Lower urinary tract symptoms
A symptom related to the lower urinary tract. It may originate from the bladder, urethra, prostate (men) and/or adjacent pelvic floor or pelvic organs, or at times be referred from similarly innervated anatomy e.g. lower ureter.
Article by Linda Nazarko
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Definition
In women, lower urinary tract symptoms are very common and occur as a result of conditions and diseases affecting the lower urinary tract. In around 50% of cases, lower urinary tract symptoms resolve without treatment (Adleman, 2022).
The International Continence Society (2023) defines lower urinary tract symptoms as:
A symptom related to the lower urinary tract. It may originate from the bladder, urethra, prostate (men) and/or adjacent pelvic floor or pelvic organs, or at times be referred from similarly innervated anatomy e.g. lower ureter.
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Symptoms
Symptoms of lower urinary tract issues commonly include:
- frequency
- urgency
- dysuria
- nocturia
- stress incontinence
- urge incontinence
- voiding difficulties
- the feeling of incomplete bladder emptying (Abrams et al, 2002: Nazarko, 2016)
Symptoms of voiding problems include slow and/or interrupted stream, terminal dribble hesitancy and straining. Post-micturition symptoms include post-micturition incontinence or dribble and the sensation of incomplete bladder emptying (Table 1).
| Table 1. Common symptoms and possible diagnosis | ||
|
Type of symptom |
Symptoms |
Possible diagnosis |
|
Storage, micturition and post micturition |
Dysuria Urinary frequency Suprapubic tenderness Urgency Polyuria Haematuria |
Infection Painful bladder syndrome |
|
Storage |
Urgency Frequency Nocturia Nocturnal polyuria Urge incontinence |
Overactive bladder syndrome |
|
Symptoms associated with sexual intercourse |
Dyspareunia, vaginal dryness, incontinence during or just after intercourse |
Oestrogen deficiency |
|
Symptoms associated with genitourinary prolapse
|
Feeling of 'something coming down', low backache, heaviness, dragging sensation, stress incontinence |
Genitourinary prolapse |
|
Urinary incontinence
|
Stress incontinence Urge incontinence Mixed incontinence Functional incontinence |
Weak |
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Aetiology
Aetiology varies according to the condition causing the symptoms. Urinary tract infection is a common cause of lower urinary tract symptoms, and affects 15% of women each year (Carr, 2006). Adult women are 30 times more likely to develop a urinary tract infection than men.
Obesity increases the risks of all lower urinary tract infection in women, as this can lead to type 2 diabetes mellitus, pelvic organ prolapse, overactive bladder, urge and stress incontinence (Pereira et al, 2022).
Multiple pregnancies, vaginal delivery and having large babies can weaken the pelvic floor. Pelvic floor weakness and prolapse can lead to stress, urge and mixed incontinence (Campbell et al, 2017).
Oestrogen deficiency, common in the peri-menopause and menopause, can lead to symptoms associated with sexual intercourse such as dyspareunia, vaginal dryness, incontinence during or just after intercourse.
Age-related changes, such as the bladder becoming fibrotic, can lead to the bladder not
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Diagnosis
Assessment is key to the diagnosis of lower urinary tract symptoms. The assessment varies according to clinical presentation, findings, comorbidities, patient preference and whether the person is being cared for in primary care or in an acute care setting. Assessment normally consists of:
- baseline history
- clinical examination
- urine testing
- bladder diary (also known as a frequency volume chart)
In some cases, a series of investigations including imaging, endoscopy and urodynamic investigations, may also be conducted (International Continence Society, 2015).
Guidance on assessment of lower urinary tract infection is incorporated within the guidance on urinary incontinence (National Institute for Health and Care Excellence (NICE), 2021). There is specific guidance for women with pelvic floor prolapse (NICE, 2019).
Urinary tract infection
NICE (2023) provides guidance on the diagnosis and treatment of urinary tract infection. A urine dipstick can be used to diagnose urinary tract infection in women under the age
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Management
Management and treatment is dependent on the diagnosis. Common causes of lower urinary tract symptoms in women and their management are listed below.
Urinary tract infection
When a urinary tract infection occurs, the patient should have an urgent assessment in secondary care if there are any features of serious or systemic illness such as sepsis. Patients should be advised on self-care measures, such as taking paracetamol or ibuprofen for pain in intake of fluids.
Cranberry products and alkalising agents such as potassium citrate are not recommended. The prescriber should consider the need for antibiotics, but most urinary tract infections will clear naturally without treatment.
If antibiotics are needed and a urine culture is not available, guidance indicates a 3 day course of either Nitrofurantoin 50 mg four times daily orally, or 100 mg (modified-release) twice daily, or Trimethoprim 200 mg twice daily or following local antibiotic prescribing guidance.
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 2: Procedures for the planning, provision and management of person-centred nursing care
6.1 observe and assess level of urinary and bowel continence to determine the need for support and intervention assisting with toileting, maintaining dignity and privacy and managing the use of appropriate aids
6.2 select and use appropriate continence products; insert, manage and remove catheters for all genders; and assist with self-catheterisation when required
6.4 assess bladder and bowel patterns to identify and respond to constipation, diarrhoea and urinary and faecal retention
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Resources
Patient information leaflets:
Treating your infection: urinary tract infection (UTI)
Urinary tract infections: a leaflet for older adults and carers
Royal College of General Practice website
References
Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002; 21(2):167-178. https://doi.org/10.1002/nau.10052
Adleman R. Lower urinary tract symptoms in women. 2022.
https://patient.info/doctor/lower-urinary-tract-symptoms-in-women-pro (accessed 28 November 2023)
Campbell P, Li W, Money-Taylor J et al. Nocturnal enuresis: prevalence and associated LUTS in adult women attending a urogynaecology clinic. Int Urogynecol J. 2017;28(2):315-320. https://doi.org/10.1007/s00192-016-3099-0
Carr J. Urinary tract infections in women: diagnosis and management in primary care. BMJ: 2006;332(7533):94-97
Cox L, Rovner ES. Lower urinary tract symptoms in women: epidemiology, diagnosis, and management. Curr Opin Urol. 2016;26(4):328-33. https://doi.org/10.1097/MOU.0000000000000283
Coyne KS, Sexton CC, Thompson CL et al. The prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK and Sweden: results from the Epidemiology of LUTS (EpiLUTS) study. BJU Int. 2009;104:352–60.
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