Recurrent Urinary Tract Infections in Females and the Overlap with Overactive Bladder

There are an estimated 33 million men and women with overactive bladder (OAB) in the USA. Despite the prevalence of OAB, it remains a frequently misdiagnosed condition. OAB has shared symptomatology with other common urologic conditions, namely recurrent urinary tract infections (UTIs). Here, we will review key distinguishing features of OAB that aid in establishing an accurate diagnosis and recent advances in OAB management.

Recent studies have shown that among women presenting with lower urinary tract symptoms, the majority were diagnosed with UTIs and treated without performing a urine culture as routine care. The authors found that when urine cultures were obtained, less than half of women had a positive urine culture, suggesting that empiric treatment of UTIs without cultures commonly led to a misdiagnosis of UTI. The symptoms of OAB have overlap with other common conditions, most notably UTI, BPH, and bladder cancer/carcinoma in situ. Despite the shared symptomatology of OAB and UTI, the timing of symptom onset is usually very different between the two. UTI symptoms are generally acute, whereas those of OAB are generally chronic. OAB and UTI share the common features of urgency, frequency, and nocturia. However, dysuria and hematuria are not features of OAB, while they are frequently seen in UTI. Of note, urgency, frequency, and nocturia are rarely seen in bladder cancer/carcinoma in situ; when these symptoms do occur, it is generally in the setting of microhematuria. One study of patients with carcinoma in situ found that 41% had macroscopic hematuria and 44% had microscopic hematuria at presentation. In patients with lower urinary tract symptoms, it is important to perform a urinalysis (UA) to evaluate for microhematuria to rule out the possibility of malignancy. First-line treatment of OAB (outside the setting of UTI) involves behavioral modification, including bladder training, fluid management, and pelvic floor exercises. Numerous studies have supported behavioral modification strategies as the most efficacious initial step in treatment. Although routinely given for recurrent UTIs and vaginal atrophy in postmenopausal women, several review articles have shown that vaginal estrogen is an effective treatment of lower urinary tract symptoms.

The importance of distinguishing OAB from other conditions presenting with similar symptoms is key in preventing misdiagnosis, treatment delays, and antibiotic overuse. Here, we have reviewed key parameters distinguishing OAB from UTI, the most commonly misdiagnosed condition among those presenting with lower urinary tract symptoms (LUTS). Given that UTI is the most commonly misdiagnosed condition among women with OAB, we recommend relying on urine cultures and the constellation of acute-onset dysuria, frequency, and urgency as more important diagnostic factors in distinguishing these conditions.