Purpose While Overactive Bladder (OAB) is traditionally viewed as a detrusor-centric dysfunction, emerging evidence suggests the urethra plays a critical role in its pathogenesis. This review aims to evaluate the contribution of urethral mechanisms—including pressure variations, sensory thresholds, and morphological changes—to OAB symptoms and to explore the efficacy of urethra-targeted interventions.Methods A comprehensive review of clinical studies was conducted, analysing urodynamic data, Current Perception Thresholds (CPT), and magnetic resonance imaging (MRI) findings across cohorts of patients with OAB, mixed urinary incontinence (MUI), and asymptomatic controls. Therapeutic outcomes from sacral neuromodulation (SNM), urethral calibration, and micro-radiofrequency (RF) therapy were also synthesized.Results Patients with OAB and MUI frequently exhibit significant ‘urethral instability’ and pressure fluctuations compared to those with pure SUI. Sensory testing demonstrated that OAB is associated with altered urethral perception thresholds, suggesting a state of hypersensitivity or neural dysfunction in the lower urinary tract. Furthermore, imaging data identified distinct structural and morphological differences in the urethral sphincter and surrounding musculature of symptomatic patients. Finally, clinical outcomes indicate that interventions specifically targeting the urethra—ranging from mechanical calibration to neuromodulation and thermal therapies—result in a meaningful reduction of urgency episodes and an overall improvement in quality of life.Conclusions The urethra acts as a dynamic modulator of the micturition reflex rather than a passive conduit. Urethral sensory and mechanical dysfunctions are key components of OAB, and therapies targeting these urethral pathways offer promising alternatives for patients who do not respond to traditional detrusor-focused treatments.