Urinary frequency and urgency

Urinary frequency is voiding more than 8 times in 24 hours (or more often than usual). Urgency is a sudden compelling desire to void that is difficult to defer. Together with nocturia and, with or without urgency urinary incontinence, they form the overactive bladder syndrome. Causes include infection, polyuria, obstruction, bladder irritation, neurological disease and drugs.

Mechanisms. Detrusor overactivity, bladder outlet obstruction with secondary detrusor changes, reduced bladder compliance or capacity, sensory urgency, increased urine production, and psychological factors.

Classification. Polyuria (over 3 L in 24 hours; diabetes mellitus, diabetes insipidus, hypercalcaemia, diuretics, polydipsia), small volume frequency (infection, interstitial cystitis, tumour, stone, overactive bladder, prostate disease, pelvic organ prolapse, pregnancy, pelvic mass), and nocturnal polyuria.

Key distinctions. Frequency with large volumes suggests polyuria. Frequency with urgency and incontinence suggests overactive bladder. Frequency with dysuria suggests infection. Frequency with a poor stream and incomplete emptying suggests outlet obstruction.

History.

• Onset, duration, daytime frequency, voided volume, nocturia, urgency, urge incontinence, stress leakage.
• Dysuria, haematuria, flow (hesitancy, weak stream, intermittency, terminal dribble, straining), incomplete emptying, pelvic pain.
• Fluid intake (volume and type: caffeine, alcohol, carbonated drinks), thirst, weight loss, fever.
• Bowel habit (constipation).
• Neurological symptoms (back pain, leg weakness, sensory loss, sexual dysfunction).
• Diabetes, hypercalcaemia symptoms, pregnancy and childbirth, menopause, pelvic surgery or radiotherapy, prostate symptoms, stones, and psychosocial impact.

Complete a bladder diary for 3 days (times, volumes, fluid intake, leaks, urgency).

Drug history.

• Diuretics (loop and thiazide), lithium, alcohol and caffeine, sodium glucose cotransporter 2 inhibitors.
• ACE inhibitors (cough with frequency), calcium channel blockers, cholinesterase inhibitors (donepezil), antipsychotics, sedatives.
• Alpha blockers (incontinence in women).
• Opioids and anticholinergics (retention with overflow).

Examination.

• General: hydration, weight, oedema, cognitive state, mobility.
• Abdomen: palpable bladder, masses.
• Genitalia and perineum: atrophy, prolapse, cystocele, rectocele, skin, discharge.
• Vaginal examination and pelvic floor muscle strength. Cough stress test.
• Digital rectal examination: prostate size and consistency in men, faecal loading, anal tone.
• Neurological examination of lower limbs, with sacral sensation and reflexes (bulbocavernosus).

Red flags

• Visible haematuria or persistent microscopic haematuria
• Age over 40 with new frequency and urgency without infection (bladder cancer, prostate cancer)
• Pelvic or perineal pain, constant suprapubic pain (interstitial cystitis, bladder tumour)
• Retention, poor stream, recurrent infection, or raised post-void residual
• Neurological signs: saddle anaesthesia, bowel dysfunction, leg weakness, back pain (cord or cauda equina compression)
• Polyuria with thirst, weight loss, high glucose or calcium
• Pelvic mass, palpable bladder, or pelvic radiotherapy history
• Unexplained weight loss or night sweats
• Pregnancy
• Recent urological, pelvic or spinal surgery or injury

Special groups. Women: pregnancy, prolapse and genitourinary syndrome of menopause. Men: benign prostatic enlargement. Children: infection, constipation, diabetes, and dysfunctional voiding; enuresis assessment. Older adults: overactive bladder with anticholinergic burden and cognitive impairment. Region specific: schistosomiasis and genitourinary tuberculosis.

