Frequent Urination

Frequent Urination
Anwer Hussain, D.O.

September 14, 2020
With thanks to Dr. Moinuddin for use of some slides
The 5-Minute Presentation
Paragraph 1: Chief Complaint
Patient is a 75 year old male brought in by his daughter due to

concerns about memory. He has been having multiple visits
regarding slowly progressive dementia.
Today, you focus on his activities of daily living and ask about
whether he is able to make his own meals, manage his own
medications, shop for himself and whether he is able to
maintain proper hygiene and toiletries.
Paragraph 2: Timeline of disease and F.I.F.E.
(Feelings, Ideas, Function, Expectations)
In discussing bathing and personal hygiene, daughter begins

to describe frustration of having noticed increasing frequency
of dribbling and wetting his underwear.
 Patient admits to increasing frequency over the past one to

two years. Not associated with coughing or sneezing.
 Occurs at times when the bladder gets too full or at times

right after he empties his bladder.
 Also is having a hard time starting the stream and sometimes

more comes out after he thinks he is done.
HPI (Breakdown of Chief Complaint)
· Onset: chronic
· Location: urinary incontinence
· Duration: 1-2 years
· Character: frustrating
· Associated symptoms: bladder fullness, hard time starting
stream
· Radiation: none
· Timing/Treatment: not associated with any specific activity, but
improves with more frequent urination and waiting to assure
completely done.
· Severity: worsening/increasing in frequency
ROS:
- Denies weight loss or gain, fever. (+) difficulty sleeping
- Denies skin rash or new/changing lesions
- GU: Denies hematuria, dysuria/burning with urination. (+) urinary
frequency, dribbling
- Denies constipation, diarrhea, or abdominal pain
- Musculoskeletal: + joint pain and stiffness of hands and knees
PMHx / PSHx:
Hypertension
Osteoarthritis
Hyperlipidemia: diet controlled
Difficulty sleeping
Circumcised as an infant
Soc Hx:
Retired librarian, never smoked, occasional alcohol on holidays.
Widowed two years ago.
MEDICATIONS
1. Hydrochlorothiazide 25mg P.O. daily

2. Amlodipine 5mg P.O. daily
3. Acetaminophen 1000mg P.O. as needed
4. Aspirin 81mg P.O. daily
5. Lorazepam 2mg P.O. as needed before bed (upto
2-3 times per week)
OBJECTIVES
1. Define frequent urination and identify common or
concerning symptoms related to it.
2. Describe the basic & instrumental components of the
activities of daily living.
3. Describe the anatomy and physiology of the anus, rectum,
and prostate.
4. Recognize the transient causes of urinary incontinence.
5. Recognize the established causes of urinary incontinence.
6. Identify five differentials for frequent urination.
7. Know how aging affects the genitourinary system in both
men and women.
OBJECTIVE# 1: DEFINE FREQUENT
URINATION, AND IDENTIFY COMMON OR
CONCERNING SYMPTOMS RELATED TO IT
-the need to urinate many times during the day,
at night (nocturia), or both
-in normal or less-than-normal volumes
-frequency may be accompanied by a sensation
of an urgent need to void (urinary urgency).
-urinary frequency is distinguished from polyuria,
which is urine output of >3 L/day-therefore,
urinary frequency can exist without polyuria.
FREQUENT URINATION
Urinary frequency usually results from disorders

of the lower GU tract.
Inflammation of the bladder, urethra, or both
causes a sensation of the need to urinate.
However, this sensation is not relieved by
emptying the bladder, so once the bladder is
emptied, patients continue trying to void but pass
only small volumes of urine
SYMPTOMS: FREQUENT URINATION
1. Burning on urination, sometimes gross hematuria
may be present: such as due to injection, stones,
tumors…
2. Urinary urgency with neurologic symptoms such
as weakness and paralysis: such as due to
strokes.
3. Hesitancy in starting urinary stream, straining
to void, reduced size and force of stream and
dribbling during or at the end of urination: such
as due to BPH, urethral stricture and other
obstructive lesions of the bladder or prostate.
OBJECTIVE #2: DESCRIBE THE BASIC &
INSTRUMENTAL COMPONENTS OF THE
ACTIVITIES OF DAILY LIVING
OBJECTIVE # 3: DESCRIBE THE ANATOMY AND PHYSIOLOGY OF THE
ANUS, RECTUM, AND PROSTATE
Anatomy of the Anus, Rectum, Anatomy of the Anus, Rectum,

