What are the treatment options for urgency retention?

Treatment Options for Urgency Retention

Behavioral therapies should be offered as first-line treatment for urgency retention, followed by pharmacologic therapy with antimuscarinics or beta-3 agonists if behavioral approaches are unsuccessful. 1

First-Line Treatment: Behavioral Therapies

• Bladder training, which includes a progressive voiding schedule with relaxation and distraction techniques for urgency suppression, is recommended as initial therapy 1, 2
• Pelvic floor muscle training (PFMT) is effective for controlling urgency and increasing the interval between voids 2, 3
• For patients with mixed symptoms, PFMT combined with bladder training is recommended for optimal results 2, 4
• Progressive urinary retention training can be implemented to decrease urinary frequency and increase functional bladder capacity 5

Lifestyle Modifications

• Weight loss and exercise are strongly recommended for obese patients with urinary urgency (strong recommendation, moderate-quality evidence) 1, 2
• Avoiding bladder irritants in diet, such as caffeine and alcohol, can help reduce symptoms 2, 6
• Fluid management with a 25% reduction in fluid intake can reduce frequency and urgency 1
• Treatment of constipation is essential as it can exacerbate urinary symptoms 2

Second-Line Treatment: Pharmacologic Options

• Oral antimuscarinics (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, or trospium) should be offered as second-line therapy when behavioral therapies are unsuccessful 1
• Beta-3 adrenergic agonists (mirabegron) are indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 7
• Tolterodine causes fewer adverse effects than oxybutynin with similar efficacy 2, 8
• Solifenacin has the lowest risk for discontinuation due to adverse effects, while oxybutynin has the highest risk 2

Special Considerations

• Antimuscarinics should be used with caution in patients with post-void residual (PVR) 250-300 mL 1
• Clinicians should discuss the potential risk for developing dementia and cognitive impairment with patients taking antimuscarinic medications 1
• Antimuscarinics should be used with extreme caution in patients with narrow-angle glaucoma, impaired gastric emptying, or a history of urinary retention 1
• For patients with refractory urinary retention who have failed catheter removal attempts, surgery is recommended if the patient is a suitable surgical candidate 1
• Alpha blockers may be administered prior to attempted catheter removal in patients with urinary retention 1

Treatment Algorithm

1. Initial Assessment:

   • Determine if symptoms are consistent with urgency retention 2
   • Assess impact on quality of life 1, 2
   • Identify risk factors (pregnancy, pelvic floor trauma, menopause, hysterectomy, obesity, UTI, cognitive impairment, chronic cough, constipation) 1, 2

2. First-Line Treatment:

   • Implement behavioral therapies (bladder training, PFMT) 1, 2
   • Address lifestyle factors (weight loss, dietary modifications, fluid management) 1, 2

3. Second-Line Treatment (if behavioral therapy unsuccessful):

   • For younger patients or those concerned about cognitive effects: Beta-3 agonists (mirabegron) 1, 7
   • For patients without cognitive concerns: Antimuscarinics (consider tolterodine or solifenacin due to better side effect profiles) 1, 2, 8

4. For Refractory Cases:

   • Consider combination therapy of behavioral interventions with pharmacologic treatment 1
   • For patients with retention: Consider intermittent catheterization with concomitant alpha blocker therapy 1
   • Surgical referral for patients with persistent symptoms despite maximal medical therapy 1

Common Pitfalls to Avoid

• Failing to identify medications that may cause or worsen urinary symptoms 2
• Overlooking conditions that may cause urinary symptoms, such as urinary tract infections and metabolic disorders 2
• Underdiagnosing urinary issues, as many patients do not report symptoms to their physicians 1, 2
• Using antimuscarinics in patients with narrow-angle glaucoma, impaired gastric emptying, or history of urinary retention without appropriate monitoring 1