Urinary, Prostate, and Gynaecological Conditions

TL;DR. These are the conditions people are least likely to mention and most likely to tolerate for years. Urinary tract infection is the commonest bacterial infection in women, affecting perhaps half of them at some point. Benign prostate enlargement affects most men over 60. Urinary incontinence affects a large minority of adults and is substantially treatable, yet most sufferers never raise it. Endometriosis affects roughly 1 in 10 women of reproductive age and takes an average of seven to ten years to diagnose, partly because severe period pain is normalised. The unifying theme is not biology; it is embarrassment, and it costs years of unnecessary suffering in conditions that mostly have effective treatments.

Key takeaways

• Roughly half of women will have a urinary tract infection, and the short female urethra is the entire anatomical explanation.
• Asymptomatic bacteria in urine should usually not be treated, except in pregnancy and before urological surgery. Treating it causes harm without benefit.
• Drinking more water measurably prevents recurrent UTI, demonstrated in a randomised trial, and it is cheaper than every alternative.
• Endometriosis affects about 10 percent of women of reproductive age with a diagnostic delay averaging seven to ten years. Period pain that stops you functioning is not normal.
• Pelvic floor muscle training is first-line for stress incontinence and works in a majority of women who do it properly, which most are never taught to do.
• Erectile dysfunction is an early vascular warning sign, frequently preceding a heart attack by three to five years, because penile arteries are narrower than coronary ones.

Urinary tract infection

In short: Gut bacteria travelling a short distance up the urethra, extremely common in women, and both over-treated and under-investigated in different groups.

What it is. Infection of the bladder (cystitis) or, if it ascends, the kidney (pyelonephritis). About 80 percent of cases are caused by E. coli from the person's own gut flora.

Why women. The female urethra is about 4 cm long against roughly 20 cm in men, and it opens close to the anus. That is the whole explanation, and it is why roughly half of women experience at least one UTI while it is uncommon in men.

Symptoms: burning on passing urine, frequency, urgency, lower abdominal discomfort, cloudy or strong-smelling urine, sometimes blood. Kidney involvement adds fever, loin pain, nausea, and feeling systemically unwell, and needs prompt treatment because it can progress to sepsis (Chapter 28).

In older adults the presentation changes, often to confusion, falls, or reduced mobility rather than urinary symptoms, which is a genuine diagnostic trap in both directions.

Don't be confused: bacteria in the urine without symptoms is not an infection to treat. Asymptomatic bacteriuria is common, particularly in older people, in catheterised patients, and in people with diabetes. Multiple trials show that treating it does not prevent symptomatic infection or improve outcomes, and it causes side effects, C. difficile infection, and resistance. The exceptions where treatment is indicated are pregnancy and before urological procedures that will breach the mucosa. The other common error runs the opposite way: in a confused older person, a positive urine dipstick is frequently blamed while the actual cause (pneumonia, a drug, dehydration, a stroke) goes unexamined.

Treatment: a short course of an appropriate antibiotic, typically 3 days for uncomplicated cystitis in women, guided by local resistance patterns. Nitrofurantoin, trimethoprim, and fosfomycin are common choices. Men, pregnant women, children, and anyone with fever or loin pain are treated as complicated and need longer courses and often investigation.

Investigate rather than simply treat if: it is a man (uncommon enough to warrant a look at the prostate and urinary tract), a child (to exclude reflux and structural problems), recurrent infections, blood in the urine that persists after treatment, or infection with unusual organisms.

Preventing recurrent UTI, in rough order of evidence:

Behavioural advice (wiping direction, urinating after sex, avoiding spermicides) is standard and has thinner evidence than its ubiquity implies, apart from spermicide avoidance which is reasonably supported.

Kidney stones

In short: Crystals precipitating out of concentrated urine, causing some of the most severe pain in medicine, and largely preventable by drinking more.

What they are. Solid crystals forming in the urinary tract, mostly calcium oxalate (about 80 percent), then uric acid, struvite (infection-related), and cystine (inherited).

Why they form. Urine is a supersaturated solution. Anything that concentrates it, or that raises the concentration of stone-forming substances or lowers the inhibitors, tips it into crystallising. Risk factors: low fluid intake (the dominant one), hot climates and heavy sweating, high sodium intake, high animal protein intake, obesity, certain drugs, gout, and inherited conditions.

What it feels like. Renal colic: sudden severe pain in the flank radiating to the groin, coming in waves, with nausea and vomiting, and an inability to find a comfortable position, which distinguishes it from peritonitis where people lie still. It is routinely described as among the worst pains people experience, and is frequently compared to childbirth by those who have had both.

Treatment. Pain relief (NSAIDs are more effective than opioids for renal colic), fluids, and time: most stones under 5 mm pass spontaneously. Larger ones may need shock wave lithotripsy (breaking them up with focused sound waves from outside), ureteroscopy, or surgery. Alpha blockers may help larger stones pass. Fever with a stone means an obstructed, infected kidney, which is a urological emergency.

