What is the best approach to manage a young woman with increased urinary urgency and frequency, assuming no urinary tract infection is present?

Management of Increased Urinary Urgency and Frequency in Young Women Without UTI

Start with bladder training as first-line therapy for urgency symptoms, as this behavioral intervention is highly effective with minimal adverse effects and should be attempted before any pharmacologic treatment. 1

Initial Diagnostic Considerations

Before initiating treatment, confirm this is not recurrent UTI masquerading as urgency symptoms:

• Document that symptoms are truly urgency-based (sudden, compelling desire to void that is difficult to defer) rather than dysuria, which would suggest infection 1
• Verify no culture-proven UTI history - recurrent UTI requires ≥3 UTIs/year or 2 UTIs in 6 months with documented positive cultures 1
• Rule out asymptomatic bacteriuria - do not treat this in non-pregnant women without risk factors, as it does not cause urgency symptoms 1

First-Line Treatment: Behavioral Interventions

Bladder Training (Primary Recommendation)

Bladder training should be the initial treatment for urgency symptoms, involving scheduled voiding with progressive extension of intervals between voids 1. This approach:

• Reduces UI frequency by ≥50% with an NNT of 2-4 1
• Has essentially no adverse effects 1
• Is more cost-effective than pharmacologic therapy 1

Pelvic Floor Muscle Training (PFMT)

If the patient has mixed symptoms (urgency plus stress incontinence with leakage on coughing/laughing):

• Combine PFMT with bladder training - this combination achieves continence with NNT of 6 and improves symptoms with NNT of 3 1
• PFMT alone is less effective for pure urgency symptoms 1

Lifestyle Modifications

• Counsel on fluid management - increase overall intake but avoid bladder irritants (caffeine, alcohol) 2
• Address constipation if present, as this exacerbates urinary symptoms 2
• Recommend weight loss and exercise if the patient is obese (NNT 4 for improvement) 1

Second-Line Treatment: Pharmacologic Therapy

Only proceed to medications if bladder training fails after an adequate trial (typically 6-12 weeks) 1. When selecting antimuscarinic agents:

Medication Selection Algorithm

1. First choice: Solifenacin - has the lowest discontinuation rate due to adverse effects among antimuscarinics 1, 3

   • Dosing: Start 5 mg daily, can increase to 10 mg 3
   • Reduces micturitions by 2.3-2.7 per 24 hours vs 1.4 with placebo 3

2. Alternative: Tolterodine - if solifenacin unavailable or not tolerated

   • Similar efficacy to oxybutynin but significantly fewer adverse effects 1
   • Discontinuation risk similar to placebo 1

3. Avoid oxybutynin as first-line - highest discontinuation rate due to adverse effects (dry mouth, constipation, blurred vision) despite efficacy 1, 4

4. Other options: Darifenacin, fesoterodine, trospium - all similarly effective but consider tolerability profiles 1

Common Pitfalls to Avoid

• Do NOT use systemic pharmacologic therapy for pure stress incontinence (leakage only with coughing/sneezing) - this is ineffective 1
• Review current medications - identify drugs that may worsen incontinence (diuretics, alpha-blockers, sedatives) 1, 2
• Do NOT routinely perform cystoscopy or imaging in young women with urgency symptoms and no red flags 1
• Recognize that urgency is often underreported - at least 50% of women don't volunteer these symptoms, so ask directly 1, 2

When Conservative Measures Fail

If both behavioral therapy and first-line antimuscarinics are unsuccessful after adequate trials:

• Consider specialist referral for evaluation of refractory overactive bladder 5
• Advanced options include neuromodulation, botulinum toxin injection, but these require specialist assessment 4, 5
• Urodynamic testing is NOT routinely needed before initiating conservative treatment, but may be considered before invasive interventions 5, 6

Special Consideration: Chronic Symptoms

In patients with prolonged urgency/frequency symptoms plus pelvic pain or dyspareunia, particularly with negative cultures:

• Consider empiric doxycycline trial (patient and partner) before labeling as interstitial cystitis, as this achieves symptom resolution in 71% of such cases 7
• This should be attempted especially before psychiatric referral 7