What is the best treatment approach for a patient with urinary urgency?

Treatment Approach for Urinary Urgency

Behavioral therapies should be offered as first-line treatment to all patients with urinary urgency, followed by pharmacotherapy with antimuscarinic agents or β3-agonists if symptoms persist. 1

Initial Assessment and Diagnosis

• Urinary urgency is defined as a sudden, compelling desire to pass urine that is difficult to defer, and may be accompanied by frequency, nocturia, and in some cases, urgency incontinence 2
• Distinguish between urgency urinary incontinence (involuntary leakage preceded by urgency) and stress incontinence (leakage with physical exertion) to guide appropriate treatment 3
• Urinary diaries documenting frequency, urgency episodes, and incontinence episodes are helpful in confirming the diagnosis 2
• Patients with urgency incontinence typically have more severe symptoms, greater psychosocial impact, and worse quality of life compared to those with urgency alone 4

First-Line Treatment: Behavioral Therapies

• Behavioral therapies should be offered to all patients with urinary urgency as first-line treatment due to excellent safety profile and lack of adverse effects 1
• Key behavioral interventions include:
  • Bladder training (scheduled voiding with progressive extension of intervals between voids) 2
  • Fluid management (timing and volume optimization) 1
  • Caffeine reduction 1
  • Physical activity/exercise 1
  • Dietary modifications 1
  • Pelvic floor muscle exercises/training 1

Second-Line Treatment: Pharmacotherapy

• For patients with persistent symptoms despite behavioral therapies, pharmacologic treatment should be initiated 1
• Antimuscarinic medications (e.g., solifenacin) are FDA-approved for treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 5
• Clinical studies show that solifenacin significantly reduces urinary frequency (2.3-2.7 fewer micturitions/24 hours), urgency incontinence episodes (1.5-1.8 fewer episodes/24 hours), and increases voided volume per micturition (32-42 mL increase) compared to placebo 5
• β3-adrenergic agonists (e.g., mirabegron) are an alternative pharmacologic option, particularly for patients who cannot tolerate anticholinergic side effects 6

Combination and Advanced Therapies

• In patients whose symptoms do not adequately respond to monotherapy, clinicians may combine behavioral therapy with pharmacotherapy for enhanced efficacy 1
• For men with concomitant benign prostatic hyperplasia (BPH), combination therapy with α-blockers (e.g., tamsulosin) and antimuscarinic agents may be more effective than monotherapy 6
• For refractory cases, consider urodynamic testing to clarify diagnosis and rule out other lower urinary tract pathology 1

Special Considerations

• For patients with mixed urinary incontinence (both stress and urgency components), treatment should target the most bothersome component first 1
• In patients with high-grade pelvic organ prolapse, reduction of the prolapse during evaluation may reveal occult stress incontinence that requires different management 1
• For patients with neurological conditions, post-void residual assessment should be performed during initial evaluation and follow-up 1
• Incontinence management strategies (pads, protective underwear, barrier creams) should be discussed with all patients who have urgency urinary incontinence 1

Treatment Algorithm

1. Start with comprehensive behavioral therapies for 4-6 weeks
2. If inadequate response, add pharmacotherapy:
   • First choice: Antimuscarinic agent (e.g., solifenacin) OR β3-agonist
   • For men with concomitant BPH: Consider combination with α-blocker
3. If still inadequate response, consider:
   • Switching medication class
   • Combination therapy
   • Urodynamic testing to confirm diagnosis
4. For refractory cases: Consider referral for advanced therapies

Common Pitfalls to Avoid

• Failing to distinguish between urgency and stress incontinence, which require different treatment approaches 3
• Not recognizing that absence of detrusor overactivity on a single urodynamic study does not exclude it as a cause of symptoms 1
• Overlooking the importance of behavioral therapies, which have excellent safety profiles and can be effective even when combined with pharmacotherapy 1
• Neglecting to assess for and address concomitant conditions like BPH in men or pelvic organ prolapse in women 6, 1