Frequent Urination

Definitions

Frequent urination in adults is defined as voiding 8 or more times per day ¹. The normal frequency of urination from the age 5 on is 4-7 times a day, including once at night ^1,2.

Excessive urination or polyuria in adults is defined as passing more than 3 liters of urine per day ⁶⁸. The normal daily (24-hour) urine volume in adults is 0.8-2 L ¹⁹.

This section describes conditions with frequent urination (>7x/day) but the normal 24-hour urine volume (<2 L/day).

1. Clear Urine, No Pain

a) Conditions with increased pressure on the bladder:

• Obesity
• Constipation
• Abdominal bloating (intestinal gas) ³
• Abdominal tumors
• Abdominal adhesions (bands of scar tissue within the abdominal cavity), which can develop after lower abdominal or pelvic surgery

b) Anxiety

Individuals with chronic anxiety may experience frequent urination “on and off” due to increased awareness of the bladder fullness ¹⁶.

c) Drugs and supplements

• Medications: acetaminophen (paracetamol) ²⁸, acetazolamide ³¹, amphetamine ³², chemotherapeutics ³⁶, dopamine ³⁰, gabapentin ³⁴, ibuprofen ²⁹
• Supplements: vitamin B3 ^8,24, vitamin C ²⁵
• Illegal drugs: cocaine ³³

d) Overactive bladder

Overactive bladder refers to a frequent urge to urinate without pain, sometimes also at night, without a known cause. Possible triggers include stress, smoking (nicotine), caffeine (tea, coffee, cola, energy drinks), acidic and spicy foods, carbonated and alcoholic beverages and certain food additives ^15,17.

e) Incontinence due to neurological disorders (neurogenic bladder)

Neurological disorders that can cause incontinence and thus frequent urination include ¹⁸:

• Brain damage due to cerebral palsy, tumor, stroke, encephalitis, multiple sclerosis, Parkinson disease or Alzheimer disease
• Spinal cord damage due to birth defects, such as spina bifida, injury or spinal stenosis caused by herniated discs
• Damage to the peripheral nerves (polyneuropathy) due to long-term, heavy alcohol use, diabetes mellitus, vitamin B12 deficiency, pelvic surgery or syphilis

2. Cloudy Urine and Burning Urination

a) Urinary tract infections (UTIs) can cause frequent and burning urination, cloudy urine and other symptoms ^7,8:

• Infection of the urethra (urethritis): smelly urine, usually no fever
• Infection of the bladder (cystitis): central lower abdominal pain, fever and occasional blood in urine
• Kidney infection (pyelonephritis): fever, chills and flank pain

b) Kidney stones

Symptoms ^12,13:

• Painful spasms in the right or left flank, abdomen or groin, which may last for several hours, often at night or early in the morning
• Frequent urination, blood in the urine, cloudy urine or passing a stone

c) Kidney inflammation

Kidney inflammation (nephritis or glomerulonephritis) can present with frequent urination, foamy urine or blood in the urine ⁽⁵⁵⁾.

d) Other causes of frequent and burning urination ^6,15:

• Chemicals, for example, in soaps, bubble baths, scented toilet paper, tampons, contraceptive sponges and spermicides
• A foreign body, catheter or recent urological procedure
• Dehydration (frequent passing of small amounts of dark yellow or brown urine)
• Schistosomiasis (a parasitic disease common in Africa, South America and South Asia with fever, skin rash, blood and worms in the urine) ²⁰
• Bladder cancer (lower central abdominal pain, frequent and burning urination and blood in the urine)
• Radiation therapy of the pelvic area ³⁷

3. Urination at Night (Nocturia)

Nocturia means waking up at night more than once to pass urine ^5,6. Most people with either frequent or excessive urination have to urinate at night more than once.

Enuresis is defined as bed-wetting after the age of 5 in a child without any organic disease ¹. Common causes include stress at home and school, night terrors, maturity delay and inappropriate toilet training ⁵⁹.

Excessive Urination at Night (Nocturnal Polyuria)

In nocturnal polyuria, the 24-hour urine volume is normal, but more than 35% of it is produced during the nighttime resulting in frequent urination only at night ⁷⁴.

Causes:

• Excessive drinking or taking diuretics before bed
• Decreased secretion of the antidiuretic hormone at night ⁷⁴ or high blood pressure ⁸⁵ in elderly people
• Disorders with swollen legs (edema), in which the blood pooled in the leg veins during the day is redistributed toward the heart after lying down:
  • Congestive heart failure ⁶⁹
  • Chronic kidney disease ⁷⁴
  • Low blood protein levels in liver or kidney disease ¹⁰
  • Varicose veins ⁷⁴
  • Autonomic neuropathy in long-term diabetes mellitus, chronic alcoholism, systemic lupus erythematosus (SLE), multiple sclerosis or Parkinson’s disease ^92,94
• Sleep apnea–repeated pauses in breathing during sleep–mostly in older obese men, and children with enlarged tonsils ³⁵
• Alzheimer’s disease ⁷⁴

To prevent or reduce urinating at night avoid drinking in the evening.

