Frequency
Differential Diagnosis
Common Diagnoses
Occasional Diagnoses
- Interstitial Cystitis (Non-Infective)
- Prostatitis
- Pregnancy
- Ureteric Calculus (in Lower Third of Ureter Precipitates Reflex Frequency)
- Iatrogenic (e.g. Diuretics)
- Bladder Neck Hypertrophy
- 'Habit Frequency'
- Pyelonephritis
- Urethritis
Rare Diagnoses
- Pelvic Space-Occupying Lesion, e.g. Fibroid, Ovarian Cyst, Carcinoma
- Secondary to Pelvic inflammation: PID, Appendicitis, Diverticulitis, Adjacent Tumour
- Bladder Tumour (Benign or Malignant), Prostate Cancer
- Post-Radiotherapy Fibrosis (Testicular, Ovarian and Prostatic Cancer)
- Tuberculous Cystitis/Renal TB
- Fibrosis Secondary to Chronic Sepsis from Long-Term Catheter Drainage
- Ketamine-Associated Ulcerative Cystitis
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Anxiety | Infective Cystitis | Overactive Bladder Syndrome | LUTS | Bladder Calculus | |
|---|---|---|---|---|---|
| Dysuria | No | Yes | No | No | Possible |
| Eased when Prone | No | No | No | No | Yes |
| Hesitancy, Slow Flow | No | No | No | Yes | Possible |
| Nocturnal Frequency | No | Yes | Yes | Possible | No |
| Abnormal Urinalysis | No | Yes | No | Possible | Yes |
Possible Investigations
Likely:Urinalysis, MSU, urinary frequency volume chart.
Possible:Urethral swab, PSA, uroflowmetry, urodynamic studies, plain abdominal X-ray, renal imaging, cystoscopy, CA-125.
Small Print:Pelvic ultrasound, U&E, pregnancy test and three EMUs for TB.
- Urinalysis: Protein, nitrites, leucocytes and possible haematuria in infection; possible stone or tumour if blood alone.
- MSU: Microscopy may show abnormal epithelial cells, blood, pus and help identify pathogen in infection.
- Urinary frequency volume chart: May be useful in men with LUTS.
- Swab any urethral discharge present for Chlamydia and gonorrhoea.
- CA-125: May be useful if ovarian cancer suspected.
- EMU: For pregnancy test; also three EMUs to check for TB if suspected (e.g. sterile pyuria).
- U&E: Check if assessment suggests chronic sepsis or outflow obstruction.
- PSA: Consider this if LUTS in male.
- Specialist tests include: Uroflowmetry (for LUTS, urodynamic studies (for unstable bladder), renal imaging and cystoscopy (for stones and tumours) and ultrasound (for pelvic masses or if CA-125 elevated).
Top Tips
- Frequency due to anxiety is typically long term, worse with stress and cold weather, and is associated with a normal urinalysis.
- It is reasonable to make an empirical diagnosis of overactive bladder syndrome in a nonpregnant female with frequency in whom CA-125, pelvic examination and urinalysis are entirely normal.
- An unrecognised pregnancy may present with frequency – ask about periods, and do a pregnancy test if a period has been missed.
Red Flags
- In the elderly, a bladder tumour may present as cystitis. If a new, recurring problem, or haematuria attributed to the cystitis does not settle with antibiotics, consider referral.
- Do not ignore sterile pyuria on the MSU – possible causes include urethritis and TB.
- The adult patient with frequency who has persistent microscopic haematuria but no other abnormalities on urinalysis may have a stone or tumour. Refer.
- Appendicitis can cause mild frequency and pyuria. Do not be misled by the urinalysis into an inappropriate diagnosis of UTI – act according to the clinical findings.
- UTI in infancy is a major cause of renal failure. Manage according to NICE guidance.
- Remember the possibility of chronic ketamine abuse in young people.