Urinary Urgency

Definition

• Campbell-Walsh Wein Urology: "Urinary urgency indicates difficulty in postponing urination... it should not occur otherwise."
• Smith & Tanagho's General Urology (19th ed.): Urgency is a lower urinary tract storage symptom distinct from the normal physiological sensation of bladder fullness ("urge").

Overactive Bladder (OAB) - The Core Syndrome

OAB = Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence (UUI), in the absence of UTI or other obvious pathology.

• OAB "wet" - urgency + urge incontinence (involuntary urine loss associated with urgency)
• OAB "dry" - urgency without incontinence

Pathophysiology

Differential Diagnosis of Urgency

Important: In patients >50 years with a smoking history, irritative voiding symptoms (urgency, frequency, dysuria) can be the only presenting sign of bladder cancer - this mandates urological evaluation.

Evaluation

1. History - onset, frequency, nocturia, incontinence, hematuria, neurological symptoms, pelvic surgery/radiation, medications
2. Bladder diary (48 hours) - volumes voided, fluid intake, urgency episodes, incontinence - reveals functional capacity (~300-400 mL normal adult), polyuria, nocturia patterns
3. Urinalysis + urine culture - exclude UTI, hematuria
4. Post-void residual (PVR) - exclude incomplete emptying
5. Urodynamics (UDS) - reserved for: diagnosis in doubt, failed initial therapy, suspected neurogenic bladder, coexisting BOO, significant PVR, or pre-surgical workup
6. Cystoscopy - if hematuria, refractory symptoms, or suspected malignancy

Treatment - Stepwise Approach

Step 1: Conservative / Behavioral (6-12 weeks minimum)

• Fluid management - reduce intake by ~25% if drinking >1 L/day; avoid caffeine, alcohol, carbonated drinks
• Bladder training - gradually increase voiding intervals; teaches suppression of urgency
• Pelvic floor muscle training (PFMT) - urgency suppression with voluntary pelvic floor contraction
• Bowel management (constipation worsens OAB)
• Weight loss, smoking cessation

Step 2: Pharmacotherapy

• Extended-release formulations preferred over immediate-release for tolerability
• Main side effects: dry mouth, constipation, blurred vision, cognitive effects (especially in elderly)

• Mirabegron - relaxes detrusor via β₃ receptors; proven superiority to tolterodine for incontinence episodes and frequency; less dry mouth/constipation than antimuscarinics; side effects include palpitations and hypertension
• Combination therapy (mirabegron 50 mg + solifenacin 5 mg) is superior to dose escalation of solifenacin alone, with better efficacy and fewer side effects (Drake et al., 2016)

Step 3: Minimally Invasive Procedures

• OnabotulinumtoxinA (Botox) intravesical injection - reduces detrusor overactivity; effective for refractory OAB and neurogenic detrusor overactivity; risk of urinary retention (patient should be able to self-catheterize)
• Sacral nerve modulation (SNM/InterStim) - implanted neuromodulation; used for refractory OAB and UUI
• Posterior tibial nerve stimulation (PTNS) - percutaneous or transcutaneous; less invasive neuromodulation option

Step 4: Surgical (rarely needed)

• Bladder augmentation cystoplasty - increases capacity; significant morbidity; for severe refractory cases
• Urinary diversion (e.g., ileal conduit) - last resort

Special Populations

• Neurogenic bladder - urgency with DO is the most common pattern in lesions above the brainstem or above the sacral cord; DESD (detrusor-external sphincter dyssynergia) may coexist in suprasacral lesions; antimuscarinics used; Botox has strong evidence
• Elderly - antimuscarinics carry cognitive risk; prefer trospium, darifenacin, or mirabegron; assess fall risk
• Women - estrogen deficiency contributes to urgency; topical vaginal estrogen may help (not systemic)
• BPH (men) - combination alpha-blocker + antimuscarinic or mirabegron for mixed LUTS

Key Points

• Urgency = sudden compelling desire to void, difficult to defer
• OAB = urgency ± frequency, nocturia, ± incontinence; no infection
• Always rule out UTI, hematuria, neurological cause
• First-line: behavioral therapy (bladder training, PFMT, fluid management)
• Second-line: antimuscarinics or mirabegron (Grade A evidence)
• Refractory: Botox injection or sacral neuromodulation
• Hematuria + urgency in a smoker >50 years = cystoscopy mandatory