4. Frequent Urination in Men

a) Prostate disorders

In men after 50, prostate enlargement (benign prostatic hyperplasia) can cause difficulty start to urinate (hesitancy), weak stream, feeling of incomplete bladder emptying, urine dribbling or sudden inability to urinate (urine retention) ³⁹.

Prostate infection (prostatitis) or cancer can cause pain and tenderness in the area between the scrotum and rectum (perineum), lower back pain, burning urination, painful ejaculation, blood in the urine or semen and fever ⁶⁵.

b) Sexually transmitted diseases (STDs)

Sexually transmitted diseases (gonorrhea, chlamydia) can cause itchy genitals, burning urination, rash on the penis, penile discharge or painful testicles few days or weeks after sex ^43,63.

c) Reactive arthritis or Reiter’s syndrome

Reactive arthritis usually develops in young men within 2-4 weeks after an infection of the urethra (chlamydia), intestine (food poisoning by salmonella) or respiratory tract. Symptoms include frequent urge to urinate, redness of the glans penis, red eyes, pain in the back, hip or knees due to the joint inflammation, low-grade fever, fatigue, rash and heel pain ⁴⁸.

d) Other causes of frequent urination in men:

Testicular torsion or inflammation (orchitis) and epididymitis can cause scrotal pain, tenderness, swelling and blue discoloration ^9,48.

Urethral scars (strictures) after an injury, surgery, bladder catheterization, irradiation or repeated infections may result in frequent urination, and blood in the urine or semen.

Interstitial cystitis, a rare inflammation of the bladder, can cause very frequent urination, bladder pain or pain in the scrotum or testicles.

5. Frequent Urination in Women

a) Common causes:

• Frequent douching (rinsing the vagina)
• Premenstrual syndrome (PMS) ⁶⁴
• Menopause (atrophic vaginitis with the vaginal itch, painful sex) ⁶⁰
• Vaginal yeast infection (vaginal thrush, candidiasis), often during treatment with antibiotics or steroids or taking birth control pills, or in diabetes mellitus (odorless, curd-like discharge) ⁴⁹
• Sexually transmitted diseases, such as bacterial vaginosis, chlamydia, gonorrhea, trichomoniasis or genital herpes (vaginal discharge with strong odor, vaginal bleeding, blisters or red bumps on the vulva or in the vagina) ^43,63
• Bladder or bowel endometriosis (pain in the lower abdomen during menstruation period) ⁶⁶
• Ovarian cysts or cancer (irregular menstruation, vaginal bleeding, pain in the lower abdomen and pain during sex) ^44,46
• Uterine cancer (vaginal bleeding between periods) ⁵⁰
• Cervical cancer (pain and vaginal bleeding during or after sex) ⁵⁸

NOTE: Ovulation by itself does NOT cause frequent urination.

b) Pregnancy

• Frequent urination can be one of the early signs of pregnancy ⁴⁵.
• The pressure of the uterus on the bladder, especially in the 3rd trimester, can trigger frequent urination ⁸.
• Ectopic pregnancy can present with a missed period, lower abdominal pain and vaginal bleeding ⁵².

c) Loose pelvic floor muscles and stress incontinence

Loose pelvic floor muscles can result from multiple vaginal deliveries, menopause, chronic straining on the toilet or pelvic floor surgery. Symptoms may include urine leaking triggered by coughing, sneezing, rising, lifting objects, exercise or sexual intercourse, tampons falling out and reduced sensation in the vagina ⁶².

Loose pelvic floor muscles may result in slipping of the uterus down into vagina–uterine prolapse–with a sense of fullness in the vagina or tissues protruding out, which can further increase the urinary frequency ¹⁴.

d) Interstitial cystitis

Interstitial cystitis is an inflammation of the bladder without a known cause. Symptoms, usually in women after 30 (rarely in adolescent girls) can include extremely frequent (>50 x/day) or urgent urination, discomfort, throbbing or spasms in the bladder.

e) Nonrelaxing pelvic floor dysfunction

Causes of nonrelaxing pelvic floor dysfunction include painful bowel or bladder conditions, such as irritable bowel syndrome (IBS), gait abnormalities, prolonged sitting and sexual abuse.