Prevention matters because recurrence is common, roughly half within 10 years:

• Drink enough to produce about 2.5 litres of urine a day. This is the single most effective measure and it is proven in trials.
• Reduce sodium, which increases calcium excretion.
• Do not restrict dietary calcium. This is counterintuitive and important: low calcium diets increase stone risk, because dietary calcium binds oxalate in the gut and prevents its absorption. Restricting it leaves more oxalate free to be absorbed and excreted.
• Moderate animal protein and oxalate-rich foods if stones recur.
• Citrate (from lemon juice or potassium citrate) inhibits crystal formation.

Benign prostatic enlargement

In short: The prostate grows throughout adult life, squeezes the urethra running through it, and produces symptoms in most older men.

What it is. The prostate sits below the bladder with the urethra passing through it. From about age 40 it enlarges, and by 60 most men have some degree of it, and by 80 the large majority.

Symptoms divide usefully:

Complications if untreated: acute urinary retention (a sudden painful inability to pass urine, a common emergency presentation), recurrent infection, bladder stones, and eventually kidney damage from back pressure.

Treatment ladder:

Don't be confused: benign prostatic enlargement is not prostate cancer and does not cause it. They are different diseases in different parts of the gland, and having one does not raise the risk of the other. They coexist often simply because both are common with age. Urinary symptoms are usually benign enlargement; prostate cancer is typically silent until advanced (Chapter 25).

Urinary incontinence

In short: Extremely common, substantially treatable, and drastically under-reported because of embarrassment.

Prevalence is high: a substantial minority of adult women and a smaller but significant proportion of men, rising with age. Most never mention it, and surveys find delays of years and frequent assumption that it is an inevitable part of ageing or childbirth. It is not.

Treatment:

• Pelvic floor muscle training is first-line for stress incontinence and helps urge incontinence too. It works in a majority when done correctly, and the crucial detail is that most people are never actually taught how, and a large proportion contract the wrong muscles when given only written instructions. Supervised training by a specialist physiotherapist substantially outperforms a leaflet.
• Bladder training for urge incontinence: gradually extending the interval between voids.
• Weight loss, which reduces stress incontinence measurably.
• Reducing caffeine and alcohol.
• Medication: antimuscarinics or mirabegron for overactive bladder. Antimuscarinics cause dry mouth, constipation, and cognitive effects in older adults, and their long-term use has been associated with dementia risk, so mirabegron is often preferred in that group.
• Topical vaginal oestrogen after menopause.
• Surgery: slings and other procedures for stress incontinence, and botulinum toxin injection into the bladder for refractory overactive bladder.

Endometriosis

In short: Tissue resembling the womb lining growing outside the womb, affecting roughly 1 in 10 women, and taking seven to ten years to diagnose.

What it is. Tissue similar to the endometrium growing outside the uterus, most often on the ovaries, the pelvic peritoneum, and the ligaments supporting the uterus, occasionally on the bowel, bladder, or further afield. It responds to the menstrual cycle, bleeding and inflaming each month with no way to escape, which causes inflammation, scarring, and adhesions that stick organs together.

Symptoms: severe period pain, chronic pelvic pain, pain during or after sex, painful bowel movements or urination especially around periods, heavy bleeding, fatigue, and subfertility. Notably the amount of visible disease correlates poorly with the amount of pain.

The diagnostic delay is the scandal. Averages of seven to ten years are reported consistently across countries. The reasons are well documented: severe period pain is normalised by patients, families, and clinicians; symptoms overlap with irritable bowel syndrome and pelvic infection; imaging is often normal in superficial disease; and definitive diagnosis has traditionally required laparoscopy.

The message that matters: period pain that regularly stops you working, studying, or functioning, or that is not controlled by ordinary painkillers, is not normal and deserves investigation rather than endurance.

Treatment:

• Hormonal suppression: combined hormonal contraception (often taken continuously to avoid bleeding), progestogens, the hormonal intrauterine device, and GnRH analogues with add-back therapy for severe disease. These suppress the cyclical stimulation rather than removing the disease.
• Pain management, including specialist pelvic pain services, since central sensitisation develops in long-standing cases (Chapter 40).
• Surgery: laparoscopic excision or ablation of deposits, which improves pain and, for some, fertility. Recurrence is common.
• Fertility treatment where conception is the goal.

Adenomyosis is the related condition in which the same tissue grows into the muscular wall of the uterus, causing heavy, painful periods and an enlarged tender uterus. It is common, under-diagnosed, and increasingly identifiable on good-quality ultrasound or MRI.

Fibroids and heavy menstrual bleeding

In short: Extremely common benign tumours of the uterine muscle, and heavy bleeding is treatable without surgery in most cases.

Uterine fibroids are benign growths of uterine smooth muscle, present in a large proportion of women by age 50 and considerably more common and more symptomatic in women of African descent. Most cause no symptoms. When they do: heavy or prolonged periods, pelvic pressure, urinary frequency, back pain, and sometimes fertility or pregnancy complications.

