Mets Day 320 - Duloxetine for incontinence?

My sister, a nurse anesthetist, alerted me to the December 2012 issue of Current Bladder Dysfunction Reports.  CBDR is a British medical journal with slightly better circulation than Current Views On Proctology.  The CBDR article of interest was titled, "Management of Male Voiding Dysfunction after Radical Cystectomy and Neobladder Reconstruction", which is exactly what I'm dealing with.  The article noted that 28% of patients with a neobladder have nighttime incontinence (tell me about it), and there is little research or information on what to do about it (as I've learned).  The report describes the treatment of neobladder incontinence with Duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI) manufactured and marketed by Eli Lilly under under the brand names Cymbalta, Ariclaim, Xeristar, Yentreve, and Duzela.   In concludes that "the off label use of Duloxetine for SUI [stress urinary incontinence] seems promising."

Here is the link to the publication (Current Bladder Dysfunction Reports,December 2012, Volume 7, Issue 4, pp 286-293,Management of Male Voiding Dysfunction after Radical Cystectomy and Neobladder Reconstruction, by Richard E. Hautmann).  Here is the Abstract:

"At centers orthotopic bladder substitution (OBS) is the preferred method of urinary diversion following radical cystectomy (RC). Daytime and nighttime incontinence (UI) are reported in up to 13% and 28% of cases, respectively. SUI is the most common reason for daytime leakage, while an absent vesicourethral reflex with reduced external sphincter tone is associated with nighttime UI. A PubMed search disclosed a paucity of data for any treatment modality, the absence of prospective randomized trials and the existence of few retrospective case reports or small case series with limited follow up. Conservative management has limited value. Pharmacologic treatment for enuresis is effective in select OBS patients, while the off label use of Duloxetine for SUI seems promising. Surgical approaches include adjustable and nonadjustable slings as well as the ProACT system in mild stress UI. The need of intermittent self catheterisation (ISC) after slings seems to be very high. Implantation of the artificial urinary sphincter AMS 800 (AUS) is the standard treatment for severe stress (UI). AUS is a relatively safe, effective continence procedure for patients with OBS and severe SUI. Complication rate, urinary symptoms, and quality of life of these patients as determined by validated questionnaires are acceptable."

That's the good news.  The bad news is that Duloxetine failed the US approval for stress urinary incontinence amidst concerns over liver toxicity and suicidal events. Duloxetine was approved in Europe for SUI, where it is recommended as an add-on medication instead of surgery. 

In the US, Duloxetine is approved in the US for major depressive disorder and generalized depressive disorder.  It can also relieve the symptoms of painful periphia neuropathy, particularly diabetic neuropathy, and it is used to control the symptoms of fibromyalgia. 

So the question is whether I should try Duloxetine for my incontinence.  I've already emailed Dr. Schoenberg at Hopkins and asked for his opinion.  I'll also ask Dr. Plimack at Fox Chase when I see her next month, and my local urologist when I see him in early April.  The question is, what's worse:  incontinence and not sleeping, or the risk of liver toxicity and suicidal events?