinary incontinence is a frequently reported side effect1; however, the literature is sparse about the combination of urinary and fecal incontinence. Here, we present a male adult patient who had transient double incontinence during clozapine treatment. Case report. Mr. A, a 35-year-old man with a 16-year history of DSM-IV schizophrenia, paranoid type, was admitted to the inpatient unit in September 2005 with psychotic symptoms after 1-month cessation of his medication (200 mg/day of clozapine). We decided to restart clozapine with a titration of 25 mg every 2 days in addition to flupen-thixol depot once every 2 weeks. After 5 weeks of hospitalization, Mr. A was discharged on treatment with 350 mg/day of clozapine in combination with flupenthixol depot once every 2 weeks. On his first outpatient visit after 3 weeks, his father reported development of double incontinence once every 2 days for the previous 2 weeks. His medical history and physical examination results were normal, so we decided to wait for his second outpatient visit in another 3 weeks and informed him that it might be a time-limited side effect and resolve spontaneously. On his second visit, it was noted that the double incontinence had remitted. Four months after Mr. A's discharge, the depot antipsychotic treatment has been stopped, and for the last 3 months he has been on treatment with clozapine 350 mg/day and has not experienced these side effects again. Although the prevalence of clozapine-induced urinary incontinence is reported to range from 2.4% to 42%,2 double incontinence has never been reported. It has been documented that patients with chronic psychotic disorders have high rates of urinary incontinence, but it is still not well understood whether the urinary incontinence is due to the severity of the mental illness or to the medication.3 Our patient had been suffering from schizophrenia for 16 years and had been on clozapine treatment for the last 2 years at a maximum dose of 200 mg/day without reporting such symptoms. It is impossible to directly link our patient's double incontinence to clozapine, as he was receiving 2 neuroleptics; however, he did not develop such side effects when he was on treatment with flupenthixol depot and clozapine titration doses of less than 350 mg/day. Clozapine-induced urinary incontinence has been shown to be dose dependent.3 Previous treatment with clozapine doses lower than 350 mg/day did not result in incontinence in our patient, which supports that double incontinence might also be dose related. The adrenergic blockade effect of clozapine is suggested to be the cause of fecal and urinary incontinence by decreasing the tonus of the internal anal sphincter4 and internal bladder sphincter,3 respectively. As the incontinence may be time-limited and resolve spontaneously,3 waiting and monitoring may be an option before starting any adjunct medication or switching to another antipsychotic. Urinary incontinence alone is an embarrassing side effect for patients to report to staff, and double incontinence would certainly be underreported, with more negative effects on patients' compliance to treatment. Thus, clinicians should consider these facts more thoroughly during their daily practice.