What are the underlying causes of urinary issues?

Underlying Causes of Urinary Issues

The primary underlying causes of urinary issues include urinary tract infections, urinary tract malignancies, urolithiasis, benign prostatic hyperplasia, anatomical abnormalities, and neurological disorders that affect bladder function. 1

Infectious Causes

• Urinary Tract Infections (UTIs): One of the most common causes of urinary issues
  • Bacterial cystitis (most commonly caused by Escherichia coli - approximately 75% of cases) 2
  • Other common pathogens include Enterococcus faecalis, Proteus mirabilis, Klebsiella, and Staphylococcus saprophyticus 1
  • Symptoms include dysuria, frequency, urgency, and suprapubic pain 3
  • Risk factors for recurrent UTIs include sexual activity, use of spermicidal contraceptives, and postmenopausal status with atrophic vaginitis 1, 2

Structural/Anatomical Causes

• Benign Prostatic Hyperplasia (BPH)

  • Causes both static obstruction (increased prostate size) and dynamic obstruction (increased smooth muscle tone) 4
  • Results in voiding symptoms including slow stream, intermittency, hesitancy, and terminal dribble 5
  • May lead to urinary retention and overflow incontinence if severe 1

• Urolithiasis (Kidney/Urinary Tract Stones)

  • Common benign urogenic cause of hematuria 1
  • Can cause obstruction, pain, and irritative voiding symptoms 1

• Anatomical Abnormalities

  • Cystoceles, bladder or urethral diverticula, fistulae 1
  • Urethral strictures causing obstruction
  • Congenital anomalies of the urinary tract

Malignant Causes

• Urinary Tract Malignancies
  • Risk factors include gross hematuria, male gender, age >35 years, smoking, occupational exposure to chemicals, analgesic abuse, history of urologic disease, irritative voiding symptoms, history of pelvic irradiation, chronic UTIs, exposure to carcinogens, and chronic indwelling foreign bodies 1
  • Gross hematuria has 30-40% association with malignancy 1
  • Microhematuria has 2.6-4% risk of malignancy 1
  • Malignancies can occur anywhere in the urinary tract and require thorough evaluation 1

Functional/Neurological Causes

• Overactive Bladder/Detrusor Overactivity

  • Causes urgency, frequency, and urgency incontinence 1
  • Common after prostate treatment (up to 48% prevalence) 1

• Stress Urinary Incontinence

  • Due to sphincter weakness or pelvic floor dysfunction 1, 6
  • Occurs when bladder pressure exceeds sphincter resistance 7
  • Can be iatrogenic from medications like alpha-blockers and antipsychotics 7

• Neurological Disorders

  • Multiple sclerosis, Parkinson's disease, spinal cord injuries
  • Can cause detrusor overactivity, detrusor-sphincter dyssynergia, or detrusor underactivity

Medication-Induced Causes

• Drug-Induced Urinary Disorders 7
  • Anticholinergics, anesthetics, and analgesics can cause urinary retention
  • Alpha-blockers can cause stress incontinence
  • Cyclophosphamide and tiaprofenic acid can cause chemical cystitis
  • Mitomycin, doxorubicin, and BCG can cause cystitis when used for bladder cancer treatment

Inflammatory/Autoimmune Causes

• Interstitial Cystitis

  • More common in women with chronic pelvic pain and microhematuria 1
  • Often difficult to diagnose 1

• Renal Parenchymal Disease

  • Glomerulonephritis, glomerulonephropathy, acute tubular necrosis 1
  • Most common benign nephrogenic cause of hematuria 1

Age-Related Considerations

• In Children

  • Enuresis (bedwetting) may be related to delayed maturation of bladder control, psychological factors, or sleep disorders 1
  • May be associated with constipation, encopresis, or sleep apnea 1

• In Elderly

  • Increased prevalence of BPH in men
  • Atrophic vaginitis and pelvic floor weakness in women
  • Higher risk of asymptomatic bacteriuria (should not be treated with antibiotics) 2, 8

Diagnostic Approach

For proper evaluation of urinary issues, consider:

1. Urinalysis and urine culture to identify infection, hematuria, or pyuria 8
2. Imaging studies for complicated cases:
   • CT urography (CTU) is the imaging procedure of choice for evaluating hematuria 1
   • Ultrasound for initial evaluation in certain populations 1
3. Cystoscopy for patients with risk factors for malignancy or aged ≥35 years with hematuria 1
4. Urodynamic testing for complex voiding dysfunction 5

Remember that urinary symptoms are often multifactorial, especially in older adults, and may require comprehensive evaluation to identify all contributing causes.