Lower Urinary Tract Symptoms (LUTS) in Women

Lower urinary tract symptoms (LUTS) are common in women of all ages, but prevalence increases with age. Many people have transient symptoms, but a significant group have ongoing and disabling problems.¹

• Age
• Post menopausal urogenital changes
• Overweight
• Smoking
• Number of children
• Poor obstetric care
• Abnormalities of the urogenital system: congenital; pelvic organ prolapse; as a result of pelvic surgery or other disease

Symptoms can be divided into seven groups:²

• Storage: increased daytime frequency, nocturia, urgency, urinary incontinence (stress incontinence, urge incontinence, mixed urinary incontinence, enuresis, continuous urinary leakage).
• Voiding symptoms: poor stream, hesitancy, intermittent stream, straining, terminal dribble.
• Postmicturition symptoms: postmicturition dribble, feeling of incomplete emptying.
• Symptoms associated with sexual intercourse: dyspareunia, vaginal dryness, incontinence.
• Symptoms associated with genitourinary prolapse: feeling of 'something coming down', low backache, heaviness, dragging sensation.
• Genital and lower urinary tract pain: pain may be associated with bladder filling, micturition, postmicturition or continuous.
• Genitourinary pain syndromes and Lower Urinary Tract Dysfunction (LUTD): symptom syndromes suggestive of LUTD may be those of an overactive bladder or of bladder outlet obstruction.

• Mostly filling symptoms:
  • Urinary tract infection: the most common cause of filling symptoms in all ages
  • Pregnancy
  • Anxiety
  • Overactive Bladder (idiopathic detrusor muscle overactivity): causes filling symptoms and urge incontinence
  • Interstitial cystitis
  • Post menopausal urogenital atrophy
  • Bladder tumour or stone
  • Genital prolapse or pelvic mass
  • Neurological disease, e.g. multiple sclerosis
• Mostly voiding symptoms:
  • Age related detrusor muscle weakness
  • Obstruction: e.g. urethral stricture, urethral wall diverticulum, periurethral fibrosis, pressure effects from pelvic masses or constipation
  • Urethritis and other genitourinary infections
  • Urethral syndrome: unknown cause; associated with urethral tenderness, dysuria, frequency and incomplete voiding
  • Stress incontinence is usually due to a combination of internal sphincter incompetence and urethral hypermobility. Additional factors such as mobility and diuretics may exacerbate symptoms
• Drugs may cause a variety of lower urinary tract symptoms, e.g.:
  • Diuretics, alcohol and lithium may cause urgency and frequency
  • Anticholinergics (e.g. tricyclic antidepressants) may cause urinary retention with overflow
  • Alpha blockers may cause urinary incontinence
• Polyuria: e.g. chronic renal failure, diabetes mellitus, diabetes insipidus

Will depend on the individual presentation. Diagnosis may be obvious and require confirmation (e.g. MSU for a UTI) or require full and detailed assessment:

• Urine: urinalysis, MSU, pregnancy test, cytology for unexplained microscopic haematuria, early morning urine samples for mycobacteria
• Renal function and electrolytes, fasting blood glucose
• Frequency volume chart, bladder diary
• Genitourinary swabs
• Intravenous pyelogram (IVP)
• Renal and/or post micturition ultrasound
• Urodynamic studies: subtracted cystometry, uroflowmetry voiding, video urodynamics
• Cystoscopy

If no urodynamic abnormalities of either the detrusor or the outlet can be detected by full evaluation, including urinary flow studies, postmicturition residual volume, and comprehensive urodynamic evaluation, factors unrelated to the lower urinary tract may be responsible for the voiding symptoms.³

• For further investigation if the cause is not apparent
• Symptoms persisting despite thorough assessment, advice and treatment in primary care
• Persistent haematuria
• Any other indication or concern of possible serious cause
• Genital prolapse
• Patient concern and/or distress

Non-drug

• Detrusor muscle overactivity may be treated in the first place with bladder training. Careful attention to fluid intake and avoiding caffeine can be very effective.
• Bladder emptying after sexual intercourse can prevent UTIs (if ineffective, antibiotics can also be prescribed).
• Reduce caffeine-containing drinks.
• Cranberry juice appears to enhance resolution of UTIs but it is not clear whether it helps to prevent recurrence.
• Stress incontinence often responds to pelvic floor exercises, weight loss and stopping smoking.
• Ring pessaries may be useful where surgery for prolapse is not possible.

Drugs

• Treat infection with antibiotics.
• Antimuscarinic drugs, e.g. oxybutinin, tolterodine are used with bladder training to treat detrusor muscle overactivity. Tolterodine has fewer side effects than oxybutinin.
• Tricyclic antidepressants may be useful for nocturia.
• Hormone replacement and topical oestrogen may be useful for non-specific urinary tract symptoms in post-menopausal women.
• Duloxetine is licensed for moderate to severe stress urinary incontinence in women.

Surgical

• Surgical repair of vaginal prolapse for stress incontinence is initially very effective, but some of the benefit may be lost after a couple of years.
• Detrusor myomectomy is a surgical treatment for detrusor muscle overactivity which may be considered if conservative measures fail.

Lower urinary tract symptoms in women can have a profound effect on quality of life.

Good obstetric management and pelvic floor care after childbirth.