What are the treatment options for urinary urgency?

Treatment Options for Urinary Urgency

Bladder training should be the first-line treatment for patients with urinary urgency, followed by pharmacologic therapy if behavioral interventions are unsuccessful. 1, 2

First-Line Treatment: Behavioral Interventions

Bladder Training

• Bladder training is strongly recommended as first-line treatment for patients with urgency urinary incontinence (UI) (strong recommendation, moderate-quality evidence) 1, 2
• This approach improves UI symptoms for women with urgency UI 1
• Bladder training includes establishing a progressive voiding schedule together with relaxation and distraction techniques for urgency suppression 3

Pelvic Floor Muscle Training (PFMT)

• For patients with stress UI, PFMT is recommended as first-line treatment (strong recommendation, high-quality evidence) 1, 2
• For patients with mixed UI, PFMT combined with bladder training is recommended (strong recommendation, moderate-quality evidence) 1, 2
• The addition of PFMT to bladder training did not improve continence compared with bladder training alone for urgency UI 1

Second-Line Treatment: Lifestyle Modifications

• Weight loss and exercise are recommended for obese individuals with UI (strong recommendation, moderate-quality evidence) 2
• Avoiding bladder irritants in diet, such as caffeine and alcohol, can help reduce symptoms 2
• Treating constipation is essential for symptom management 2
• Fluid management, including appropriate but not excessive fluid intake, can help control symptoms 3

Third-Line Treatment: Pharmacologic Options

• Pharmacologic treatment is recommended if bladder training was unsuccessful for patients with urgency UI (strong recommendation, high-quality evidence) 1, 2
• For urgency UI, medications including oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium have been shown to increase continence rates and improve UI 1
• Mirabegron is indicated for the treatment of overactive bladder (OAB) in adult patients with symptoms of urge urinary incontinence, urgency, and urinary frequency 4
• The recommended starting dose of mirabegron is 25 mg once daily, which can be increased to 50 mg once daily after 4-8 weeks if needed 4

Medication Selection Considerations

• Tolterodine causes fewer adverse effects than oxybutynin with similar efficacy 2
• Solifenacin has the lowest risk for discontinuation due to adverse effects, while oxybutynin has the highest risk 2
• Common adverse effects of anticholinergic medications include dry mouth, constipation, and blurred vision 2
• Mirabegron 25 mg was effective in treating OAB symptoms within 8 weeks, while the 50 mg dose was effective within 4 weeks 4
• Adherence to pharmacologic treatments for UI is generally poor, with adverse effects being a major reason for discontinuation 1

Treatment Algorithm for Urinary Urgency

1. Start with bladder training - Implement scheduled voiding with progressive increases in voiding intervals 1, 2, 3
2. Add lifestyle modifications - Weight loss (if applicable), avoiding bladder irritants, managing fluid intake, treating constipation 2
3. If unsuccessful after 8-12 weeks, initiate pharmacologic therapy 1, 2
   • Start with either an antimuscarinic agent (e.g., tolterodine, solifenacin) or mirabegron 25 mg daily 1, 4
   • Base medication choice on tolerability, adverse effect profile, ease of use, and cost 1
   • Consider increasing mirabegron to 50 mg daily after 4-8 weeks if needed 4

Special Considerations and Common Pitfalls

• Underdiagnosis is common, with at least half of women with UI not reporting the issue to their physicians 2
• Failure to identify medications that may cause or worsen UI is a common pitfall 2
• Overlooking conditions that may cause UI, such as urinary tract infections and metabolic disorders, can lead to ineffective treatment 2
• In men, lower urinary tract symptoms including urgency can be caused by bladder outlet obstruction due to benign prostatic hyperplasia, overactive bladder detrusor, or both 5
• For men with urinary urgency, additional treatment options include α-blockers (e.g., tamsulosin), 5α-reductase inhibitors (e.g., finasteride), and phosphodiesterase 5 inhibitors (e.g., tadalafil) 5
• Dosage adjustments are necessary for patients with renal or hepatic impairment when using medications like mirabegron 4