What is the appropriate workup for a patient presenting with increased urinary frequency?

Workup for Increased Urinary Frequency

The appropriate workup for increased urinary frequency begins with a careful history, physical examination, and urinalysis as the minimum essential requirements, with additional testing guided by specific clinical findings and risk factors. 1

Initial Essential Evaluation

History Taking

• Document the duration and severity of symptoms, including daytime frequency (normal is up to 7 voids during waking hours), nocturia episodes, and presence of urgency or pain. 1
• Assess for the hallmark symptom of overactive bladder: urgency (sudden, compelling desire to void that is difficult to defer), which distinguishes OAB from other causes. 1
• Determine if bladder or pelvic pain is present, as this distinguishes interstitial cystitis/bladder pain syndrome from overactive bladder. 2
• Review current medications to exclude drug-induced frequency. 1
• Screen for risk factors for bladder cancer: smoking history, age >35-40 years, occupational chemical exposures, chronic UTIs, pelvic irradiation, and irritative voiding symptoms. 1
• Assess for neurological diseases, diabetes, and other comorbidities that directly impact bladder function. 1

Physical Examination

• Perform an abdominal examination to assess for masses or distension. 1
• Conduct a rectal/genitourinary examination (rectal exam in men, pelvic exam in women) to evaluate for prostatic enlargement, pelvic organ prolapse, or masses. 1
• Assess lower extremities for edema suggesting fluid redistribution. 1

Urinalysis (Mandatory)

• Perform urinalysis to rule out urinary tract infection and hematuria in all patients. 1
• If hematuria not associated with infection is found, refer for urologic evaluation including cystoscopy. 1

Additional Testing Based on Clinical Findings

Urine Culture

• Obtain urine culture if urinalysis is unreliable or if UTI is suspected, preferably before antibiotic therapy. 1

Bladder Diary (Frequency-Volume Chart)

• Request a bladder diary to reliably measure voiding frequency and volumes, which distinguishes small-volume voids (OAB, interstitial cystitis) from large-volume voids (polyuria, nocturnal polyuria). 1, 2
• This tool is particularly useful for patient education and documenting baseline symptoms. 1

Post-Void Residual (PVR) Measurement

• Measure PVR in patients with obstructive symptoms, history of urinary retention or incontinence surgery, neurologic diagnoses, or long-standing diabetes. 1, 2
• PVR is not necessary for uncomplicated patients receiving first-line behavioral interventions. 1
• Use antimuscarinics with caution if PVR is 250-300 mL or higher, as they can precipitate urinary retention. 1, 3, 2

Risk-Stratified Advanced Evaluation

For Patients with Hematuria

• All patients with gross hematuria require complete urologic workup including office cystoscopy, as malignancy risk is 30-40%. 1
• Patients aged ≥35 years with asymptomatic microhematuria should undergo cystoscopy. 1
• Obtain upper tract imaging with CT urography (preferred if patient can receive IV contrast) or alternative imaging (renal ultrasound with retrograde pyelography, MR urography, or ureteroscopy). 1

For Suspected Bladder Cancer

• If cystoscopy documents a lesion, schedule transurethral resection of bladder tumor (TURBT) to confirm diagnosis and determine disease extent. 1
• Obtain CT or MRI of abdomen and pelvis before TURBT if the tumor appears solid, high-grade, or muscle-invasive. 1
• Obtain urine cytology around the time of cystoscopy. 1
• Initiate smoking cessation treatment if appropriate. 1

For Suspected Overactive Bladder

• Do not perform extensive routine workup (cystoscopy, full abdominal ultrasound) in women younger than 40 years with recurrent frequency and no risk factors. 1
• Consider symptom questionnaires to quantify bladder symptoms and bother. 1
• Urodynamics and cystoscopy are not routinely indicated for initial OAB diagnosis. 1

For Patients with Neurologic Disease

• Perform pressure flow studies in patients with relevant neurologic disease, especially those with elevated PVR, hydronephrosis, or complicated UTIs. 1
• Consider videourodynamics (VUDS) when available to identify anatomic abnormalities and vesicoureteral reflux. 1
• Perform EMG in combination with cystometry to diagnose detrusor-sphincter dyssynergia. 1

Critical Pitfalls to Avoid

• Failure to measure PVR in appropriate patients can lead to misdiagnosing overflow incontinence as OAB, resulting in antimuscarinic treatment that worsens retention. 3, 2
• Do not assume anticoagulation therapy explains hematuria; full urologic and nephrologic workup is required regardless of anticoagulation type or level. 1
• Do not delay evaluation of microhematuria in patients with suspected UTI; confirm infection with urine culture before attributing hematuria to infection. 1
• In patients with positive urine cytology and normal cystoscopy, evaluate upper tracts and prostatic urethra (in men) as urothelial tumor can occur anywhere in the urinary tract. 1
• Distinguish nocturnal polyuria (normal or large volume nocturnal voids) from OAB-related nocturia (small volume voids) using bladder diary. 1, 2