Lower Urinary Tract Symptoms in Women

Lower urinary tract symptoms (LUTS) in women are storage symptoms (frequency, urgency, nocturia, urgency incontinence, stress incontinence, bladder pain), voiding symptoms (hesitancy, slow or intermittent stream, straining, incomplete emptying) and post-micturition symptoms (dribbling, a feeling of residual urine).

• Prevalence is high: about 40 to 60 percent of adult women report at least one symptom, and it rises with age and parity.
• Main causes:
  • Overactive bladder (urgency with or without urgency incontinence, usually with frequency and nocturia).
  • Stress urinary incontinence from urethral hypermobility or sphincter weakness (pregnancy, vaginal delivery, obesity, chronic cough, menopause).
  • Mixed incontinence.
  • Urinary tract infection and recurrent cystitis.
  • Genitourinary syndrome of menopause (atrophic urethritis and vaginitis).
  • Pelvic organ prolapse (cystocele, urethrocele) causing obstructed voiding.
  • Bladder pain syndrome (interstitial cystitis), bladder stones and tumours, urethral diverticulum, urethral stricture.
  • Neurological disease (multiple sclerosis, diabetic neuropathy, spinal cord lesions), detrusor underactivity, pelvic masses (fibroids, ovarian mass), constipation.
  • Medicines and fluids (diuretics, anticholinergics, alpha agonists, opioids, ACE inhibitor cough, SGLT2 inhibitors, caffeine, alcohol, high fluid intake), diabetes mellitus, hypercalcaemia, nocturnal polyuria.
• Impact: sleep loss, falls, depression, social isolation, sexual dysfunction, perineal skin breakdown.

• Record each symptom with its duration, severity and bother. Ask about leakage with cough, laugh or exertion (stress), leakage with a sudden urge (urgency), daytime and night voids, fluid intake, caffeine and alcohol, dysuria, haematuria, pelvic pain, dyspareunia, vaginal dryness, bulge or heaviness, bowel habit, obstetric and surgical history, menopausal status, neurological symptoms and medicines.
• Examination: BMI, abdomen (bladder, mass), pelvic examination for atrophy, prolapse (with straining, ideally in left lateral position with a Sims speculum), urethral mass or tenderness, cough stress test with a comfortably full bladder, pelvic floor contraction strength (Oxford scale 0 to 5), anal tone, perineal sensation, rectal examination for faecal loading.
• Red flags: visible haematuria, persistent microscopic haematuria, recurrent infections, pelvic mass, palpable bladder, neurological signs, symptoms after pelvic surgery or radiotherapy, pain, voiding difficulty, fistula (continuous leakage), age over 50 with new symptoms and haematuria.

• Bladder diary for at least 3 days (voiding times and volumes, fluid intake, leaks, pad use).
• Urinalysis for blood, glucose, protein, leucocytes and nitrites; culture if positive or symptoms suggest infection.
• Post-void residual by bladder scan or catheter when voiding symptoms, recurrent infection, neurological disease or before treatment with antimuscarinics (a residual over 100 to 150 mL calls for further assessment).
• Bloods: urea, creatinine and eGFR, HbA1c, calcium.
• Pregnancy test in women of reproductive age.
• Urodynamics before surgery for stress incontinence, mixed or complex symptoms, failure of initial treatment, or voiding dysfunction.
• Cystoscopy and renal tract imaging for haematuria, persistent irritative symptoms with sterile urine, suspected stone, tumour, fistula or diverticulum.
• Pelvic ultrasound or MRI for suspected mass, diverticulum or prolapse assessment.

• Lifestyle: fluids 1.5 to 2 litres daily spread through the day; reduce caffeine (below 200 mg per day), alcohol and fizzy drinks; weight loss (5 to 10 percent reduces incontinence episodes); stop smoking; treat constipation and chronic cough.
• Supervised pelvic floor muscle training for stress or mixed incontinence: at least 3 sets of 8 contractions daily, each held up to 10 seconds, for at least 3 months; refer to a pelvic floor physiotherapist.
• Bladder training for urgency: scheduled voiding, starting at an interval the patient manages and lengthening by 15 to 30 minutes weekly to 3 to 4 hours, with urge suppression (pelvic floor squeeze, relaxation) for at least 6 weeks.
• Atrophy: estradiol 10 microgram vaginal tablet nightly for 2 weeks then twice weekly (or estriol 0.1 percent cream 0.5 g nightly for 2 weeks then twice weekly), continued long term.
• Overactive bladder drugs after 6 weeks of conservative measures:
  • Mirabegron 50 mg orally once daily (25 mg if eGFR 15 to 29 or moderate hepatic impairment; avoid with uncontrolled hypertension; monitor blood pressure), or vibegron 75 mg once daily.
  • Solifenacin 5 mg once daily, increased to 10 mg after 4 weeks; oxybutynin immediate release 2.5 to 5 mg two to three times daily or modified release 5 to 10 mg once daily; tolterodine 2 mg twice daily; fesoterodine 4 mg once daily increased to 8 mg; trospium 20 mg twice daily. Cautions: narrow angle glaucoma, retention, severe constipation, myasthenia gravis, dementia and frailty (cognitive decline and falls with high anticholinergic burden). Review at 4 weeks.
• Stress incontinence drugs: duloxetine 40 mg twice daily (start 20 mg twice daily for 2 weeks; nausea and suicidal ideation warnings; second line); vaginal pessary or incontinence ring for prolapse or stress incontinence; surgery (mid-urethral sling, autologous fascial sling, colposuspension, bulking agents) after failed conservative treatment and urodynamics.
• Refractory urgency: onabotulinumtoxinA 100 units into the detrusor by cystoscopy (risk of retention and infection, teach intermittent self-catheterisation if needed), sacral or tibial nerve neuromodulation.
• Urinary tract infection: choose the antibiotic by culture; for uncomplicated cystitis nitrofurantoin 100 mg modified release twice daily for 3 days.
• Nocturia from nocturnal polyuria: desmopressin melt 25 micrograms sublingually one hour before bed, with sodium checks at baseline, day 3 and 1 month.
• Voiding dysfunction or retention: treat cause (prolapse, constipation, drugs), intermittent self-catheterisation, urology referral.
• Containment: absorbent pads, skin barrier cream, toileting plan.
• Review at 4 to 8 weeks. Refer for haematuria, failed first line treatment, pain, prolapse, neurological disease or suspected fistula.