Editors: M. S. Rahnama'i, J. Meijlink, M. Drake, C. Naranjo-Ortiz
Edited May 2, 2016




CURRENT DEFINITION:

Urgency is a lower urinary tract (LUT) storage symptom defined as the complaint of a sudden compelling desire to pass urine, which is difficult to defer (Abrams et al., 2002__; Haylen et al., 2010__).

1.1“Urge(ncy) urinary incontinence is the complaint of involuntary leakage accompanied or immediately preceded by urgency”.

See also 1.7.2: “Symptoms syndromes suggestive of lower urinary tract dysfunction”

“Urgency, with or without urge incontinence, usually with frequency and nocturia, can be described as the overactive bladder syndrome, urge syndrome or urgency-frequency syndrome.”

See also 3.2.1: “Bladder sensation during filling cystometry”.

- “Urgency, during filling cystometry, is a sudden compelling desire to void”.

These definitions derive from the ICS Standardisation of Terminology of Lower Urinary Tract Function, 2002. The Urgency definition is restated in the joint IUGA ICS report on pelvic floor terminology in women, 2010. “Urge incontinence can present in different symptomatic forms, for example, as frequent small losses between micturitions, or as a catastrophic leak with complete bladder emptying”.

In a subsequent explanatory editorial, the term was updated to “Urgency urinary incontinence” (Abrams et al. 2009).

“The ICS no longer recommends the terms “motor urgency” and “sensory urgency”. These terms are often misused and have little intuitive meaning. Furthermore, it may be simplistic to relate urgency just to the presence or absence of detrusor overactivity when there is usually a concomitant fall in urethral pressure.

An ICS Terminology Workshop held at the Annual Scientific Meeting in 2004 decided to make no changes despite many suggestions.


OLD DEFINITIONS:

Other definitions explain urgency as a pathologic sensation that is different than the normal urge to void because it is an intensification of this one (Blaivas, Panagopoulos, Weiss, & Somaroo, 2009__).

Previous standardisation reports defined urgency differently. In the 1988 standardisation report (Abrams et al. 1988), urgency was defined as; "a strong desire to void accompanied by fear of leakage or fear of pain".
URGENCY IN OVERACTIVE BLADDER SYNDROME

In 2004, “Urgency” was debated at the Annual Scientific Meeting of the ICS in Paris (Brubaker L, 2004): “Attempts to measure urgency are confounded by difficulties in understanding its definition, the context of normal urge to void, and the power of suggestion in most clinical environments”. In a response to this article, Meijlink noted that it does “seem premature to draw up a restrictive definition of the term “urgency” - automatically excluding all patients with a painful bladder syndrome - before adequate research has been carried out into the nature and all causes of the sensation of urgency in all patients with an urgency/frequency bladder problem.” (Meijlink JM, 2005). Response from the author: “We must keep in mind that this is a symptom, and the definition of urgency must be applicable in whatever clinical situation the symptom is present, including such entities as urinary tract infection”.(Urology. 2005 Jul;66(1):231)

It has been indicated that, while urge is experienced by normal people, urgency is always pathological (Chapple CR et al. 2005). The authors concluded that based on the existing ICS definition of urgency as 'a compelling desire to pass urine that is difficult to defer', the concept of qualitative assessment of urgency may be flawed.

The study of urinary urgency is challenging for a number of reasons, including our lack of understanding of the normal physiology of urinary sensation and the pathophysiology of abnormal sensation (Dmochowski RR et al., 2009). Issues with nomenclature and lack of agreement about the nature of the experience of normal and abnormal urinary sensation add to this difficulty. Currently available tools for measurement of urgency provide some information about the experience of urinary urgency, but no single measure currently captures its multidimensional nature. They conclude that measurement of urgency in clinical practice and indeed the optimal treatment strategy has yet to come of age.

In current clinical research, it is considered that urgency should be the primary or co-primary endpoint for research into OAB and detrusor overactivity (Abrams P et al.). Greater clarity is needed in the development of instruments for measuring urgency, so that they do not confuse urgency with normal bladder sensations; more education and guidance are needed on how urgency is defined.

Freeman RM, 2005. How urgent is urgency? A review of current methods of assessment.

Abrams P, 2005. Urgency: the key to defining the overactive bladder.

Blaivas JG, et al. 2009. The purpose of this study was to determine whether urinary urgency, as defined by the International Continence Society, is an intensification of the normal sensation that occurs when micturition must be delayed once the urge to void is felt (Type 1 urgency) or a discrete, pathologic symptom different from the normal urge (Type 2 urgency). The authors concluded that urgency is comprised of at least two different sensations. One is an intensification of the normal urge to void and the other is a different sensation. The implications of this distinction are important insofar as they may have different aetiology and respond differently to treatment.


