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 LUTS may be divided into:

• Filling or irritative symptoms, e.g. frequency, urgency, dysuria, nocturia, stress incontinence, urge incontinence.
• Voiding or obstructive symptoms, e.g. poor stream, hesitancy, terminal dribbling, incomplete voiding, overflow incontinence (due to chronic urinary retention).

More detailed information on the specific causes and symptoms of LUTS in women can be accessed by following the links from this article.

Risk factors for urinary incontinence

• Age.
• Postmenopausal urogenital changes.
• Overweight.
• Smoking.
• Number of children.
• Poor obstetric care.
• Abnormalities of the urogenital system:
  • Congenital female genital tract abnormalities.
  • Pelvic organ prolapse, as a result of pelvic surgery or other disease.

Presentation

See also separate articles Genitourinary History and Examination (Female), Gynaecology History and Examination, and Voiding Difficulties. Symptoms can be divided into seven groups:²

• Storage: increased daytime urinary frequency, nocturia, urgency, incontinence, enuresis, continuous urinary leakage), interstitial cystitis.
• Voiding symptoms: urinary retention, 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.

Differential diagnosis

• Mostly filling symptoms:
  • Urinary tract infection (UTI): the most common cause of filling symptoms in all ages.
  • Pregnancy.
  • Anxiety.
  • Overactive bladder (idiopathic detrusor muscle overactivity): causes filling symptoms and urge incontinence.
  • Urinary incontinence (stress incontinence, urge incontinence, overflow incontinence, mixed urinary incontinence).
  • Interstitial cystitis.
  • Postmenopausal 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: acute urinary retention, chronic urinary retention. Causes of urinary outflow obstruction include 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, for example:
  • 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.

Investigations

Will depend on the individual presentation. Diagnosis may be obvious and require confirmation (e.g. a mid-stream specimen of urine (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 postmicturition ultrasound.
• Urodynamic studies: subtracted cystometry, uroflowmetry voiding, video urodynamics.
• Cystoscopy.

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

Referral

• 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 a possible serious cause. Arrange urgent referral for any suspicion of malignancy, including:⁴
  • Any age with painless macroscopic haematuria.
  • Aged 40 years and older who present with recurrent or persistent UTI associated with haematuria.
  • Aged 50 years and older who are found to have unexplained microscopic haematuria.
  • Abdominal mass identified clinically or on imaging that is thought to arise from the urinary tract.
• Genital prolapse.
• Patient concern and/or distress.

Management

Nondrug

• 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 nonspecific urinary tract symptoms in postmenopausal 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.

Complications

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

Prevention

Good obstetric management and pelvic floor care after childbirth.

Document references

1. Moller LA, Lose G, Jorgensen T; Incidence and remission rates of lower urinary tract symptoms at one year in women aged 40-60: longitudinal study. BMJ. 2000 May 27;320(7247):1429-32. [abstract]
2. Al-Hayek S, Abrams P; Women's lower urinary tract function and dysfunction: definitions and epidemiology. Minerva Ginecol. 2004 Aug;56(4):311-25. [abstract]
3. Takeda M, Araki I, Kamiyama M, et al; Diagnosis and treatment of voiding symptoms. Urology. 2003 Nov;62(5 Suppl 2):11-9. [abstract]
4. Referral for suspected cancer, NICE Clinical Guideline (2005)

Internet and further reading

• Takeda M, Araki I, Kamiyama M, et al; Diagnosis and treatment of voiding symptoms. Urology. 2003 Nov;62(5 Suppl 2):11-9. [abstract]

Acknowledgements