What is the workup for urinary urgency in a female patient?

From the Guidelines

The workup for urinary urgency in a female patient should begin with a thorough history and physical examination, focusing on urinary symptoms, medical conditions, medications, and gynecological history, as recommended by the Women's Preventive Services Initiative 1. The initial evaluation should include urinalysis to rule out urinary tract infection, and a voiding diary to document frequency, volume, and circumstances of urination. Further testing may include:

• Post-void residual measurement
• Urine culture if infection is suspected
• Basic metabolic panel to assess kidney function For persistent symptoms, urodynamic testing may be indicated to evaluate bladder function. Pelvic examination should assess for pelvic organ prolapse or atrophic vaginitis. First-line treatment typically includes behavioral modifications such as:
• Timed voiding
• Fluid management
• Pelvic floor exercises, as recommended by the American College of Physicians 1 Pharmacotherapy options include:
• Anticholinergics (oxybutynin 5mg BID, tolterodine 2-4mg daily, solifenacin 5-10mg daily)
• Beta-3 adrenergic agonists (mirabegron 25-50mg daily), which have been shown to be effective in managing urgency UI with a moderate magnitude of benefit in achieving continence rates, but are associated with adverse effects 1 These medications work by reducing detrusor muscle contractions or increasing bladder capacity. For postmenopausal women, vaginal estrogen therapy may help if atrophic vaginitis contributes to symptoms. Referral to urology or urogynecology is appropriate for patients with complicated presentations, failed initial therapy, or when considering advanced treatments like botulinum toxin injections or neuromodulation. The Women's Preventive Services Initiative recommends screening women for urinary incontinence annually, using validated assessment instruments that include questions about symptoms, type and degree of incontinence, and how symptoms affect health, function, and quality of life 1.

From the FDA Drug Label

The majority of patients were Caucasian (94%) and female (72%) with a mean age of 59 years (range 18 to 95 years) Entry criteria required that patients had symptoms of overactive bladder for at least 3 months duration, at least 8 micturitions per day, and at least 3 episodes of urgency with or without incontinence over a 3-day period. The work up for urinary urgency in females may include assessing symptoms of overactive bladder, such as urge urinary incontinence, urgency, and urinary frequency.

• Symptom duration: at least 3 months
• Micturitions per day: at least 8
• Episodes of urgency: at least 3 over a 3-day period 2

From the Research

Urinary Urgency Workup in Females

• The clinical management of urinary incontinence in women involves a stepped-care approach, advancing from least invasive to more invasive interventions 3.
• Urge incontinence can be treated with bladder retraining and pelvic floor muscle exercises as first-line treatments, followed by neuromodulation devices, pharmacologic therapy with anticholinergic medications, and sacral nerve stimulators if necessary 3.
• Extended release oxybutynin has been shown to be effective and well-tolerated for the treatment of urge urinary incontinence, with individualized dosing producing a significant decrease in incontinence episodes 4.
• Oxybutynin has been widely used for the treatment of urge urinary incontinence and overactive bladder, with various delivery forms available, including extended-release and transdermal systems 5.
• Patient-reported outcomes are important for determining the clinical effectiveness of treatment for overactive bladder, as they provide insight into the patient's symptoms and treatment satisfaction 6.
• Treatment patterns for women with urinary urgency and/or urgency urinary incontinence vary, with many patients receiving conservative or medical therapies, and highlighting the need for improved treatment algorithms to escalate patients with persistent symptoms 7.

Treatment Options

• Behavioral modification, such as bladder retraining and pelvic floor muscle exercises, is a first-line treatment for urge incontinence 3.
• Pharmacologic therapy with anticholinergic medications, such as oxybutynin, is an option for treating urge incontinence if behavioral therapy is unsuccessful 3, 4, 5.
• Neuromodulation devices, such as posterior tibial nerve stimulators, and sacral nerve stimulators are also options for treating urge incontinence 3.
• Treatment patterns may involve escalation or de-escalation of treatment levels, with predictors of the highest level of treatment including starting level of treatment, hypertension, UUI severity, stress urinary incontinence, and anticholinergic burden score 7.