Heavy menstrual bleeding affects a large minority of women, is the commonest cause of iron deficiency (Chapter 53), and is frequently endured because women have no comparison and assume their experience is typical.

Practical markers that bleeding is heavy: flooding through protection, passing clots larger than a coin, needing to change protection hourly, bleeding for more than 7 days, or bleeding that restricts what you can do.

Treatment, in order of invasiveness:

Investigate rather than treat empirically if there is bleeding between periods, after sex, or after menopause. Any bleeding after menopause requires urgent investigation for endometrial cancer, which is highly curable when caught early and is rising in incidence alongside obesity.

Pregnancy-related conditions

In short: Four complications that account for most maternal harm, all of which are detectable and manageable.

Covered here only insofar as they are common and consequential; obstetrics is beyond this book's scope.

Perinatal mental health deserves naming here: depression affects roughly 10 to 15 percent of mothers and a smaller proportion of fathers, and postpartum psychosis, occurring in 1 to 2 per 1,000 deliveries and far more often in women with bipolar disorder, is a psychiatric emergency (Chapter 42).

Erectile dysfunction

In short: Common, treatable, and an early warning sign for cardiovascular disease that is frequently ignored.

An erection is a vascular event: arteries dilate, blood fills the erectile tissue, and outflow is compressed. It requires healthy blood vessels, intact nerves, adequate testosterone, and the absence of psychological inhibition.

The vascular warning is the point most worth making. The arteries supplying the penis are narrower than the coronary arteries, so the same atherosclerotic process produces symptoms there first. Erectile dysfunction commonly precedes a cardiovascular event by three to five years, and it is an independent predictor of future cardiac events. A man presenting with new erectile dysfunction should have his cardiovascular risk assessed, and frequently is not.

Causes: vascular disease, diabetes (very common, through both vessels and nerves), smoking, obesity, hypertension and some of its drugs, low testosterone, prostate surgery, neurological disease, depression and anxiety, and many medications including SSRIs and beta blockers.

Treatment: address the cause and cardiovascular risk factors, then PDE5 inhibitors (sildenafil, tadalafil), which work by prolonging the nitric oxide signal that dilates the arteries. They require sexual stimulation to work and are contraindicated with nitrates, because the combination can cause a catastrophic drop in blood pressure. Second-line options include vacuum devices, injections, and implants. Psychological treatment where relevant, and it is frequently a mixed picture rather than purely one or the other.

What the person can do

In short: Raise it, because almost everything here is treatable and almost nobody mentions it.

• Mention it. Incontinence, erectile dysfunction, painful sex, and heavy periods are all common, all treatable, and all systematically under-reported. Clinicians frequently do not ask.
• Drink enough to prevent both recurrent UTI and kidney stones. This single habit addresses two chapters' worth of conditions.
• Learn pelvic floor exercises properly, ideally taught by a specialist physiotherapist rather than from a leaflet, during and after pregnancy and at any age with symptoms.
• Do not accept debilitating period pain as normal. Pain that stops you functioning is a symptom.
• Get post-menopausal bleeding investigated urgently, always.
• Get new erectile dysfunction treated as a cardiovascular signal, not just a sexual one.
• Do not ask for antibiotics for a positive urine dipstick without symptoms, and be sceptical if confusion in an older relative is attributed to a UTI without anything else being examined.

Sources and notes

UTI lifetime incidence in women and E. coli proportion: standard urology and infectious disease references. Asymptomatic bacteriuria: IDSA guidelines, 2019, and multiple randomised trials showing no benefit from treatment outside pregnancy and pre-procedure. Increased water intake for recurrent UTI: Hooton et al., JAMA Internal Medicine, 2018. Methenamine hippurate: ALTAR trial, BMJ, 2022. Vaginal oestrogen for recurrent UTI: Cochrane review. Kidney stone recurrence and prevention including the dietary calcium finding: Borghi et al., NEJM, 2002. Benign prostatic hyperplasia prevalence and treatment: MTOPS and CombAT trials. Pelvic floor muscle training: Dumoulin et al., Cochrane review. Antimuscarinics and dementia risk: Coupland et al., JAMA Internal Medicine, 2019. Endometriosis prevalence and diagnostic delay: Zondervan, Becker, and Missmer, NEJM, 2020. Hormonal intrauterine device and menstrual blood loss: multiple randomised trials. Aspirin for pre-eclampsia prevention: ASPRE trial, NEJM, 2017. Tranexamic acid for postpartum haemorrhage: WOMAN trial, The Lancet, 2017. Erectile dysfunction preceding cardiovascular events: Montorsi et al., and subsequent cohort analyses.

Open questions. The cause of endometriosis is not established, with retrograde menstruation, coelomic metaplasia, and stem cell theories all incompletely explaining its distribution. Why some people form kidney stones repeatedly and others never do, at similar urine chemistry, is not fully understood. The long-term cognitive safety of antimuscarinic bladder drugs is debated.

Next: the causes of death that are not diseases at all. 👉