Frequent urination—daytime, nighttime, or both—is an annoying symptom and a common reason for seeing a urologist. The bladder diary, a.k.a. voiding diary, a.k.a. 24-hour frequency/volume chart, is an extremely useful yet underutilized resource to help pinpoint the underlying source of frequent urination. Its cost is the price of a piece of paper, a measuring cup, and a pen or pencil, but its yield is rich in terms of facilitating the proper diagnosis. Today’s entry will give you the wherewithal to help diagnose the issue underlying the urinary frequency, but does NOT substitute for an evaluation by a urologist, the type of physician who specializes in urinary problems. Urologists, including yours truly, have significant training and experience in this field (in my case 4 years college, 4 years medical school, 2 years surgery residency, 4 years urology residency, 1 year urology fellowship and many years in the urology clinics).
Note well: Truth be told regarding urinary frequency: many cases are NOT urological in origin, although they present with urinary symptoms.
To do a bladder diary: Maintain your normal diet and drinking habits. For a 24-hour period, record the exact time that you urinate and the volume. You do this by urinating into a measuring cup, recording the volume, and emptying the urine into the toilet. Repeat for every urination for 24 hours. Bring the bladder diary with you to the office for review and analysis. For optimal efficiency, do this before your urology visit.
What you need to do a bladder diary: Measuring cup, paper, pencil
There are three major categories of diagnosis based upon the bladder diary, although this is an over-simplification because there can be overlap of symptoms and the symptoms are not always consistent:
Full-volume frequency occurring day and night. This is frequent urination of full bladder volumes that occurs during virtually every urination.
Full-volume frequency occurring only during sleep. This is frequent urination of full bladder volumes that occurs only during sleep time hours. Daytimes are fine.
Small-volume frequency. This is frequent urination of small bladder volumes indicative of a small “anatomical” bladder capacity (bladder is incapable of storing full volumes) or small “functional” bladder capacity (bladder is anatomically capable of storing full volumes, but urgency prevents doing so).
Causes of full-volume frequency occurring day and night
- Over-hydration, especially diuretic beverages including caffeine and alcohol
- Diabetes mellitus (“sweet” diabetes) either undiagnosed or poorly controlled
- Certain diabetic medications (SGLT-2 Inhibitors) that function by eliminating excess blood sugar in the urine, causing a diuretic effect and the side effect of urinary frequency. These medications include Jardiance, Invokana and Farxiga.
- Diabetes insipidus (“tasteless” diabetes). The pituitary gland produces an important hormone responsible for water regulation–anti-diuretic hormone (ADH)–that gives the message to the kidneys to concentrate urine. Diabetes insipidus is a disease of kidney origin in which the kidneys do not respond to ADH, or pituitary origin in which there is deficient secretion of ADH. In either case, lots of urine will be made, resulting in frequent urination, both daytime and nighttime
- Kidney disease (renal insufficiency) with loss of kidney concentrating ability
- Medications including diuretics, SSRIs (selective serotonin re-uptake inhibitors), calcium blockers, tetracycline and lithium
- Temporary issue from recent high-salt intake, fluid retention, and ultimate mobilization of fluid: culprits may be prepared foods, soups, breads, cheeses, Chinese, Mexican, Indian foods, etc.
- Primary polydipsia (excessive drinking) due to dysfunctional thirst mechanism from brain trauma, radiation or surgery
- Over-hydration: fluid, caffeine, alcohol moderation
- Diabetes mellitus: improved diabetic control
- Diabetes insipidus: endocrinology referral to evaluate possible central or nephrogenic diabetes insipidus,
- Renal insufficiency: nephrology consultation
- Medication-induced: consider alternative medication
- High salt intake: eat healthier!
- Primary polydipsia: medical consultation
Causes of full-volume frequency occurring only during sleep
- Over-hydration, particularly in evening hours
- Obstructive sleep apnea: *****This is a hugely prevalent and often unrecognized cause
- Age-related nocturnal defect in ADH secretion or unresponsiveness of the kidneys to the action of ADH
- Congestive heart failure
- Peripheral edema caused by heart, kidney or liver impairment, nephrotic syndrome, malnutrition or venous stasis. These conditions can result in gravitational accumulation of fluids in the legs. When lying down to sleep with legs elevated, the fluid returns to the intravascular (within the blood vessels) compartment and is released from the kidneys as urine.
- Over-hydration: fluid, caffeine, alcohol moderation
- Obstructive sleep apnea: pulmonology referral for sleep testing and treatment
- ADH issues: consideration for treatment with synthetic ADH medication
- Congestive heart failure: cardiology referral
- Peripheral edema: internal medicine consultation; salt restriction, daytime leg elevation, compression stockings
Causes of small-volume frequency at night only
- Primary sleep disorders including insomnia, restless leg syndrome, narcolepsy, and arousal disorders (sleepwalking, nightmares, etc.)
Management: referral to sleep specialist
Causes of small-volume frequency day and night
- Small “functional” bladder capacity: bacterial cystitis, bladder stones, bladder cancer, radiation cystitis, interstitial cystitis, overactive bladder, pelvic floor muscle tension myalgia
- Small “anatomical” bladder capacity: scarring, radiation, other forms of bladder damage
- Prostate enlargement
- Incomplete bladder emptying: prostate enlargement, scar tissue in the urethra, neurologic issues affecting bladder function, bladder prolapse
- Anxiety voiding
- Extrinsic compression on bladder: uterine fibroid, constipation, pelvic mass, pregnancy
- Bacterial cystitis: antibiotics
- Bladder stones: laser removal
- Bladder cancer: treated by urologist with surgery, bladder instillations
- Radiation cystitis: treated by urologist
- Interstitial cystitis: treated by urologist: hydro-distension; medications
- Overactive bladder: treated by urologist: behavioral modification; pelvic floor muscle training; medications; Botox; neuro-modulation techniques
- Pelvic floor tension myalgia: relaxation techniques; pelvic physical therapy
- Small “anatomical” bladder capacity: difficult problem sometimes addressed with bladder augmentation
- Prostate enlargement: medications; surgical procedures to open obstruction
- Scar tissue in the urethra: dilation; incision; repair
- Neurologic issues: optimize management of specific issue by neurologist; bladder relaxant medications for bladder overactivity; voiding facilitation, medications, intermittent catheterization for bladder under-activity with failure to empty the bladder
- Bladder prolapse: Kegel exercises; pessary; pelvic reconstructive surgery
- Anxiety voiding: psychology/psychiatry consultation, cognitive behavioral therapy, anti-anxiety medications
- Uterine fibroid: observation; hormone therapy; surgical procedures
- Constipation: high fiber diet, exercise, cathartics
- Pelvic mass: evaluation with imaging and then dealt with
- Pregnancy: delivery
Bottom Line: If you suffer with urinary frequency, it is easy enough to do a bladder diary to quantitate the precise frequency and voided volumes. The information in this entry will provide you with a general idea about the possible underlying causes. Bring in the diary to your urology appointment as it will likely save you an additional office visit.