Urinary urgency is the sudden, compelling desire to void that is difficult to defer. It may occur alone or with bladder pain, frequency, or incontinence. Urgency can be transient or chronic and often reflects irritation of the bladder mucosa, detrusor overactivity, or impaired neurologic control.

Pathophysiology

• Bladder inflammation or irritation→ Mucosal edema and increased sensory nerve activity reduce bladder capacity and trigger involuntary contractions.

• Neurologic dysfunction→ Lesions in the brain, spinal cord, or peripheral nerves (e.g., multiple sclerosis, spinal trauma) interrupt inhibitory pathways, producing detrusor hyperreflexia.

• Obstructive or mechanical factors→ Bladder calculi, urethral strictures, or tumors cause incomplete emptying, increasing detrusor pressure.

• Treatment-related irritation→ Radiation or intravesical agents may inflame the bladder wall.

History and Physical Examination

History

• Onset: sudden vs. gradual, intermittent vs. constant

• Associated urinary symptoms: dysuria, hematuria, cloudy urine, frequency, nocturia, hesitancy

• Pain: suprapubic, flank, or referred (penis, vulva, low back)

• Neurologic symptoms: paresthesia, weakness, gait changes, visual problems

• Sexual & exposure history: recent intercourse (consider Reiter’s), use of bubble baths (children), radiation therapy

• Past medical/surgical history: recurrent UTIs, neurologic disorders, pelvic or spinal procedures

Physical Examination

• Inspect urethral meatus and external genitalia for inflammation, discharge, or lesions

• Palpate the suprapubic region for bladder distention/tenderness

• Percuss or palpate flanks for renal tenderness

• Perform a focused neurologic exam: motor strength, tone, reflexes, sensation, gait

• In children: examine perineal skin for irritation; assess for vulvovaginitis

Medical causes of urinary urgency

Other causes

• Intravesical chemotherapy or BCG therapy

• Bladder tumors (carcinoma in situ may present with irritative voiding)

• Postoperative irritation (e.g., following transurethral procedures)

Emergency interventions

• Acute urinary retention with urgency → Prompt bladder decompression via catheterization.

• Neurologic lesion with overflow symptoms → Monitor residual volumes; consider intermittent catheterization.

Special considerations

• Encourage adequate hydration unless contraindicated.

• For irritative causes, avoid bladder irritants (caffeine, alcohol, acidic beverages).

• Bladder retraining may benefit patients with detrusor overactivity.

• Monitor urine output and residual volumes in neurologic or post-surgical patients.

Patient counseling

• Teach proper perineal hygiene (front-to-back wiping in women).

• Review safer sex and prompt STI treatment.

• Explain Kegel or pelvic floor exercises for urgency associated with sphincter weakness.

• Emphasize adherence to treatment for infections or neurologic disease.

• Discuss lifestyle modifications: timed voiding, fluid management, avoiding bladder irritants.

Pediatric pointers

• Sudden onset of urgency or daytime accidents in toilet-trained children may signal UTI or behavioral regression.

• Bubble bath–related urethral irritation is a common benign cause.

• Girls may present with vulvovaginitis or discharge; consider pinworm infestation.

Geriatric pointers

• Older adults may present with urgency or incontinence as the first sign of UTI or delirium.

• Age-related detrusor overactivity and reduced compliance increase urgency risk.

• Evaluate for polypharmacy (diuretics, anticholinesterases) contributing to symptoms.

References

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