11/13/24, 8\:09 PM Guide | Female LUTS

Female LUTS

Table of contents

Background

Normal functioning of the urinary system relies upon producing a normal quantity of urine, which can be stored in a bladder
of normal capacity. Voiding urine requires voluntary and involuntary neurological control of the bladder and the urethral
sphincters, correctly functioning pelvic
When each part of this system functions correctly, the bladder
phase, which is under sympathetic control, there is no detrusor activity and the muscle tone of the urethral sphincter
increases.
When the bladder reaches capacity, the voiding phase (which is under parasympathetic control) begins with the relaxation of
the urethral sphincter and contraction of the detrusor muscle in the bladder wall. If the person does not wish to pass urine at
that time, the distal (voluntary) urethral sphincter contracts and enables the person to delay voiding. The frontal lobe controls
this voluntary part of the process via the somatic nervous system.

Lower urinary tract symptoms (LUTS)

A problem with this system can give rise to two broad groups of symptoms\:
Storage symptoms (caused by problems storing urine)\: urgency, frequency, nocturia and incontinence
Voiding symptoms (caused by problems voiding urine)\: hesitancy, incomplete bladder emptying and chronic retention
These symptoms are collectively called lower urinary tract symptoms (LUTS).

Causes of LUTS

Over-production of urine
Primary (or psychogenic) polydipsia\: a primarily psychological problem seen in conditions such as schizophrenia, which
causes the patient to consume a greater volume of
Diabetes insipidus\: an inability to concentrate urine, which may be cranial or nephrogenic in origin
Acute kidney injury (AKI)\: although most commonly associated with oliguria, in some patients, the urine volume may be
increased due to reduced tubular reabsorption; additionally, during recovery from AKI, some patients experience a diuretic
phase
Osmotic polyuria\: due to hyperglycaemia (diabetes mellitus) or hypercalcaemia
Diuretics (particularly loop diuretics)\: cause increased urine production secondary to increased excretion of sodium
chloride
Nocturnal polyuria can also be considered here. Whilst the overall volume of urine produced may be normal, more than 35%
occurs at night, secondary to redistribution of
which can be very disruptive to sleep and may increase the risk of falls. This is seen in conditions such as heart failure, liver
failure and chronic venous insu
Reduction in actual bladder capacity
Constipation\: due to pressure on the bladder from a loaded colon and/or rectum
Rectal tumour\: due to pressure on the bladder
Pelvic mass\: due to pressure on the bladder from ovarian tumour/cyst or uterine
Reduction in functional bladder capacity
Overactive bladder (OAB)\: over-activity of the detrusor muscle causes increased bladder pressure during the
This stresses the urethral sphincter, resulting in urgency with or without urge incontinence
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Sensory urgency (resulting from irritation or inurinary tract infection (UTI),
bladder pain syndrome (also known as interstitial cystitis), bladder stones, bladder tumour, or postmenopausal genitourinary
syndrome; it can also be caused by ca
Ketamine\: although the precise mechanism is unknown, using ketamine can cause bladder in
frequency and urgency
Loss of unconscious bladder control
Upper motor neuron lesions (e.g. multiple sclerosis)\: occurring in the pons or spinal cord; this results in a spastic bladder,
with frequency, urgency, and urge incontinence. In spinal cord compression, there may be painless urinary retention.
Lower motor neuron lesion (e.g. trauma, malignancy)\: occurring in the sacral nerve roots, conus medullaris or within the
pelvis; this results in a cauda equina
syndrome, there may be a loss of awareness of the need to pass urine, or of the fact that urine is being passed.
Autonomic neuropathy (e.g. diabetes mellitus)\: causes an atonic bladder, which results in voiding and/or storage symptoms
Loss of voluntary bladder control
Damage to the frontal lobe\: trauma, dementia, hydrocephalus, and tumours
Weakness of the pelvic
abdominal pressure rises (e.g. coughing or sneezing), pressure in the bladder exceeds urethral pressure, and there is
leakage of urine referred to as stress incontinence
Problems with the
Urethral stricture
Distortion of the normal anatomy of the urethra due to pelvic organ prolapse\: cystocoele, rectocoele, uterine prolapse, or
prolapse of the vaginal vault following hysterectomy
Presence of a
bladder and the colon (colo-vesical
Urinary retention secondary to antimuscarinics\: such as tricyclic antidepressants
Types of urinary incontinence
Urinary incontinence is a common reason for seeking medical attention in female patients. The main types are\:
Urge incontinence\: urine leakage is preceded by a strong desire to pass urine, which may occur suddenly.
Stress incontinence\: urine leakage is brought on by actions which increase intra-abdominal pressure, such as
coughing, laughing and physical activity.
Mixed\: a combination of urge and stress incontinence.
The less common types of incontinence are\:
Over
when it reaches full capacity.
Continuous\: persistent urine leakage is seen, for example, with a vesico-vaginal
vagina.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
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General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t t h e u r i n a r y s y m p t o m s ?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Gather further details about the patient’s urinary symptoms using the SOCRATES acronym.

