Voiding dysfunction: urinary frequency or overactive bladder

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Dr. Katherine Klos is a board certified urologist practicing in Washington, DC. She completed her medical training at the University of Alabama and urology residency at George Washington University. Since graduating residency in 2012, she has developed a practice that focuses on pelvic health in the male and female patient. She understands the multidimensional aspects of urologic care and strives to educate her patients about the benefits of traditional and nontraditional medicine. She maintains an interest in research and serves an advisory for the FDA.

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It is estimated that 20% of adult women are affected by frequent and urgent urination (1, 2). These symptoms are associated with poor quality of life, mental health and productivity.

This condition is also known as overactive bladder (OAB) and causes a frequent and sudden urge to urinate that may be difficult to control. You can learn more about incontinence here.

Urinary frequency is a conversation that begins and ends with a lot of questions. Why have this conversation then? Well, to better understand your urination, you need to ask yourself these questions and realize there are many factors affecting your voiding (urination) pattern. Let’s dive in.

The International Incontinence Society defines urinary frequency as the perception of more frequent urination while awake and when studied it appears “normal” frequency is 7 times while awake, roughly every 2 hours (3). But these numbers are very controversial. Determining urinary frequency needs to take into account volume of fluid, type of fluid, diet, bowel pattern, stress/social factors, medication and the skeletal muscles of your pelvic floor, all of which affect urination.

It's important to be mindful of not only how much liquid is consumed daily to determine healthy or abnormal levels of urination, but also the type of liquid.

The daily recommended fluid intake for the average female is 2.7L, with 20% coming from food (4). Thanks to apps, fancy water bottles and of course basic thirst, most of us achieve this goal. But if you are drinking 4L of water daily, trust me, you will be going more frequently. When evaluating your frequency, first assess: HOW MUCH AM I DRINKING? If your fluid intake is high, great, but realize your frequent trips to the bathroom are healthy and normal. Now, what type of liquid you take in makes a big difference, too. Caffeine, carbonation, alcohol, artificial sweeteners and acid beverages are among the more common bladder irritants. Based on animal studies, these irritants increase bladder pressure and bladder muscle contraction which results in frequency and urgency (5-7).

Few studies have focused on specific diets and associated urinary frequency but certain themes do predominate. On a macroscopic level, a diet high in calories, acid (tomatoes, citrus), salt and spice correlate with an increased prevalence of urinary frequency (8). On a microscopic level, small scale data suggests that a diet low in micronutrients, specifically Vitamins D and B can play a role in developing urinary frequency (9). What goes in is important but what comes out is also key. Stool sitting in the colon at a basic level can just take up space. The external pressure on the bladder is an irritant and promotes more frequent trips to the bathroom. Furthermore, in animal studies, constipation has been demonstrated to cause an enhancement of nerve pathways promoting frequency. (10) Like I said, the answer to urinary frequency is long.

The prevalence of anxiety disorders in the general population is estimated at 15%, yet data points to 50% of patients with urinary frequency reporting anxiety (11). But this begs the question, which came first? If you are worried about where every bathroom is located, your stress is going to increase. No concrete data is available to link anxiety and urinary frequency but small studies do show that the two have shared biological pathways (12-13), so it would be realistic to believe that stress and anxiety can trigger that pesky urge to urinate.

The pelvic floor is a network of skeletal muscles that connects your hips, pubic bone and tailbone. In essence, these muscles form a hammock to support the urethra/bladder, vagina/uterus and rectum. The strength or tone of the pelvic floor muscles can greatly affect these organs, specifically the bladder and urethra. When working properly, the pelvic floor muscles relax to allow for urination and contract when empty. But in certain instances, the muscles can form abnormal contractions that impede urethral relaxation and lead to irritation in the surrounding nerves and tissues. Additionally, when these muscles are at a higher contracted state, there is decreased ability to “hold in” the urge, thus prompting a run to the toilet. (14)

Last but not least, on the quest to determine if “this is normal urinary frequency” is medication. More straightforward than the former, but also important.

Diuretics are a class of medication that increases urine production. Diuretics are typically used to reduce blood pressure or abnormal swelling that can occur in the body. In addition to diuretics, certain types of medication to treat diabetes will increase the glucose content in your urine, resulting in a frequent urge to urinate.

It is important to assess urinary frequency and put it in the context of your overall health. Better knowledge about what affects urinary frequency can not only provide a level of understanding but possibly provide an initial treatment pathway.

Unfortunately, not everything can be solved with a change to flat water and meditation. Seeking a doctor’s care is key for further discussion. And objective research, along with personal experiences, confirm urinary frequency is a true measure of quality of life.

1. Kupelian V, Wei JT, O'Leary MP, et al. Prevalence of lower urinary tract symptoms and effect on quality of life in a racially and ethnically diverse random sample: the Boston Area Community Health (BACH) Survey. Arch Intern Med. 2006; 166(21): 2381–2387
2. D.E. Irwin, Z.S. Kopp, B. Agathen, I. Milsom, P. Abrams. Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. BJU Int, 108 (2011), pp 1132-1138
3. Fitzgerald MP (2003) Variability of 24 hour voiding diary variables amongst asymptomatic women. J Urol 169(1): 207-209
4. National Academies of Sciences , Engineering and Medicine: Dietary Reference Intakes for Water, Potassium, Sodium, Chloride and Sulfate. February 11, 2004.
5. Lee JG, Wein AJ, Levin RM. The effect of caffeine on the contractile response of the rabbit urinary bladder to field stimulation. Gen Pharmacol. 1993;24(4):1007–1011.
6. Dasgupta J, Elliott RA, Doshani A, et al. Enhancement of rat bladder contraction by artificial sweeteners via increased extracellular Ca2+ influx. Toxicol Appl Pharmacol. 2006;217(2):216–224.
7. Dasgupta J, Elliott RA, Tincello DG. Modification of rat detrusor muscle contraction by ascorbic acid and citric acid involving enhanced neurotransmitter release and Ca2+ influx. Neurourol Urodyn. 2009;28(6):542–548.
8. McGrother CW, Donaldson J, Thompson et al. Etiology of overactive bladder: a diet and lifestyle model for diabetes and obesity in older women Neurourol Urodyn, 31 (2012), p487
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10. Iguchi N, Pineda R, Carrasco A, et al. MP38-14 Constipation induces overactive bladder through alterations of nicotinic and purinergic pathways in mouse bladders. J Urol, 1999 (2018): p e506
11. Lai, HH, Rawal A, Shen B et al. The Relationship Between Anxiety and Overactive Bladder or Urinary Incontinence Symptoms in the Clinical Population. Urology 98 (2016), pp. 50-57
12. Gordon, JA, Hen R. The serotonergic system and anxiety. Neuromolecular Med, 5 (2004), pp. 27-40
13. Groat WC, influence of central serotonergic mechanisms on the lower urinary tract function. Urology 59 (2002), pp. 30-36
14. Hastings, J, Machek, M. Pelvic floor dysfunction in women. Curr Phys Med Rehabil Rep 8, 64-75 (2020).