What are the treatment options for a patient experiencing urine urgency, possibly due to overactive bladder or urinary tract infection, with or without underlying neurological conditions such as multiple sclerosis or spinal cord injuries?

Treatment of Urinary Urgency

Behavioral therapies should be offered as first-line treatment to all patients with urinary urgency, followed by oral antimuscarinic medications or beta-3 agonists as second-line therapy if symptoms persist. 1

Initial Diagnostic Evaluation

Before initiating treatment, clinicians must exclude reversible causes and characterize the type of urgency:

• Perform urinalysis to rule out urinary tract infection, which is the most common treatable cause of urgency symptoms 1, 2, 3
• Measure post-void residual (PVR) volume to exclude overflow incontinence, particularly critical before prescribing antimuscarinics 1, 3, 4
• Review current medications to ensure symptoms are not medication-induced 3
• Assess for neurological conditions (multiple sclerosis, spinal cord injury, Parkinson's disease) through targeted history and examination, as these require specialized evaluation 1, 2

Critical pitfall: Antimuscarinics should be used with caution in patients with PVR 250-300 mL and avoided in those with higher residuals, as they may precipitate acute urinary retention 1, 4

First-Line Treatment: Behavioral Therapies

All patients should receive behavioral interventions regardless of severity 1:

• Bladder training (scheduled voiding with progressive interval increases) 1, 3
• Pelvic floor muscle training for urge suppression techniques 1
• Fluid management with 25% reduction in fluid intake 1
• Caffeine reduction 1
• Weight loss and exercise for obese patients (8% weight loss reduces urgency incontinence episodes by 42%) 1

Behavioral therapies are as effective as antimuscarinic medications in reducing symptom levels and have excellent safety profiles with no adverse effects 1

Second-Line Treatment: Pharmacotherapy

Oral Antimuscarinic Medications

Offer oral antimuscarinics as second-line therapy when behavioral interventions provide insufficient relief 1:

• Darifenacin
• Fesoterodine
• Oxybutynin
• Solifenacin
• Tolterodine
• Trospium

(Listed alphabetically; no hierarchy of efficacy exists among these agents) 1

Common side effects include dry mouth, constipation, dry eyes, blurred vision, and potential cognitive impairment 1

Transdermal oxybutynin may be offered if dry mouth is a concern with oral formulations 1

Beta-3 Adrenergic Agonist

Mirabegron is FDA-approved for adult overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 5:

• Dosing: 25 mg or 50 mg once daily 5
• Efficacy: Reduces incontinence episodes by 0.34-0.42 per 24 hours and micturitions by 0.42-0.61 per 24 hours compared to placebo 5
• Onset: 50 mg dose effective within 4 weeks; 25 mg dose within 8 weeks 5
• Advantages: Different mechanism than antimuscarinics, useful alternative for patients with antimuscarinic side effects 6

Combination Therapy

Behavioral therapies may be combined with antimuscarinic medications for enhanced efficacy 1

Special Populations: Neurological Conditions

Multiple Sclerosis and Spinal Cord Injury

Patients with relevant neurological conditions require specialized evaluation 1:

• Perform PVR assessment during initial urological evaluation and ongoing follow-up 1
• Perform complex cystometrogram (CMG) at initial consultation (or after spinal shock phase in spinal cord injury) even without symptoms, as these patients are at risk for renal complications 1
• Perform pressure flow analysis in patients with elevated PVR or urinary symptoms to distinguish between bladder outlet obstruction and detrusor hypocontractility 1

Treatment approach: Anticholinergic medications combined with clean intermittent self-catheterization effectively manages detrusor hyperreflexia and incomplete bladder emptying in MS patients 7, 8

Critical warning: Patients with neurogenic bladder are at grave risk of mortality and morbidity from untreated urinary complications, including upper tract deterioration, renal stones, and life-threatening infections 9

Treatment Algorithm

1. Exclude UTI and measure PVR before any treatment 1, 2, 3, 4
2. Initiate behavioral therapies immediately for all patients 1, 3
3. Add antimuscarinic or mirabegron if symptoms persist after 4-8 weeks of behavioral therapy 1, 5
4. Consider combination therapy (behavioral + pharmacologic) for refractory symptoms 1
5. For neurological patients: Obtain urodynamic studies and consider intermittent catheterization if PVR elevated 1, 7, 8

Monitoring and Follow-Up

• Assess treatment efficacy and adverse events at regular intervals 1
• Use bladder diaries and validated symptom questionnaires to document baseline symptoms and treatment response 1
• Reassess with urinalysis, PVR, and symptom questionnaires if treatment goals are not met 3

Important caveat: The absence of detrusor overactivity on a single urodynamic study does not exclude it as the cause of urgency symptoms; urodynamic findings must be interpreted in the context of global assessment including examination and bladder diaries 1