Treatment of Urinary Urgency
Bladder training is the first-line treatment for urinary urgency, and if this fails after an adequate trial, pharmacologic therapy should be initiated with medication selection based on tolerability and adverse effect profile rather than efficacy, since all agents work similarly well. 1
Step 1: Initial Behavioral Interventions (Mandatory First-Line)
Bladder training must be attempted first for patients with urgency urinary incontinence before considering any pharmacologic options 2, 1. This involves:
- Progressive voiding schedules combined with urgency suppression techniques using relaxation and distraction 3
- Establishing normal voiding intervals to retrain bladder function 3
- Duration of at least 3 months before declaring treatment failure 4
For mixed incontinence (urgency plus stress symptoms), combine pelvic floor muscle training with bladder training 2, 1.
Step 2: Lifestyle Modifications (Concurrent with Behavioral Therapy)
Implement these evidence-based modifications simultaneously 1:
- Eliminate bladder irritants: Remove caffeine and alcohol from diet 1
- Weight loss: Strongly recommended for obese patients, as this improves continence rates 1
- Fluid management: Avoid excessive fluid intake 5
- Treat constipation: Essential component of management 1
- Medication review: Identify and discontinue medications that worsen urgency 1
Common pitfall: At least half of women with urinary incontinence never report symptoms to physicians, so active screening is necessary 1.
Step 3: Pharmacologic Treatment (Only After Behavioral Therapy Fails)
Initiate pharmacologic therapy only if bladder training was unsuccessful 2, 1. All antimuscarinic medications have similar efficacy, so selection is based entirely on adverse effect profiles 2:
Preferred Agents (in order of tolerability):
- Solifenacin: Lowest discontinuation rate due to adverse effects 1
- Tolterodine: Fewer adverse effects than oxybutynin with equivalent efficacy 1, 6
- Mirabegron (beta-3 agonist): Starting dose 25 mg daily, may increase to 50 mg after 4-8 weeks 7
Alternative Agents:
- Oxybutynin, darifenacin, fesoterodine, trospium: All effective but oxybutynin has highest discontinuation rate 2, 1
Dosing Adjustments:
For renal impairment with mirabegron 7:
- eGFR 30-89: Start 25 mg, max 50 mg daily
- eGFR 15-29: Start 25 mg, max 25 mg daily
- eGFR <15 or dialysis: Not recommended
For hepatic impairment with mirabegron 7:
- Child-Pugh A: Start 25 mg, max 50 mg daily
- Child-Pugh B: Start 25 mg, max 25 mg daily
- Child-Pugh C: Not recommended
Expected Adverse Effects:
Warn patients about dry mouth, constipation, and blurred vision with antimuscarinics 1. Poor adherence is common, so set realistic expectations about side effects versus symptom improvement 2.
Step 4: Procedural Interventions (Refractory Cases)
If pharmacologic therapy fails, consider 5, 8:
- OnabotulinumtoxinA bladder injections: Effective for refractory urgency
- Percutaneous tibial nerve stimulation: Less invasive neuromodulation option
- Sacral neuromodulation: Superior to conservative and pharmacologic therapy for urgency incontinence
Critical Management Principles
Do NOT use systemic pharmacologic therapy for pure stress incontinence - it is ineffective 2, 1. Only vaginal estrogen formulations improve stress incontinence in postmenopausal women 2.
Before initiating any treatment, rule out reversible causes 1:
- Urinary tract infections
- Metabolic disorders
- Delirium or cognitive impairment
- Medications causing urgency
For mixed incontinence, treat the most bothersome symptom first, but control urgency symptoms before considering surgical intervention for stress components 8.