urinary frequency and its associated symptoms diagnosis

QUESTION

A 50 y.o. male presents with c/o urinary frequency. He claims, “All I seem to do is go to the bathroom—I’m going to put a desk and TV in there.” He says it has been going on for months and cannot recall exactly how long, but he voids every 1 to 2 hours during the day and then must get up to void through the night. He does not have any other urinary symptoms and has not noticed any change in the appearance or color of his urine, including no visible blood. Patient has a history of type 2 diabetes for the past 10 years, which he admits has been poorly controlled. He occasionally checks his blood glucose at home, and it is usually “closer to 200 than 100.” He takes metformin 1000 mg BID and liraglutide daily. He pretty much eats what he chooses. “I know better, but I live alone and have bad habits.” His review of systems is positive for tingling and discomfort in his feet. He tires easily but says he really does limited activity. He denies blurred vision, rashes, dizziness, chest pain, palpitations, shortness of breath or cough, abdominal pain, diarrhea, constipation, or joint pain.

1. What three conditions would be considered in your differential diagnosis, with most likely condition listed first (with rationale)?

ANSWER

Based on the patient’s presenting complaint of urinary frequency along with his medical history and associated symptoms, the following three conditions would be considered in the differential diagnosis

Uncontrolled Diabetes Mellitus: The most likely condition contributing to the patient’s urinary frequency is uncontrolled diabetes mellitus. Diabetes can lead to increased urine production (polyuria) due to the excess glucose in the bloodstream that spills into the urine. Hyperglycemia results in osmotic diuresis, causing increased urine volume and frequency. The patient’s history of poorly controlled type 2 diabetes, as evidenced by his high blood glucose levels, supports this consideration. Additionally, the presence of associated symptoms such as tingling and discomfort in his feet further supports the likelihood of diabetes-related urinary frequency.

Urinary Tract Infection (UTI): UTI is another potential condition to consider in the differential diagnosis. Although the patient denies any urinary symptoms such as dysuria or visible blood in the urine, urinary frequency can still be a presenting symptom of UTI, especially in older adults. Diabetes can increase the risk of UTIs due to altered immune function and impaired urinary tract clearance. Therefore, the patient’s history of poorly controlled diabetes and increased vulnerability to infections make UTI a relevant consideration.

Benign Prostatic Hyperplasia (BPH): BPH is a common condition characterized by the enlargement of the prostate gland, leading to urinary symptoms such as urinary frequency and nocturia. While the patient does not specifically mention hesitancy, weak stream, or incomplete bladder emptying, which are classic BPH symptoms, BPH can sometimes present with predominant urinary frequency. The patient’s age (50 years) is also within the range when BPH becomes more prevalent. Although other lower urinary tract symptoms associated with BPH are absent, it remains a consideration to explore further.

Considering the patient’s medical history, poorly controlled diabetes, associated symptoms of peripheral neuropathy, and the absence of other urinary symptoms, uncontrolled diabetes mellitus is the most likely condition contributing to the patient’s urinary frequency. However, UTI and BPH should also be evaluated and ruled out through appropriate diagnostic testing and further assessment. It is important to conduct a comprehensive physical examination, including a digital rectal examination, and consider additional investigations such as urinalysis, blood glucose monitoring, and prostate-specific antigen (PSA) testing to confirm the diagnosis and guide appropriate management strategies.