Symptoms start insidiously at an early age, progress over the years and may include urinary urgency, constipation, pain in the pelvic floor, vulva (vulvodynia), clitoris, vagina, groin, and pain during urination or sex ⁵⁶.

f) Pelvic congestion syndrome

In women 20-45 years of age, varicose veins in the pelvis due to repeated pregnancies or polycystic ovaries can cause frequent urination, pelvic pain that increases throughout the day when standing, or pain after intercourse, swelling and varicose veins in the vulva, buttocks and upper inner thighs, and hemorrhoids ²⁷.

6. Frequent Urination in Infants

Newborns normally urinate at least once the first day, 3-4 times per day in the next few days and 6 times or more per day by the end of the first week ⁴². Infants (1-12 months) can normally urinate as often as 20 times per day ^1,51.

Common causes of frequent urination in infants are urinary tract infections and genetic disorders, such as vesicoureteral reflux ⁵³.

7. Frequent Urination in Toddlers and Older Children

Toddlers (1-4 years) normally urinate up to about 10 times per day and older children up to 8 times per day ¹.

a) Pollakiuria

Frequent daytime urination or pollakiuria [Greek pollakis = often] refers to very frequent (every hour or even every 5 or 10 minutes) passing of small amounts of urine in boys or girls around the age of 5 (the range: 3-14 years), usually without pain or abnormal urine color or change in bowel habits. Symptoms usually disappear in few days or weeks and usually resolve completely within 7-12 months ⁴¹.

Triggers may include stress, bullying in school, increased bladder sensitivity in winter, chemical irritation of the urethra by soaps and increased calcium excretion with urine (hypercalciuria).

b) Overactive bladder

Overactive bladder in children can result from congenital disorders, such as cerebral palsy, spinal cord disorders or posterior urethral valves. In average, symptoms last for 2.7 years ⁶⁷. Associated features include repeated squatting position and pressing the heel into perineum or crossing the legs in the attempt to prevent urine leakage, constipation and fecal soiling ⁶⁷.

c) Rare causes of frequent urination in children:

Interstitial cystitis can cause pain in the bladder area and urinary urgency ⁵⁷.

A streptococcal infection of the throat (strep throat) can trigger Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS), which is a type of obsessive-compulsive disorder (OCD) with jerky movements, unusual behavior and frequent urination ⁴⁷. The condition usually resolves when the throat heals.

Causes of frequent urination with somewhat increased daily urine volume (2-3 L/day):

• High-salt diet, mainly because of the associated high water intake ¹⁰²
• Caffeine (in coffee, tea, cola, energy drinks), when consumed in single doses greater than 240-500 mg (for example, >2-5 cups of coffee) ⁸⁸
• Alcohol (ethanol) ⁸⁹
• Licorice (a natural product, not the artificial flavor), when ingested in large amounts ⁶¹
• The start of fasting, starving or a low-carbohydrate (ketogenic) diet ⁹⁰
• Cold weather or hypothermia, which leads to “cold diuresis” (increased urination) ^79,80
• Swimming, which leads to “immersion diuresis” (due to the water that puts pressure on the limbs causes constriction of the arteries,) ¹²⁰
• Hyperventilation in severe anxiety or panic attack ⁸³ or after arriving at high altitudes ⁸⁴
• Kidney failure, which usually results in decreased urination (oliguria), but sometimes in increased urination ¹²²
• High doses of calcium ²², vitamin B2 (riboflavin) ¹⁰⁴ and vitamin C ⁷⁸ supplements

Excessive urination or polyuria in adults is defined as excreting of more than 3 liters of urine per day ⁶⁸. A person who urinates excessively also urinates frequently.

Symptoms associated with polyuria:

• Excreting a large volume of urine each day, also at bedtime
• Excessive thirst, dry mouth and sudden weight loss due to dehydration

1. General Causes of Polyuria

a) Excessive water drinking due to a habit, “water diet,” “juicing,” alcoholism, bulimia nervosa or psychogenic polydipsia.

b) Diabetes mellitus

Diabetes mellitus means passing large amounts of honey-sweet urine.

Excessive urination is an early symptom of diabetes type 1 (usually with a sudden onset in childhood or early adulthood) or a late symptom of uncontrolled diabetes type 2 (usually with a gradual onset after the age of 30) ⁹⁶. Other symptoms: increased or decreased hunger, fatigue, fruit-smelling breath and urine, itchy genitals and history of diabetes in the family ^96,99. Sometimes, excessive urination and thirst are the only symptoms of diabetes mellitus.

c) Diabetes insipidus

Diabetes insipidus means passing large amounts of clear, tasteless urine ⁷².

Neurogenic or central diabetes insipidus

Certain brain disorders (tuberculosis, injuries, tumors, multiple sclerosis), brain surgery or irradiation, and anorexia nervosa can inhibit the release of the antidiuretic hormone from the pituitary gland and thus cause excessive urination ^{8,71, 103}. Other symptoms include headache and craving for ice-cold water ^91,103.