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most
commonly used to explore pain but can be applied to other symptoms, although some of the elements of SOCRATES may not
be relevant to all symptoms.
Site
N/A
Onset
Clarify how and when the urinary symptoms started\:
" H o w l o n g h a v e t h e u r i n a r y s y m p t o m s b e e n go i n g o n f o r ?"
" H o w d i d t h e u r i n a r y s y m p t o m s s t a r t ? D i d t h e y c o m e o n s u d d e n l y o r g r a d u a l l y ?"
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Presentation within hours to days of the onset of symptoms may suggest an infective or acute neurological cause. It may also
be seen in acute hyperglycaemia, or AKI. Other causes would likely cause a more gradual onset of symptoms and a longer
history before presentation.
Character
Ask about the speci
" C a n y o u d e s c r i b e w h a t y o u f e e l w h e n y o u n e e d t o p a s s u r i n e ?"
" W h i c h s y m p t o m i s t h e m o s t t r o u b l e s o m e ?"
It is helpful to establish whether the symptoms primarily relate to storage or voiding of urine.
Storage vs voiding symptoms
Urgency, frequency, nocturia and incontinence suggest a storage problem. If the patient describes incontinence, ask
what tends to trigger this\:
D o y o u l e a k u r i n e w h e n y o u c o u g h , s n e e z e o r e x e r c i s e ?
D o y o u l e a k u r i n e i f y o u c a n n o t g e t t o t h e t o i l e t i n t i m e , t h e u r g e t o d o s o ?
o r d o y o u
Di
Nocturia may also be seen with a voiding problem, as the bladder has not been fully emptied during the day. In some
patients who cannot fully empty the bladder, chronic retention leads to nocturnal enuresis due to over
Radiation
N/A
Associated symptoms
Ask if there are other symptoms that are associated with the urinary symptoms\:
" H a v e y o u n o t i c e d a n y o t h e r s y m p t o m s ?"
Pain is a common associated symptom\:
Dysuria (urethral pain during urination)\: suggests UTI or bladder pain syndrome; it may also be a symptom of bladder cancer
Supra-pubic or pelvic pain\: UTI or bladder pain syndrome; also seen in gynaecological causes including uterine
ovarian cysts and ovarian tumours
Flank pain\: pyelonephritis (where infection migrates from the bladder to one of the kidneys) or ureteric calculi
Groin pain\: ureteric calculi (classically 'loin to groin' pain)
Lower back pain\: seen in some neurological causes of LUTS, such as cauda equina syndrome; it may also occur in ovarian
cancer
Dyspareunia\: may occur in bladder pain syndrome or in postmenopausal genitourinary syndrome
Fever suggests an infective cause (e.g. pyelonephritis).
Haematuria has a broad range of causes, including UTI, ureteric calculi, and bladder cancer.
Other symptoms that patients may experience include\:
Abdominal bloating\: a red ovarian cancer
Menstrual abnormalities (e.g. dysmenorrhoea or heavy menstrual bleeding)\: may occur in gynaecological causes of LUTS
Menopausal/perimenopausal symptoms (e.g. hot
Excessive thirst\: either in the context of primary polydipsia or secondary to polyuria in diabetes mellitus, diabetes insipidus
and hypercalcaemia
Bone pain, abdominal pain, vomiting and constipation\: in the context of hypercalcaemia
Other neurological symptoms (e.g. limb weakness, sensory disturbance, visual disturbance, or cognitive di
is a neurological cause of LUTS
Time course and exacerbating or relieving factors
Clarify how the symptoms change over time\:
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" A r e t h e u r i n a r y s y m p t o m s t h e r e a l l t h e t i m e , o r d o t h e y c o m e a n d go ?"
Ask if anything makes the urinary symptoms worse or better\:
" I s t h e r e a n y t h i n g t h a t m a k e s t h e u r i n a r y s y m p t o m s w o r s e o r b e t t e r ?"
Episodic symptoms may occur with\:
Recurrent infections
Recurrent episodes of constipation
Bladder pain syndrome\: symptoms may vary with the menstrual cycle, being at their worst just before the onset of
menstruation; they can also be made worse by stress and certain foods
Exposure to causative agents, such as ca
Diabetes mellitus, depending upon the degree of hyperglycaemia
Relapsing-remitting multiple sclerosis
When symptoms are due to pelvic organ prolapse, the patient may
before going to the toilet, as this reduces the degree of prolapse. They may also need to manually reduce the prolapse before
they can pass urine.
Asking the patient to complete a frequency-volume chart ('bladder diary') is a very helpful way to gain objective information
about the nature of the symptoms and possible triggers.
Severity
The severity of symptoms is not particularly helpful in guiding the diagnosis of LUTS
However, when patients report incontinence, it is important to ask about the average number of episodes of incontinence per
day, and whether incontinence products, such as pads, are required to deal with it.
Red
Red bladder cancer include\:
Haematuria (visible or non-visible)
Recurrent or persistent UTI
Dysuria
Urinary frequency
Weight loss
Red ovarian cancer include\:
Abdominal distension (bloating)
Early satiety and/or loss of appetite
Pelvic or abdominal pain
Increased urinary urgency and/or frequency
Age >50 and symptoms suggestive of irritable bowel syndrome (IBS) in the last 12 months
Weight loss
Fatigue
Change in bowel habit

