What medications are used to treat urinary frequency?

Medications for Urinary Frequency

For urinary frequency associated with overactive bladder, antimuscarinic agents (solifenacin, tolterodine, fesoterodine, oxybutynin) or the beta-3 agonist mirabegron are the primary pharmacologic options, but only after behavioral interventions have failed. 1, 2, 3

Treatment Algorithm

First-Line: Non-Pharmacologic Approaches

• Bladder training is the mandatory first-line treatment for urgency-related urinary frequency with strong recommendation and moderate-quality evidence 3
• Pelvic floor muscle training combined with bladder training should be implemented before any medication 3
• Lifestyle modifications including fluid management and weight loss (if obese) are essential initial steps 3

Second-Line: Pharmacologic Therapy

When behavioral interventions fail, proceed to medication based on the following hierarchy:

Preferred First-Choice Antimuscarinic Agents:

• Solifenacin has the lowest discontinuation rate due to adverse effects and achieves continence with NNTB of 9 (95% CI: 6-17) 1, 3
• Tolterodine achieves continence with NNTB of 12 (95% CI: 8-25) and has discontinuation rates similar to placebo 1, 3
• Fesoterodine is superior to tolterodine for achieving continence (NNTB 18 vs tolterodine) 1, 2

Alternative Beta-3 Agonist:

• Mirabegron achieves continence with NNTB of 12 (95% CI: 7-29) and reduces micturition frequency by 0.42-0.61 episodes per 24 hours compared to placebo 1, 4
• FDA-approved for adult overactive bladder with urge incontinence, urgency, and urinary frequency 4
• May be preferred in patients concerned about anticholinergic side effects 5

Less Preferred Option:

• Oxybutynin has the highest discontinuation rate due to adverse effects among antimuscarinics, though it remains effective 2, 3
• Should be reserved as second-line antimuscarinic therapy after better-tolerated agents 2

Medication Selection Criteria:

Base your choice on tolerability, adverse effect profile, ease of use, and cost rather than small efficacy differences, as all approved agents show similar effectiveness 3

Key Contraindications and Precautions

Before Initiating Antimuscarinic Therapy:

• Absolute contraindications include narrow-angle glaucoma, impaired gastric emptying, and history of urinary retention 2
• Assess post-void residual in patients at higher risk of urinary retention 2
• Exclude or treat constipation before starting therapy 2

Special Population Considerations:

• Age alone does not modify clinical outcomes - antimuscarinics remain effective in older women 1, 2
• Consider lower starting doses in elderly patients due to increased side effect risk 3
• Long-term antimuscarinic use raises concerns about cognition, dementia, cardiovascular events, and mortality related to antimuscarinic load 5

Treatment Monitoring and Adjustment

• Reassess patients after 4-8 weeks to evaluate treatment efficacy 2
• If standard treatment fails after 2 months, consider combination therapy or third-line treatments 2
• Common antimuscarinic side effects include dry mouth, constipation, and blurred vision 3
• Mirabegron commonly causes nasopharyngitis and gastrointestinal disorders 3

Important Clinical Pitfalls

Do not use duloxetine for urinary frequency - it has limited efficacy (NNTB 13) and is not statistically superior to placebo for improving urinary incontinence 1, 3

Avoid vasopressin analogues in children with ADPKD who present with urinary frequency, as vasopressin antagonists reduce cyst growth and analogues may be detrimental 1

Pharmacologic therapy is not recommended for stress urinary incontinence - pelvic floor muscle training is the appropriate first-line treatment 3