Nephrogenic diabetes insipidus

Nephrogenic means arising from the kidneys. In nephrogenic diabetes insipidus, kidneys do not respond to the antidiuretic hormone (ADH) and therefore produce excessive amounts of urine. Other symptoms may include lower back pain arising from the kidneys, tiredness and foamy urine. Causes include treatment with lithium, hypercalcemia ⁹⁷, hypokalemia ⁹⁹, chronic kidney failure ¹⁰³, chronic kidney infection, Sjögren’s syndrome and surgery ^{17,23,71,94,103}.

Gestational Diabetes Insipidus

Gestational diabetes insipidus with excessive urination can develop in the third trimester of pregnancy, especially in women who carry two or more babies; it resolves spontaneously after delivery ^75,87.

d) Kidney inflammation (nephritis)

Acute nephritis with excessive urination, flank pain, fever and rash can develop within days to months after exposure to bacterial, viral, fungal (candida) or toxoplasma infection or as a side effect of certain drugs ⁷⁷.

Chronic nephritis can develop in polycystic kidney disease, hypertension, sarcoidosis, chronic analgesic abuse or heavy metal poisoning ⁷⁷.

e) Migraine

Some migraineurs experience excessive urination within hours to days before the headache attack ⁴. Other symptoms include constipation, food craving and increased sensitivity to light.

f) Benign tumors and cancers

Tumors and cancers that can cause excessive urination include lung cancer ⁷⁰, breast cancer ¹⁰³, tumors in the brain ^21,71, parathyroid glands ⁶ or adrenal glands ¹⁰⁵, leukemia and multiple myeloma ¹⁰³.

g) Drugs

Drugs that can cause excessive urination:

• Diuretics
• Other medications: acyclovir, allopurinol, amphotericin B, captopril, chemotherapeutics, cimetidine, ciprofloxacin, cyclophosphamide, cyclosporine, demeclocycline, diazepam, epinephrine (adrenalin), ethambutol, foscarnet, gentamicin, isoniazid, lithium, mesalazine, metronidazole, omeprazole, orlistat, phenytoin, prednisone (and other steroids), ranitidine, rifampin, expired tetracycline, theophylline, trimethoprim-sulfamethoxazole, vancomycin
• Long-term abuse of nonsteroidal anti-inflammatory drugs (NSAIDs): aspirin, diclofenac, ibuprofen, indomethacin, naproxen
• Vitamin D overdose
  
• Herbs overdose: foxglove, savin oil plant, white bryony, Chinese medicinal herbal mixtures containing aristolochic acid
• Illegal drugs: ecstasy (MDMA), phencyclidine
• References: ^{26,36,54,72,77,81,82,93,96,100,103,106,107}

h) Medical procedures

Excessive urination can persist for up to 24 hours after:

• Injecting a contrast substance into a vein in X-ray or CT investigations
• Hysteroscopy and urologic procedures that require irrigation with large amounts of fluids ³
• Resolution of the urinary tract obstruction (excessive urination can persist for few days or weeks) ¹⁰³

2. Excessive Urination in Infants and Children

Excessive urination in children is defined as urine output greater than 2 L/m² of body surface per day or >1 L/day in preschool and >2 L/day in school children ¹¹³. Causes include:

a) Diabetes mellitus

• Transient diabetes mellitus of the newborn (TDMN), which spontaneously resolves within 4 months ⁸⁶
• Diabetes mellitus type 1:
  • “Usual” type: rarely, in the first year of life; more often in puberty ⁷⁶
  • Diabetes associated with hereditary disorders, such as hemochromatosis ³⁰, cystic fibrosis ³⁰ and Wolfram’s or DIDMOAD syndrome (Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy, Deafness) ⁹⁵

b) Diabetes insipidus

Diabetes insipidus in small children can result from the same conditions as in adults but also from:

• Hereditary nephrogenic diabetes insipidus ¹⁰³
• The head tumor called craniopharyngioma ¹⁰³

c) Other causes of excessive urination in children:

A type of heart arrhythmia called paroxysmal supraventricular tachycardia can present with occasional pounding heart (palpitations), rapid pulse, chest tightness, anxiety, shortness of breath, dizziness and excessive urination ⁷⁰.

Essential fatty acid (omega-3) deficiency may cause, thirst, excessive urination, dry hair, eczema and attention-deficit hyperactivity disorder (ADHD) ¹¹.

Congenital kidney disorders with excessive urination in children include cystinosis, galactosemia, hereditary fructose intolerance, tyrosinemia and Wilson’s disease ¹⁰⁰.

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