Differential Diagnosis

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

AnxietyInfective CystitisOveractive Bladder SyndromeLUTS Bladder Calculus
Eased when ProneNoNoNoNoYes
Hesitancy, Slow FlowNoNoNoYesPossible
Nocturnal FrequencyNoYesYesPossibleNo
Abnormal UrinalysisNoYesNoPossibleYes

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.
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