What are the treatment options for urinary urgency?

Treatment Options for Urinary Urgency

Bladder training should be the first-line treatment for urinary urgency, followed by pharmacologic therapy with mirabegron if bladder training is unsuccessful. 1, 2

First-Line Treatments: Non-Pharmacological Approaches

Behavioral Modifications

• Bladder training: Strong recommendation with moderate-quality evidence 1
  • Involves scheduled voiding and gradually extending time between voids
  • Shown to significantly reduce urgency episodes

Lifestyle Modifications

• Weight loss and exercise: Strong recommendation for obese patients 1
• Fluid management:
  • Moderate fluid restriction, especially in evening hours 2
  • Reducing fluid intake by 25-50% can decrease urgency symptoms 3
• Avoid bladder irritants: 2, 4
  • Caffeinated, carbonated, and citrus beverages (associated with 37% higher odds of urgency incontinence) 4
  • High-acid foods (associated with 29% higher odds of urgency incontinence) 4
  • Alcohol, spicy foods, chocolate, and artificial sweeteners

Physical Therapy

• Pelvic floor muscle training (PFMT):
  • Particularly effective for mixed urinary incontinence when combined with bladder training 1
  • Can improve urinary frequency even without incontinence 2

Second-Line Treatments: Pharmacological Approaches

If bladder training is unsuccessful, pharmacologic treatment is recommended (strong recommendation, high-quality evidence) 1.

Recommended Medication Algorithm:

1. First choice: Mirabegron (β3 agonist) 2, 5

   • FDA-approved for overactive bladder with symptoms of urge incontinence, urgency, and frequency 5
   • Starting dose: 25 mg once daily, may increase to 50 mg after 4-8 weeks if needed 5
   • Preferred for patients with risk factors for urinary retention 2
   • Does not cause antimuscarinic side effects (dry mouth, constipation)

2. Second choice: Solifenacin or Darifenacin 2

   • Solifenacin achieves continence better than placebo (NNTB: 9) 2
   • Lower discontinuation rates due to adverse effects compared to other antimuscarinics 2

3. Third choice: Tolterodine 2, 6

   • Achieves continence (NNTB: 12) and improves urinary incontinence (NNTB: 10) better than placebo 2
   • Better side effect profile than oxybutynin, with fewer adverse effects (NNTH: 12) 2
   • Proven effective in multiple randomized controlled trials 6

4. Last resort: Oxybutynin or Fesoterodine 2

   • Higher rates of adverse effects than placebo (NNTH: 8) 2
   • Oxybutynin has high rates of dry mouth (71.4%), constipation (15.1%), and other side effects 2

Special Considerations

Dosage Adjustments

• Renal impairment: Reduce mirabegron dose for patients with eGFR <30 mL/min/1.73m² 5
• Hepatic impairment: Reduce mirabegron dose for moderate hepatic impairment; avoid in severe impairment 5

Managing Side Effects

• Constipation: Consider switching to an antimuscarinic with lower constipation risk 2
• Dry mouth: Ensure adequate hydration, sugar-free gum/candy, or consider transdermal formulations 2
• Cognitive concerns: Consider trospium which has lower blood-brain barrier penetration 2

Men with Urinary Urgency

• Consider combination therapy with α-blockers if BPH is present 2, 7
• α-blockers with 5α-reductase inhibitors reduce progression risk to <10% compared to 10-15% with monotherapy 7

Advanced Therapies for Refractory Cases

For patients who fail conservative and pharmacologic treatments:

• Sacral neuromodulation (SNS) 2
• Peripheral tibial nerve stimulation (PTNS) 2
• OnabotulinumtoxinA injections (with counseling about potential self-catheterization) 2
• Consider referral to urology for surgical options 2

Pitfalls to Avoid

• Don't overlook potential infectious causes in women with persistent symptoms; consider doxycycline treatment which has shown 71% effectiveness in some studies 8
• Don't start antimuscarinic therapy without measuring post-void residual volume to minimize urinary retention risk 2
• Avoid high doses of antimuscarinics in elderly patients due to increased risk of cognitive side effects
• Don't ignore fluid intake modification as a simple but effective intervention