URGENCY IN PAINFUL BLADDER SYNDROME

See also ICS Wiki page on PBS

Abrams P, Hanno P, Wein A. Overactive bladder and painful bladder syndrome: There need not be confusion. Neurourol Urodyn 2005;24:149–50.

A Multidisciplinary Consensus Meeting on IC/PBS was held 10 February 2007 in Washington (ICA, Association of Reproductive Health Professionals (ARHP) and others) coined a new term “persistent urge” in the Consensus group majority definition of IC/PBS: “Pelvic pain, pressure or discomfort related to the bladder, typically associated with persistent urge to void or urinary frequency, in the absence of infection or other pathology”. Reported in; Chancellor MB. A Multidisciplinary Consensus Meeting on IC/PBS. Rev Urol. 2007;9(2):81-83.A 2nd International Consultation on Interstitial Cystitis in Japan (ICICJ) was held in March 2007. The meeting was designed to further international discussions on nomenclature, definition, and diagnostic algorithm and thereby foster more international cooperation. Y. Homma presented a proposal for a new umbrella term “hypersensitive bladder syndrome”. He saw confusion in the fact that IC can be viewed as both a symptom syndrome and as a distinct disease. He would like to refer to the syndrome of increased sensation, frequency, urgency, with or without bladder pain as "hypersensitive bladder syndrome" (HBS). It was agreed by all that urgency is an important aspect of interstitial cystitis and should therefore be included in the definition. The term persistent urge was not acceptable to all. It does not mean the same as urgency.Diggs C et al. 2007. In a study looking at the Interstitial Cystitis Symptom Index (ICSI), also known as the O'Leary-Sant Symptom Index, the authors noted that asking about urgency “with little or no warning” underestimates the prevalence and degree of urinary urgency in IC/PBS. This observation is consistent with the views of others that sudden urgency does not define the sensation experienced by many patients with IC/PBS. What might be viewed simply as an artifact of question wording may actually be addressing an issue of pathophysiologic importance: why do patients with IC/ PBS have urgency?

Homma Y, 2008. “Terminology for lower urinary tract symptoms has been popularized since an extensive revision by the International Continence Society (ICS) in 2002, however the revision incurred significant confusion and inconvenience among the users.…..bladder filling and urge to void must be differentiated; symptom syndromes are not applicable to non-functional abnormality; a syndrome for bladder hypersensitivity is lacking”. He noted that “‘Urgency’ is urinary urgency, and it has been conventionally used simply to imply ‘a strong urge to void’. The new urgency defined by the Report has lost part of its conventional meaning due to an exact qualifier ‘sudden’”. Homma suggests adding a new syndrome: hypersensitive bladder syndrome (HBS). He adds: “The terminology should be continuously challenged for scientific validity to develop a more accurate, refined and user-friendly vocabulary of words.”

Greenberg P et al., 2008. The authors comment on the IC/PBS symptom commonly referred to as "urgency" and its relationship to IC/PBS pain in a group of women with recent onset of the disease. They found that at least two distinct experiences of urge to urinate are evident in this population. For most, urge is linked with pain relief and is associated with bladder filling/emptying. About 1/5 reported urge to prevent incontinence. A similar portion did not agree with either urge, indicating that they may experience something altogether different, which requires further inquiry.

Hanno P, Dmochowski R. 2009 In 2008, the Society for Urodynamics and Female Urology (SUFU) organised a Definition Meeting - a pre-SUFU international invitational consensus workshop on painful bladder syndrome/interstitial cystitis in Miami, chaired by Philip Hanno. The terms urge and urgency were extensively discussed and it was felt that these terms may need revision. A review of the meeting was published in 2009.

Clemens JQ, et al. 2011.This study compared urgency symptoms in women with interstitial cystitis/bladder pain syndrome (IC/BPS) and overactive bladder (OAB), concluding that urgency symptoms differed in women diagnosed with IC/BPS versus those diagnosed with OAB, but there was significant overlap. This suggests that "urgency" is not a well-defined and commonly understood symptom that can be utilized to clearly discriminate between IC/BPS and OAB. These findings reinforce the clinical observation that it is often challenging to differentiate between these two conditions.
PATHOPHYSIOLOGY:

There are three types of receptors in the lower urinary tract: cholinergic, adrenergic and purinergic receptors. From a pharmacological standpoint we can distinguish different subtypes of muscarinic receptors by selective antagonist affinity for pirenzepine. The description of other antagonists has identified new subtypes of muscarinic receptors reaching the M5. The bladder filling and voiding involve a complex system of afferent and efferent signals through sympathetic, parasympathetic, somatic and sensory nerves. These nerves are part of reflex arcs which either maintain the bladder in a relaxation state, allowing the storage of urine in the bladder at low pressure, or they start urination relaxing the urethral sphincter and contracting the detrusor (Naranjo-Ortiz, 2013__).