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
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Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fever, weight loss, anorexia, lethargy
Cardiovascular\: peripheral oedema
Gastrointestinal\: early satiety or loss of appetite, nausea and vomiting, abdominal pain, abdominal distension, constipation,
diarrhoea
Neurological\: weakness, sensory disturbance, visual disturbance, cognitive changes
Gynaecological\: pelvic pain, heavy or irregular menstrual bleeding, dyspareunia
Musculoskeletal\: back pain
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Past medical history

Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
Ask if the patient has previously undergone any surgery (e.g. gynaecological surgery)\:
“ H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?”
“ W h e n w a s t h e o p e r a t i o n / p r o c e d u r e , a n d w h y w a s i t p e r f o r m e d ?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Take a focused obstetric and gynaecology history\:
Obstetric history\: including the number of deliveries, the mode of each delivery, and any associated complications
Gynaecology history (menopause history)\: taking a menstrual history, including the date of the last menstrual period, is
helpful
Examples of relevant medical conditions
Relevant medical conditions in the context of urinary symptoms include\:
Diabetes mellitus (may be causing or exacerbating LUTS, but also a risk factor for infection)
Any previous history of malignancy
Neurological conditions, such as multiple sclerosis
Conditions associated with renal disease, such as systemic lupus erythematosus or systemic vasculitis
Trauma to the head, spine, or pelvis
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
“ D o y o u t h i n k y o u r u r i n a r y s y m p t o m s s t a r t e d a f t e r y o u b e g a n t a k i n g a n y o f y o u r c u r r e n t m e d i c a t i o n s ?”
Medication examples
Medications that can cause or exacerbate LUTS include\:
Loop diuretics, such as furosemide and bumetanide
Sodium-glucose co-transporter 2 (SGLT-2) inhibitors, such as dapagli
due to the increase in urinary glucose excretion which they promote.
Ketamine causes bladder in
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Drugs with anti-muscarinic e
anticholinergics prescribed to help with urinary incontinence, may cause urinary retention
Angiotensin-converting enzyme inhibitors (ACE-i) can cause a chronic cough in some patients, which may
exacerbate stress incontinence.
Medications that patients may already be taking to treat LUTS include\:
An anti-cholinergic, such as solifenacin or oxybutynin, for detrusor instability
Mirabegron for overactive bladder

Family history

Ask the patient if there is any family history of urological problems or malignancy.
“ D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y m e d i c a l c o n d i t i o n s ?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic
factors).
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
“ I’ m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r m u m w a s w h e n s h e d i e d ?”
“ D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h e r d e a t h ?”

Social history

General social context
Explore the patient’s general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Urinary symptoms, particularly urgency, frequency and nocturia, can increase the risk of falls in older people. It is helpful to
know how easy it is for the person to get to their toilet and whether they have had any falls due to their urinary symptoms. For
more information, see our guide to fall history taking.
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Smoking is a risk factor for the development of bladder cancer. A 'smoker's cough' may also exacerbate stress incontinence.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Excessive alcohol use can cause or worsen LUTS.
Recreational drug use
Ask the patient if they use recreational drugs, and if so, determine the type of drugs used and their frequency of use. The use
of ketamine is a risk factor for LUTS.
Occupation
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Exposure to chemicals, such as those used in the rubber and dye industries, is a risk factor for bladder cancer.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

Anderson, Danyon J. et al. K e t a m i n e-I n d u c e d C y s t i t i s \: A C o m p r e h e n s i v e R e v i e w o f t h e U r o l o gi c E
D r u g . Health Psychology Research 2022; 10(3). Available from\: [LINK]
Barraclough, Kevin. C a u d a e q u i n a s y n d r o m e . BMJ 2021; 372\:n32. Available from\: [LINK]
t h
Boon, NA. Colledge, NR, Walker, BR (eds). D a v i d s o n’ s P r i n c i p l e s & P r a c t i c e o f M e d i c i n e 2 0 E d . Churchill Livingstone Elsevier,
2006
BMJ Best Practice. B l a d d e r c a n c e r . Available from\: [LINK]
BMJ Best Practice. C a u d a e q u i n a s y n d r o m e . Available from\: [LINK]
BMJ Best Practice. N e p h r o l i t h i a s i s . Available from\: [LINK]
BMJ Best Practice. P s y c h o g e n i c P o l y d i p s i a . Available from\: [LINK]
BMJ Best Practice. U r i n a r y t r a c t i n f e c t i o n s i n w o m e n . Available from\: [LINK]
Cottrell, Angela M. et al. U r i n a r y t r a c t d i s e a s e a s s o c i a t e d w i t h c h r o n i c k e t a m i n e u s e . BMJ 2008; 336. Available from\: [LINK]
NICE CKS. I n c o n t i n e n c e - u r i n a r y , i n w o m e n . Available from\: [LINK]
NICE CKS U l i l i t i d f l A il bl f [LINK]
Source\: geekymedics.com
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