Polyuria related

• Diabetes mellitus (hyperglycaemia), diabetes insipidus (central and nephrogenic), hypercalcaemia, hypokalaemia, primary polydipsia, chronic kidney disease (tubular concentrating defect), post-obstructive diuresis, resolution of acute tubular necrosis
• Drugs and substances (diuretics, caffeine, alcohol, lithium, sodium glucose cotransporter 2 inhibitors)

Infective and inflammatory

• Urinary tract infection, prostatitis, urethritis, vaginitis, interstitial cystitis and bladder pain syndrome, radiation cystitis, tuberculosis, schistosomiasis, chemical and ketamine cystitis

Obstructive and structural

• Benign prostatic enlargement, urethral stricture, bladder stones, bladder diverticulum, pelvic organ prolapse, pelvic masses (fibroids, ovarian mass), pregnancy, constipation and faecal impaction, urethral stenosis in women

Neoplastic

• Bladder cancer (including carcinoma in situ), prostate cancer, cervical, uterine and ovarian cancer, rectal cancer, and pelvic metastases

Neurological and functional

• Overactive bladder (idiopathic), neurogenic detrusor overactivity (multiple sclerosis, stroke, Parkinson disease, spinal cord injury, spina bifida, cauda equina syndrome, diabetic neuropathy, dementia, normal pressure hydrocephalus)
• Bladder outlet dysfunction, detrusor underactivity with overflow, behavioural and habitual frequency, anxiety, and psychogenic polydipsia

Reasoning. Use the bladder diary and urine tests to separate polyuria from small volume frequency, test for infection and diabetes, and then assess outlet obstruction and neurology. Investigate for cancer where red flags are present.

First line. Bladder diary (3 days), urine dipstick and midstream urine culture, blood glucose or HbA1c, urea, creatinine, electrolytes and calcium, abdominal and pelvic examination, post-void residual (bladder scan), and pregnancy test.

Targeted tests.

• Prostate specific antigen (after counselling) in men with lower urinary tract symptoms when prostate cancer is suspected or the patient requests; not within 6 weeks of infection or catheterisation.
• Renal tract ultrasound (kidneys, bladder, post-void residual, prostate) for raised residual, recurrent infection, haematuria, or renal impairment.
• Flexible cystoscopy and imaging (CT urogram) for haematuria, persistent unexplained symptoms, suspected tumour, interstitial cystitis, or stone; urine cytology.
• Urodynamic studies (cystometry, pressure flow) before surgery or when diagnosis is unclear, with neurogenic bladder, or failure of initial treatment.
• Water deprivation and desmopressin test, plasma and urine osmolality, serum sodium (diabetes insipidus: urine osmolality under 300 mOsm/kg with plasma osmolality over 295 mOsm/kg after water deprivation and rising over 50 percent with desmopressin in central disease), copeptin where available.
• Parathyroid hormone, vitamin D, myeloma screen (serum protein electrophoresis) for hypercalcaemia.
• MRI spine and brain for suspected neurological cause; sacral reflex testing and EMG when indicated.
• Pelvic ultrasound or MRI for pelvic mass or prolapse; examination under anaesthesia and cystoscopy for suspected fistula.
• Urine for acid fast bacilli and schistosoma eggs in endemic areas.

Limitations. Frequency and urgency symptoms correlate poorly with urodynamic findings. Bladder diaries rely on patient adherence.

Treat the cause (all patients).

• Treat infection after culture: nitrofurantoin 100 mg modified release orally twice daily for 3 days, or trimethoprim 200 mg orally twice daily for 3 days.
• Correct diabetes and hypercalcaemia. Urgent: 0.9 percent sodium chloride 1 to 2 L IV bolus then 200 to 300 mL/hour. After rehydration, give zoledronic acid 4 mg IV over 15 minutes when calcium is over 3.0 mmol/L, adjusted to renal function.
• Stop or adjust diuretics and drugs causing frequency (with prescriber).
• Manage constipation (macrogol 1 sachet one to three times daily).
• Address pregnancy and pelvic masses.

Behavioural measures for overactive bladder (first line).

• Reduce caffeine, alcohol and carbonated drinks.
• Fluid intake of about 1.5 to 2 L daily (not restricted excessively).
• Weight loss when overweight.
• Bladder training: gradually extend the voiding interval, aiming for 2 to 4 hours, for at least 6 weeks.
• Urge suppression techniques.
• Pelvic floor muscle training (supervised, at least 3 months for women with stress component).
• Timed voiding, and containment products as needed.

Antimuscarinics (after behavioural measures fail). Choose by age and anticholinergic burden. Review at 4 weeks (effect), and annually. Common adverse effects: dry mouth, constipation, blurred vision, cognitive effects. Contraindications: urinary retention, uncontrolled angle closure glaucoma, gastric retention, myasthenia gravis, severe ulcerative colitis.

