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Urinary Frequency

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by Anuja P. Shah, MD

Urinary frequency is the need to urinate many times during the day, at night (nocturia), or both but in normal or less-than-normal volumes. Frequency may be accompanied by a sensation of an urgent need to void (urinary urgency). Urinary frequency is distinguished from polyuria, which is urine output of >3 L/day.

Pathophysiology

Urinary frequency usually results from disorders of the lower GU tract. Inflammation of the bladder, urethra, or both causes a sensation of the need to urinate. However, this sensation is not relieved by emptying the bladder, so once the bladder is emptied, patients continue trying to void but pass only small volumes of urine.

Etiology

There are many causes of urinary frequency (see Table: Some Causes of Urinary Frequency), but the most common include

  • UTIs

  • Urinary incontinence

  • Benign prostatic hyperplasia (BPH)

  • Urinary tract calculi

Some Causes of Urinary Frequency

Cause

Suggestive Findings

Diagnostic Approach

Benign prostatic hyperplasia or prostate cancer

Progressive onset of urinary hesitancy, incontinence, poor urine stream, a sensation of incomplete voiding

Rectal examination

Ultrasonography

Cystometry

Cystocele

Urinary incontinence

Sensation of vaginal fullness

Pain or urinary leakage during sexual intercourse

Pelvic examination

Voiding cystourethrography

Drugs and substances

  • Caffeine

  • Alcohol

  • Diuretics

Urinary frequency in an otherwise healthy patient

Empiric elimination of offending substance (to confirm that frequency resolves)

Pregnancy

3rd trimester of pregnancy

Clinical evaluation

Prostatitis

Urgency, dysuria, nocturia, purulent urethral discharge with fever, chills, low back pain, myalgia, arthralgia, and perineal fullness

Prostate tender to palpation

Rectal examination

Culture of secretions after prostatic massage

Radiation cystitis

History of radiation therapy of the lower abdomen, prostate, or perineum for treatment of cancer

Clinical evaluation

Cystoscopy and biopsy

Reactive arthritis

Asymmetric arthritis of knees, ankles, and metatarsophalangeal joints

Unilateral or bilateral conjunctivitis

Small, painless ulcers on the mouth, tongue, glans penis, palms, and soles 1–2 wk after sexual contact

STD testing

Spinal cord injury or lesion

Lower-extremity weakness, decreased anal sphincter tone, absent anal wink reflex

Loss of sensation at a segmental level

Injury usually clinically obvious

MRI of the spine

Urethral stricture

Hesitancy, tenesmus, reduced caliber and force of the urine stream

Urethrography

Urinary incontinence

Unintentional passage of urine, particularly when bending, coughing, or sneezing

Cystometry

Urinary tract calculi

Colicky flank or groin pain

Urinalysis for hematuria

Ultrasonography or CT of the kidneys, ureters, and bladder

UTIs

Dysuria and foul-smelling urine, sometimes fever, confusion, and flank pain, particularly in women and girls

Dysuria and frequency in young sexually active men (which suggests an STD)

Urinalysis and culture

STD testing

Bladder detrusor overactivity

Nocturia, urge incontinence, weak urinary stream, and sometimes urinary retention

Cystometry

STD = sexually transmitted disease.

Evaluation

History

History of present illness should first ask about the amounts of fluid consumed and voided to distinguish between urinary frequency and polyuria. If urinary frequency is present, patients are asked about acuity of onset, presence or absence of irritative symptoms (eg, irritation, urgency, dysuria), obstructive symptoms (eg, hesitancy, poor flow, sensation of incomplete voiding, nocturia), and recent sexual contacts.

Review of systems should cover symptoms suggestive of a cause, including fever, flank or groin pain, and hematuria (infection); missed menses, breast swelling, and morning sickness (pregnancy); and arthritis and conjunctivitis (reactive arthritis).

Past medical history should ask about known causes, including prostate disease and previous pelvic radiation therapy or surgeries. Drugs and diet are reviewed for the use of agents that increase urine output (eg, diuretics, alcohol, caffeinated beverages).

Physical examination

Examination focuses on the GU system.

Any urethral discharge or any lesions consistent with sexually transmitted diseases are noted. Rectal examination in men should note the size and consistency of the prostate and rectal tone; pelvic examination in women should note the presence of any cystocele. Patients should be instructed to cough while the urethra is observed for signs of urinary leakage.

The costovertebral angle should be palpated for tenderness, and the abdominal examination should note the presence of any masses or suprapubic tenderness.

Neurologic examination should test for lower-extremity weakness and loss of sensation.

Red flags

The following findings are of particular concern:

  • Lower-extremity weakness or signs of spinal cord damage (eg, loss of sensation at a segmental level, loss of anal sphincter tone and anal wink reflex)

  • Fever and back pain

Interpretation of findings

Dysuria suggests frequency is due to UTI or calculi. Prior pelvic surgery suggests incontinence. Weak urine stream, nocturia, or both suggests BPH. Urinary frequency in an otherwise healthy young patient may be due to excessive intake of alcohol or caffeinated beverages. Gross hematuria suggests UTI and calculi in younger patients and cancer in older patients.

Testing

All patients require urinalysis and culture, which are easily done and can detect infection and hematuria.

Cytoscopy, cystometry, and urethrography can be done to diagnose cystitis, bladder outlet obstruction, and cystocele. Prostate-specific antigen level determination, ultrasonography, and prostate biopsy may be required, especially in older men, to differentiate BPH from prostate cancer.

Treatment

Treatment varies by cause.

Geriatrics Essentials

Urinary frequency in elderly men is often caused by bladder neck obstruction secondary to prostate enlargement or cancer. These patients usually require postvoid residual urine volume determination. UTI or use of diuretics may be a cause in both sexes.

Key Points

  • UTI is the most common cause in children and women.

  • Prostate disease is a common cause in men > 50 yr.

  • Excessive intake of caffeine can cause urinary frequency in healthy people.

Resources In This Article

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