Reasoning GP · Algorithm · 1-page summary
Urinary frequency, urgency and nocturia
For: adults with frequency, urgency or nocturia in primary care. Not for: children (children's pathways); pregnancy (antenatal care); established incontinence plans (use the protocol).
Core rule: first ask big volumes or small volumes? Polyuria needs glucose, calcium and a drug review; small-volume frequency needs a dipstick, examination and a 3-day bladder diary.
0Stop — call 999 now
- Saddle anaesthesia, new bladder or bowel dysfunction, leg weakness (cauda equina, cord compression) → 999 or emergency pathway
- High-risk sepsis from urinary source; drowsy with polyuria and vomiting (DKA, hyperosmolar) → 999
1Triage — the volume question
| Picture | First move |
|---|---|
| Large volumes, thirst | Glucose/HbA1c, U&E, calcium, drug review |
| Acute + dysuria | Dipstick ± culture → UTI pathway |
| Small volumes, urgency | Exam, dipstick, bladder diary → OAB |
| Mostly at night | Diary: nocturnal polyuria? HF, OSA, evening fluids |
| Voiding symptoms (men) | IPSS, DRE, U&E, PSA counselling |
2Screen
- Retention, acute or with renal impairment → Same-day
- Fever, loin pain → Same-day
- Visible haematuria aged 45 or over (unexplained or after UTI) → Suspected cancer pathway
- Non-visible haematuria aged 60 or over + dysuria or raised WCC → Suspected cancer pathway
- Hard irregular prostate → Suspected cancer pathway
- Woman aged 40 or over, persistent urgency/frequency + bloating or pelvic pain → CA125 (NG12)
3Assess
☐ Dipstick ± culture ☐ 3-day bladder diary ☐ Abdomen (palpable bladder) ☐ Men: genitalia, DRE, IPSS ☐ Women: pelvic exam (prolapse, atrophy) ☐ Glucose, U&E, calcium if polyuria ☐ Post-void residual if emptying concern
Nocturnal polyuria: more than about 33% of 24-hour output at night (older adults).
4Classify
- UTI / prostatitis — acute, dysuria, nitrites → NG109.
- OAB — urgency, small volumes, normal urine → bladder training.
- Polyuria — diabetes, hypercalcaemia, diuretics, lithium, intake.
- Nocturnal polyuria — HF, OSA, evening fluids.
- Prostate, prolapse, bladder pain syndrome — by examination and pattern.
- Uncertain — diary, review in 6 weeks; persistent sterile pyuria → urology.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Bladder training at least 6 weeks; fluids about 1.5–2 L; cut caffeine.
- Antimuscarinic (e.g. solifenacin 5 mg daily) — weigh anticholinergic burden; no IR oxybutynin in frail older women.
- Mirabegron 50 mg daily if antimuscarinic unsuitable — BP first; not if 180/110 mmHg or more.
- Men, voiding: tamsulosin MR 400 micrograms daily.
6Refer routinely
- Refractory OAB, symptomatic prolapse, voiding dysfunction → urogynaecology / urology.
- Recurrent UTI in men, bladder pain syndrome, suspected stone → urology.
7Never reassure by
- "Just OAB" without a dipstick and diary.
- A normal PSA when the prostate feels hard.
- Haematuria explained by a UTI without a repeat dipstick.
- No pain — chronic retention is painless.
- "Old age" for nocturia before checking for HF, diabetes and calcium.
- Irritative symptoms with sterile pyuria in a smoker.
8Safety-net — say it, then document it
999 “Call 999 if you get numbness between the legs, new leg weakness, or lose bladder or bowel control.” Same-day “Contact us today if you can't pass urine, get a fever with back pain or shivering, see blood in your urine, or have extreme thirst with weight loss or vomiting.” Drug review at 4 weeks.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Dipstick done; haematuria acted on
Polyuria excluded or investigated
Bladder examined; diary given
Review booked; safety-net given
Summary of the full Reasoning GP urinary frequency algorithm, which holds the detail, examination, investigations and evidence. Sources: NICE NG123, CG97, NG12 (updated April 2026), NG109, TA290; MHRA. Clinical reference — follow local pathways; doses: NICE/SPC, BNF, local formulary.