Full bladder sensation is subjective, it is important to be careful with the first diagnosis of the patient. The normal perception starts with a first sensation, it is followed by a normal sensation and, finally, we have an important desire to void. Patients with urgency have a pathological sensation and have an imperious need to void when the bladder is not full enough. Urgency may be accompanied by polyuria and the patients usually report that they feel a very big need to void but when they go to the bathroom the urine volume is small.

In several cases of urgency, the urodynamics could show involuntary contractions and the patient could have an OAB diagnosis. But in other cases, urodynamic doesn’t show any variations of the normality. In this case, there is an intensification of the normal urge to void not related to the amount of urine stored in the bladder (Blaivas, et al., 2009__; Nixon et al., 2005__).


THERAPY:

The implication of the distinction between these two types of bladder sensations and the different aetiologies may make the difference in the response to treatment. There is international consensus on that the initial treatment of LUTS should be conservative. In general, conservative treatment is easy to implement, is low cost and with few side effects and, moreover, does not impair the effects of other treatments (Wilson, Berghmans, Hagen, Hay-Smith, & Moore, 2004__). The objectives focus on functional recovery and to control of the bladder. At the discretion of the committee members of the 3rd conservative International Consultation on Incontinence (ICI) in 2004, a program of pelvic floor exercises is defined as one that aims at teaching, by a physiotherapist, repetition of maximum voluntary contraction of the pelvic floor muscles (Wilson, et al., 2004__). Thus, intravesical instillation administration of hyaluronic acid has variable effects in terms of duration with a loss of efficiency in some cases. Physiotherapy approach using sedative type electrotherapy performs well without side effects. The empirical use of anticholinergic drugs and B3 agonists can have good results in addressing the urgency (Naranjo-Ortiz, 2013__).

Trends in the management of OAB are developing different concepts and treatments. Neuromodulation is using in the treatment of patients with anticholinergics refractory UUI. This treatment requires surgical implantation of an electronic device that stimulates the sacral nerves to modulate bladder, sphincter and the pelvic floor muscles, which contribute to the appearance of UUI (Bosch, 2006__). The neurostimulator seems established treatment for selected cases, but its main problem is the price, however, more studies are needed to compare with other therapies neuromodulation for refractory OAB (Siddiqui, Wu, & Amundsen, 2010__).

The administration of intravesical botulinum toxin effects presents variable in duration, with proven loss from the year. Repeat injections do not appear to influence the efficiency and maintaining no additional risks or adverse effects (Reitz et al., 2007__). Generally accepted that patients with botulinum toxin therapy involved a complex interaction between the effectiveness and the onset of complications, in spite of this, the balance between this and those treatment were acceptable (Digesu et al., 2010__).

PERSPECTIVES AND CONTROVERSIES:

There are many authors who insist in the necessity of distinguishing the two types of urgency, the first one, when the bladder is full and there is a sudden desire to void directly related with the filling of the bladder, and other one, in which there is not a real relation between the liquid ingest, the replection of the bladder and the sudden and uncontrolled sensation to void (Blaivas, et al., 2009__; Chapple et al., 2005__).

Although various classifications of female UI considers previous urinary infections are a common cause of UTI, this factor was absent in 90,7% of cases in our series (Moreno Sierra, Galante Romo, Prieto Noga, Fernández Montarroso, & Silmi Moyano, 2007__). The lower urinary tract infection (UTI) is the main suspect in the differential diagnosis of women with daytime and night time urinary frequency, and sense of urgency. Diagnosis of overactive bladder (OAB) excludes, by definition, the presence of infection (Abrams, et al., 2002__). Previous work has shown the relationship between detrusor overactivity and the existence of significant bacteriuria, cystitis finding routine bacterial cultures (> 105 colonies / ml) was demonstrated in 6% of patients with involuntary (CI) detrusor had been subject to his control cystometry IUU being 1% of the total (Moore, Simons, Mukerjee, & Lynch, 2000__), consistent with other studies (Choe, Lee, & Seo, 2007__). The role of low count bacteriuria in women with UI and / or sense of urgency and increased urinary frequency without dysuria, needs further clarification. Until 2011 there was only one published study that corroborated the theory that bacteriuria with low colony count was prevalent in women with VH (Khasriya, Bignall, & Hkan, 2008__). Furthermore, a large number of scientific studies have identified the existence of intracellular bacterial communities in chronic infections, including cystitis (Anderson et al., 2003__; Rosen, Hooton, Stamm, Humphrey, & Hultgren, 2007__). Walsh and Moore conclude that the relationship between bacteriuria with low colony number and symptoms such as frequency and urgency in women with OAB needs further study (Walsh & Moore, 2011__).


