Causes of Urinary Urgency
The primary causes of urinary urgency include detrusor overactivity, bladder outlet obstruction, neurological conditions, medication side effects, and bladder inflammation or infection, with detrusor overactivity being the most common underlying mechanism. 1
Pathophysiological Mechanisms
Detrusor Overactivity
- Involuntary contractions of the detrusor muscle during bladder filling
- Most common cause of urgency in overactive bladder syndrome
- Can be demonstrated on urodynamic testing as spontaneous or provoked contractions 1
- Results in a sudden, compelling urge to void that is difficult to defer 1
Bladder Outlet Obstruction
- Common in men with benign prostatic hyperplasia
- Creates secondary detrusor changes that lead to urgency
- Can cause both storage (urgency) and voiding symptoms 2
- May require pressure flow studies to diagnose properly 1
Neurological Conditions
- Disruption of normal neural pathways controlling micturition
- Conditions include:
- Spinal cord injury
- Multiple sclerosis
- Parkinson's disease
- Stroke
- Myelomeningocele 1
- Can lead to uninhibited bladder contractions causing urgency
Inflammation and Infection
- Urinary tract infections
- Interstitial cystitis/bladder pain syndrome
- Chemical irritation from certain foods or medications
- Bladder stones or tumors 1
- Radiation cystitis
Medication-Induced Urgency
- Diuretics (increased urine production)
- Sedatives and anticholinergics (urinary retention leading to overflow)
- Certain antipsychotics
- Alpha-blockers (can cause sphincter weakness) 3
- Cyclophosphamide and tiaprofenic acid (chemical cystitis) 3
Clinical Presentation and Diagnosis
Key Symptoms Associated with Urgency
- Sudden, compelling desire to void that is difficult to postpone
- Often accompanied by frequency and nocturia
- May progress to urgency urinary incontinence if severe 4
- Pain may be present in cases of interstitial cystitis 1
Diagnostic Considerations
- Multichannel filling cystometry may be necessary to determine if detrusor overactivity is present 1
- Post-void residual assessment to rule out urinary retention 5
- Urinalysis to exclude infection
- Careful medication review to identify potential iatrogenic causes 3
Special Populations
Women with Mixed Incontinence
- Often have both stress and urgency components
- Urgency may be related to pelvic organ prolapse
- Requires comprehensive assessment to determine predominant component 5
Men with Lower Urinary Tract Symptoms
- Urgency may be secondary to bladder outlet obstruction
- May have overlapping symptoms with chronic prostatitis/chronic pelvic pain syndrome 1
- Requires careful differentiation between primary bladder and prostate pathology 2
Elderly Patients
- Higher prevalence of detrusor overactivity
- May have impaired contractility along with overactivity
- More likely to have multiple contributing factors 6
Clinical Pearls and Pitfalls
Important Clinical Considerations
- Urgency is not always reported using textbook definitions - patients may describe it as "pressure" or "discomfort" rather than "urgency" 7
- The absence of detrusor overactivity on a single urodynamic study does not exclude it as a cause of symptoms 1
- Patients with urgency urinary incontinence typically have more severe symptoms and worse quality of life than those with urgency alone 4
Common Pitfalls
- Failing to distinguish between urgency in overactive bladder (voiding to avoid incontinence) versus interstitial cystitis (voiding to avoid pain) 1
- Missing medication-induced causes of urgency
- Overlooking neurological conditions as underlying causes
- Assuming all urgency in men is due to prostate issues 2
Understanding the specific cause of urinary urgency is essential for selecting appropriate treatment strategies, whether behavioral, pharmacological, or surgical, to improve patients' quality of life and reduce morbidity associated with this troublesome symptom.