What could be causing frequent urination and unbalanced gait?

Frequent Urination and Unbalanced Gait: Evaluation and Management

The combination of frequent urination and gait disturbance is a red flag for underlying neurological disease and requires urgent neurological referral, as these "suspicious" symptoms together suggest conditions like multiple sclerosis, Parkinson's disease, multiple system atrophy, normal pressure hydrocephalus, or spinal cord pathology. 1

Immediate Clinical Assessment

Critical Red Flag Features to Identify

The European Urology Association identifies this symptom combination as requiring direct neurological referral when presenting with: 1

• New-onset severe lower urinary tract symptoms (excluding infection) 1
• Gait disturbance combined with urinary symptoms 1
• Additional neurological symptoms including numbness, weakness, speech disturbance, memory loss/cognitive impairment, or autonomic symptoms 1

Targeted History Questions

Ask these specific screening questions to characterize the neurological involvement: 1

• "Do you have any problems controlling your legs? Do you experience slowness of movement? Have you noticed a tremor in your hands?" 1
• "Do you get lightheaded on standing?" (screens for orthostatic hypotension/autonomic failure) 1
• "Do you experience ankle swelling?" 1
• "Do you get short of breath on walking for a certain distance?" 1

Physical Examination Priorities

Focus on these specific neurological findings: 1

• Lower limb weakness 1
• Abnormalities of gait or speech 1
• Tremor 1
• Lying/standing blood pressure (measure within 1st minute and at 3 minutes; a fall of 20 mmHg systolic or 10 mmHg diastolic is diagnostic for orthostatic hypotension and suggests autonomic failure) 1

Baseline Investigations Before Referral

Order these tests immediately: 1

• Blood tests: electrolytes/renal function, thyroid function, calcium, HbA1c 1
• Urine dipstick: albumin:creatinine ratio, blood, protein 1
• Blood pressure assessment 1
• 72-hour bladder diary 1

Differential Diagnosis Framework

Primary Neurological Conditions to Consider

Normal Pressure Hydrocephalus (NPH): The cardinal sign is a hypokinetic "magnetic" gait where feet appear glued to the floor, combined with urinary urgency, frequency, nocturia, and incontinence, plus mild dementia. 2 This is one of the few reversible causes of dementia and accounts for approximately 6% of all dementias. 2

Multiple System Atrophy/Parkinson's Disease: These conditions commonly present with gait disturbance, autonomic symptoms (including urinary dysfunction and orthostatic hypotension), and motor symptoms like tremor and slowness. 1

Multiple Sclerosis: Can present with new-onset severe lower urinary tract symptoms combined with neurological deficits including gait abnormalities. 3

Spinal Cord Disorders: Including spinal stenosis or tethered cord, which can cause both lower urinary tract symptoms and lower limb weakness/gait disturbance. 3

Secondary Causes to Screen For

Cardiovascular disease: Heart failure can cause both peripheral edema (affecting gait) and nocturia. 1

Medication-induced: Review for drugs causing both urinary symptoms and gait problems, including antiparkinsonians, antimuscarinics, anxiolytics, and antidepressants. 1 Baclofen can cause ataxia, gait disturbance, and urinary frequency. 4 Oxybutynin can cause dizziness, somnolence, and urinary retention. 5

Management Algorithm

Step 1: Urgent Neurological Referral

Make direct referral to neurology immediately when gait disturbance occurs with urinary symptoms, as this combination requires specialist evaluation to avoid poor outcomes and initiate appropriate neurological management. 1, 3

Step 2: Do NOT Order CNS Imaging from Primary Care

Central nervous system imaging booked from the outpatient clinic is not recommended; this should be coordinated by neurology. 3

Step 3: Assess Functional Impact and Safety

Evaluate: 1

• Ability to undertake activities of daily living 1
• Review of home or living environment (fall risk assessment) 1
• Safety considerations: Patients must avoid dangerous situations when experiencing gait instability, such as driving or working at heights 1

Step 4: Medication Review and Adjustment

Review and adjust medications that may exacerbate symptoms: 1

• Consider timing of diuretics, diabetes medications, and antiparkinsonian drugs relative to bedtime 1
• Evaluate whether antimuscarinics, anxiolytics, antidepressants, antihistamines, or antipsychotics can be adjusted or reduced 1

Common Pitfalls to Avoid

Delaying neurological referral: The combination of gait disturbance and urinary symptoms is a "suspicious" presentation requiring prompt specialist input to prevent deterioration and identify reversible causes like normal pressure hydrocephalus. 1, 3, 2

Attributing symptoms solely to aging or benign prostatic hyperplasia: In elderly patients, antimuscarinics are often underutilized due to concerns about adverse events, but the presence of gait disturbance suggests a more serious underlying neurological condition requiring different management. 6

Ordering brain imaging from primary care: This delays appropriate specialist evaluation and may not include the specific sequences or spinal imaging needed for conditions like multiple sclerosis or spinal stenosis. 3

Assuming psychogenic cause: While psychogenic urinary dysfunction exists (0.7% of urodynamic cases), it typically presents with situational symptoms and normal neurological examination, not with concurrent gait disturbance. 7

Missing orthostatic hypotension: Failure to perform lying/standing blood pressure measurements can miss autonomic failure, which is a key feature of multiple system atrophy and other neurodegenerative conditions. 1