REFERENCES:



Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten, U., & Van Kerrenbroek, P. (2002). The standardisation of terminology of lower urinary tract function: report from the standardisation sub-committee of the International Continente Society. Neurourology and Urodinamics, 21, 167-178.

Anderson, G. G., Palermo, J. J., Schilling, J. D., Roth, R., Heuser, J., & Hultgren, S. J. (2003). Intracellular bacterial biofilm-like pods in urinary tract infections. Science, 301(5629), 105-107. doi: 10.1126/science.1084550

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Blaivas, J. G., Panagopoulos, G., Weiss, J. P., & Somaroo, C. (2009). Two types of urgency. Neurourology and Urodinamics, 28, 188-190.

Bosch, J. L. (2006). Electrical neuromodulatory therapy in female voiding dysfunction. BJU Int, 98 Suppl 1, 43-48; discussion 49. doi: BJU6316 [pii]

10.1111/j.1464-410X.2006.06316.x

Chapple, C. R., Artibani, W., Cardozo, L. D., Castro-Diaz, D., Craggs, M., Haab, F., . . . Versi, E. (2005). The role of urinary urgency and its measurement in the overactive bladder symptom syndrome: current concepts and future prospects. BJU Int, 95(3), 335-340. doi: BJU5294 [pii]

10.1111/j.1464-410X.2005.05294.x

Choe, J. H., Lee, J. S., & Seo, J. T. (2007). Urodynamic studies in women with stress urinary incontinence: Significant bacteriuria and risk factors. Neurourol Urodyn, 26(6), 847-851. doi: 10.1002/nau.20416

Digesu, G. A., Panayi, D., Hendricken, C., Camarata, M., Fernando, R., & Khullar, V. (2010). Women's perspective of botulinum toxin treatment for overactive bladder symptoms. Int Urogynecol J Pelvic Floor Dysfunct, 22(4), 425-431. doi: 10.1007/s00192-010-1315-x

Haylen, B. T., de Ridder, D., Freeman, R. M., Swift, S. E., Berghmans, B., Lee, J., . . . Schaer, G. N. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J, 21(1), 5-26. doi: 10.1007/s00192-009-0976-9

Khasriya, R., Bignall, J., & Hkan, S. (2008). Routine MSU culture in patients with symptoms of OAB may be missing many genuine infections. Int Urognecol J, 19(S48).

Moore, K. H., Simons, A., Mukerjee, C., & Lynch, W. (2000). The relative incidence of detrusor instability and bacterial cystitis detected on the urodynamic-test day. BJU Int, 85(7), 786-792. doi: bju619 [pii]

Moreno Sierra, J., Galante Romo, M. I., Prieto Noga, S. B., Fernández Montarroso, L., & Silmi Moyano, A. (2007). Etiología, patogenía, tipos y clasificaciones de incontinencia urinaria y prolapsos genitales. In J. Moreno Sierra (Ed.), Atlas de incontinencia urinaria y suelo pélvico (pp. 83-100): Glaxo SmithKline.

Naranjo-Ortiz, C. (2013). Incontinencia Urinaria Femenina: Aproximación urodinámica al tratamiento refractario de la incontinencia urinaria femenina con anticolinérgicos: Editorial Académica Española.

Nixon, A., Colman, S., Sabounjian, L., Sandage, B., Schwiderski, U. E., Staskin, D. R., & Zinners, N. (2005). A validated patient reported measure of urinary urgency severity in overactive bladder for use in clinical trials. The Journal of Urology, 174, 604-607.

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Rosen, D. A., Hooton, T. M., Stamm, W. E., Humphrey, P. A., & Hultgren, S. J. (2007). Detection of intracellular bacterial communities in human urinary tract infection. PLoS Med, 4(12), e329. doi: 07-PLME-RA-0798 [pii]

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Siddiqui, N. Y., Wu, J. M., & Amundsen, C. L. (2010). Efficacy and adverse events of sacral nerve stimulation for overactive bladder: A systematic review. Neurourol Urodyn, 29 Suppl 1, S18-23. doi: 10.1002/nau.20786

Walsh, C. A., & Moore, K. H. (2011). Overactive bladder in women: does low-count bacteriuria matter? A review. Neurourol Urodyn, 30(1), 32-37. doi: 10.1002/nau.20927

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