Urgency Persistence in Detrusor Overactivity Treated with Anticholinergics

Normal Sensory Physiology

Normal bladder‑filling sensation is a gradual, physiologic awareness of bladder volume mediated by low‑level afferent signaling during the storage phase. 1
Urgency is defined as a sudden, compelling desire to void that is difficult to defer and is pathologically distinct from the normal urge to void. 1

Persistence of urgency despite adequate anticholinergic therapy indicates incomplete suppression of detrusor overactivity or the presence of additional pathology beyond simple detrusor overactivity. 3

Pelvic‑floor hypertonicity generates extra afferent input through increased muscle tension and altered proprioceptive signaling, which can independently trigger or amplify urgency sensations. 2

Dual‑targeted therapy is recommended: continue bladder‑directed anticholinergic treatment while adding pelvic‑floor physical therapy to address the hypertonicity component. 2
Pelvic‑floor muscle training is advised as a behavioral intervention for urgency because it can reduce hypertonicity‑related afferent signaling that anticholinergics do not affect. 2
Combining behavioral therapy (e.g., pelvic‑floor training) with pharmacotherapy improves symptom control in patients whose urgency persists on monotherapy. 2

If urgency remains after optimization of anticholinergic dosing and pelvic‑floor therapy, urodynamic testing should be performed to verify whether detrusor overactivity is adequately suppressed or to identify alternative diagnoses such as bladder hypersensitivity without detrusor overactivity. 3