and Prostate – Side View and Prostate – Posterior View
ANATOMY
The gastrointestinal tract terminates in a short segment, the anal
canal
 Normally, the anal canal is held in a closed position by two muscles,
the voluntary external anal sphincter and involuntary internal anal
sphincter
 The angle of the anal canal lies on a line roughly between the anus
and umbilicus
 The anal canal is liberally supplied by somatic sensory nerves
ANAL SPHINCTERS
External anal sphincter is under
voluntary control.
Internal anal sphincter is under
involuntary control.
The internal anal sphincter is an
extension of the muscular coat of the
rectal wall. The external anal
sphincter though is striated muscle
under voluntary control.
Both the external and internal
sphincters act to normally hold the anal
canal closed.
Numerous somatic sensory nerves
supply the anal canal, which can
produce significant pain. Different
from the rectum.
ANATOMY AND PHYSIOLOGY-RECTUM
A serrated line demarcates the anal canal from the rectum
The anorectal junction (often called the pectinate or dentate line) is the
boundary between somatic and visceral nerve supplies
Sigmoid colon terminates at the rectum, which merges with the short
segment of the anal canal.
Rectum extends from rectosigmoid junction, anterior to the S3 vertebra, to
the anorectal junction at the tip of the coccyx.
External margin of anal canal is poorly demarcated, but its moist hairless
appearance distinguishes it from the surrounding perianal skin.
The anorectal junction is the boundary between anal canal and rectum.
The rectum has visceral nerve supply, not somatic. Thus, pain is not a
prominent feature.
ANATOMY - RECTUM
 Approx 12 cm long, above
anorectal junction, rectum
dilates onto sacrum.
 Rectal ampulla stores flatus
and feces.
 Rectal wall consists of three
transverse folds (Houston
valves).
 Proximal end is continuous with
the sigmoid colon.
 Females: anterior rectal wall
lies in contact with vagina, via
the rectovaginal septum.
Figure 20-01. Anatomy of the anus and rectum.
ANATOMY
In the male, the prostate gland lies against the anterior rectal
wall
 It is rounded, heart-shaped, and normally

2.5 cm long
 Only the lateral lobes and median sulcus

are palpable
In the female, the uterine cervix usually is palpable through the

anterior wall of the rectum
Figure 20-02C. Anatomy of the prostate gland and seminal vesicles. A, Cross section. B, Lateral view. C,
Posterior view.
Figure 20-05. Palpation of the posterior surface of the prostate gland. Feel for the lateral lobes and median
sulcus.
PROSTATE
In males, surrounds the urethra and
lies anterior to the bladder outlet.
Increases roughly fivefold in size
between puberty and end of
teenage years.
Palpable: right and left lateral
lobes, which lie against the
anterior rectal wall. Approx 2.5
cm long.
Nonpalpable: anterior and central
areas. Seminal vesicles above the
prostate are also not palpable.
In females, uterine cervix is
palpable through anterior wall of
the rectum.
ROS FOR PROSTATE
Frequent or urgent need to urinate

Increased frequency of urination at night (nocturia)
Difficulty starting urination
Weak urine stream or a stream that stops and starts
Dribbling at the end of urination
Straining while urinating
Inability to completely empty the bladder
OBJECTIVE #4: RECOGNIZE THE TRANSIENT
CAUSES OF URINARY INCONTINENCE
1. Delirium: most common cause in hospitalized patients
 Disturbance in mental abilities resulting in confused thinking and
reduced awareness of surroundings.
2. Infection
3. Atrophic urethritis/vaginitis: physical exam findings
4. Medications: must review medication list thoroughly
5. Severe depression
6. Excessive urinary output: diuretics, metabolic abnormalities
7. Restricted mobility
8. Stool impaction
OBJECTIVE #5: RECOGNIZE THE ESTABLISHED
CAUSES OF URINARY INCONTINENCE
1. Urge Incontinence (Detrusor overactivity)
 Detrusor muscle is smooth muscle under autonomic control
 Uninhibited bladder contractions
 Most common cause of incontinence
 Usually idiopathic
2. Stress Incontinence (Urethral incompetence)

-most commonly seen in men after radical prostatectomy (complete
surgical removal of prostate gland)
-instantaneous leakage of urine in response to a stress maneuver:
laughing, coughing or lifting heavy objects
-coexists with detrusor overactivity
ESTABLISHED CAUSES
3. Urethral Obstruction
Prostatic enlargement, urethral stricture, bladder
neck contracture, prostate cancer
Outflow obstruction
4. Overflow Incontinence (Detrusor underactivity)
Least common cause
Frequent leakage of small amount of urine
Elevated postvoid residual urine (generally over
450 cc)-normal postvoid residual < 50 cc.
OBJECTIVE #6: IDENTIFY 5 DIFFERENTIALS
FOR FREQUENT URINATION
1. Metabolic: Diabetic ketoacidosis-poorly controlled
diabetes-causing osmolar diuresis, Nephrolithiasis
2. Infection/sepsis: sexually transmitted disease (STD),
cystitis, urinary tract infection
3. Anatomical: Benign Prostate Hyperplasia, Bladder
malignancy/Prostate malignancy
4. Medication induced: Poly-pharmacy/medication
abuse
5. Urge vs Stress Incontinence
OBJECTIVE #7: HOW AGING AFFECTS THE
GENITOURINARY SYSTEM IN BOTH MEN AND WOMEN
QUESTIONS?

Frequent Urination

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Frequent Urination

Anwer Hussain, D.O.

Paragraph 1: Chief Complaint

Patient is a 75 year old male brought in by his daughter due to

In discussing bathing and personal hygiene, daughter begins

 Patient admits to increasing frequency over the past one to

 Occurs at times when the bladder gets too full or at times

 Also is having a hard time starting the stream and sometimes

1. Hydrochlorothiazide 25mg P.O. daily

Urinary frequency usually results from disorders

Anatomy of the Anus, Rectum, Anatomy of the Anus, Rectum,

 It is rounded, heart-shaped, and normally

 Only the lateral lobes and median sulcus

In the female, the uterine cervix usually is palpable through the

Frequent or urgent need to urinate

2. Stress Incontinence (Urethral incompetence)

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