• Solifenacin 5 mg orally once daily, increased to 10 mg daily (maximum 10 mg daily; maximum 5 mg with severe renal or moderate hepatic impairment or strong CYP3A4 inhibitors).
• Tolterodine 2 mg orally twice daily (1 mg twice daily with hepatic impairment or CYP3A4 inhibitors) or modified release 4 mg once daily.
• Oxybutynin 2.5 to 5 mg orally two to three times daily (maximum 5 mg four times daily). Avoid in older adults and cognitive impairment because of central effects.
• Fesoterodine 4 mg once daily, increased to 8 mg daily.
• Trospium 20 mg twice daily (reduce in renal impairment).
• Darifenacin 7.5 mg once daily increased to 15 mg.
• Transdermal oxybutynin 3.9 mg/day patch twice weekly or oxybutynin gel have fewer dry mouth effects.

Beta 3 agonist.

• Mirabegron 25 mg orally once daily, increased to 50 mg daily after 4 to 8 weeks.
• Maximum 25 mg with creatinine clearance 15 to 29 mL/min or moderate hepatic impairment. Avoid in severe uncontrolled hypertension of 180/110 mmHg or more. Monitor blood pressure. It interacts with digoxin and flecainide.
• Alternative: vibegron 75 mg once daily.
• Use first in older adults and those with dementia or high anticholinergic burden.

Men with lower urinary tract symptoms and bladder outlet obstruction.

• Alpha blocker: tamsulosin 400 micrograms orally once daily after food, or alfuzosin 10 mg once daily. Adverse effects are orthostatic hypotension and floppy iris syndrome before cataract surgery.
• Add a 5 alpha reductase inhibitor for prostates over 30 g: finasteride 5 mg once daily or dutasteride 0.5 mg once daily. Full effect at 6 months. Sexual adverse effects. Prostate specific antigen halved.
• Add an antimuscarinic or mirabegron for persistent storage symptoms once residual volume is under 150 mL.
• Tadalafil 5 mg once daily as an alternative.
• Surgery (transurethral resection or laser enucleation) for refractory symptoms, retention, recurrent infection, stones, or renal impairment.

Genitourinary syndrome of menopause. Vaginal oestrogen (estradiol 10 microgram pessary daily for 2 weeks then twice weekly, or estriol cream 0.5 mg nightly for 2 weeks then twice weekly), reviewed at 3 months.

Pelvic organ prolapse. Pelvic floor training, pessary, and surgery by gynaecology or urogynaecology.

Diabetes insipidus.

• Central: desmopressin 100 to 200 micrograms orally two to three times daily (or 10 to 20 micrograms intranasally once or twice daily). Check sodium at baseline, 3 days, 7 days, then regularly. Avoid fluid overload.
• Nephrogenic: treat the cause (stop lithium, correct hypercalcaemia and hypokalaemia). Low salt and low protein diet. Thiazide diuretic (hydrochlorothiazide 25 to 50 mg daily) with amiloride.

Interstitial cystitis and bladder pain syndrome. Specialist care: diet, amitriptyline 10 mg at night increased by 10 mg weekly to 25 to 75 mg, pentosan polysulfate 100 mg orally three times daily, and bladder instillation.

Neurogenic bladder. Specialist urology and neurology care. Clean intermittent catheterisation. Antimuscarinics or mirabegron. Intradetrusor botulinum toxin A 100 to 200 units. Protection of the upper tracts.

Cancer. Urgent urology or gynaecology oncology referral with cystoscopy and staging.

Third line for refractory overactive bladder (specialist). Intradetrusor onabotulinum toxin A 100 units (intermittent self catheterisation may be needed), sacral neuromodulation, and percutaneous tibial nerve stimulation. Surgery rarely.

Monitoring. Bladder diary at 4 weeks for treatment response. Post-void residual after starting antimuscarinics in older adults and men. Blood pressure on mirabegron. Sodium on desmopressin. Cognitive screening with long term anticholinergic use. Annual review.

Referral and escalation. Urgent urology for haematuria, suspected cancer, retention, or neurological deficit. Gynaecology or urogynaecology for prolapse and refractory symptoms in women. Endocrinology for diabetes insipidus and hypercalcaemia. Neurology and spinal surgery for cord or cauda equina syndromes.

Admission criteria. Retention with renal impairment, pyelonephritis, severe hypercalcaemia, diabetic ketoacidosis, cauda equina syndrome, or severe dehydration.

Discharge and safety netting. Advise on bladder training and fluids. Return for blood in urine, retention, back pain with leg weakness or numbness, fever, loin pain, severe thirst, or worsening symptoms.