European Journal of Cardiovascular Medicine

Lower urinary tract symptoms (LUTS) are highly prevalent among women, with population-based studies reporting rates ranging from 64% to 76% [1,2]. The burden of these symptoms is particularly pronounced in postmenopausal women, in whom hormonal changes—especially declining estrogen levels—contribute to alterations in genitourinary tissues and increased symptom severity [3,4]. Beyond their physical manifestations, LUTS have a substantial impact on quality of life, with affected women frequently experiencing psychological distress, including anxiety and depressive symptoms, thereby making LUTS a significant source of morbidity [5].

In outpatient clinical settings, women commonly present with symptoms such as dysuria, urinary frequency, urgency, nocturia, suprapubic discomfort, and sensations of incomplete bladder emptying [6]. These symptoms are often assumed to reflect urinary tract infection (UTI) by both patients and healthcare providers, resulting in frequent antibiotic prescribing [7]. However, LUTS do not necessarily indicate infection and may arise from a variety of non-infectious conditions, including overactive bladder, interstitial cystitis, pelvic floor dysfunction, urolithiasis, gynecological disorders, and psychosomatic causes [6].

Urine dipstick testing for leukocyte esterase and nitrite is widely used as a rapid screening method in outpatient practice and has a high negative predictive value for ruling out UTI when results are normal [8]. Despite this objective evidence, many patients continue to associate LUTS exclusively with infection and expect antibiotic treatment, often perceiving the absence of antibiotics as inadequate or incomplete care [9]. Such expectations and direct requests for antibiotics place considerable pressure on clinicians and contribute to unnecessary prescribing, thereby undermining antimicrobial stewardship initiatives [10].

Inappropriate antibiotic use is a major factor driving antimicrobial resistance, in addition to increasing the risk of adverse drug reactions and healthcare expenditure [11]. Gaining insight into patient perceptions regarding LUTS and antibiotic necessity—particularly in cases where UTI has been reasonably excluded—is therefore essential for developing effective counselling strategies and reducing inappropriate antibiotic use. In this context, the present study examines how misinterpretation of LUTS influences antibiotic expectations and evaluates the impact of repeated counselling on modifying patient beliefs and acceptance of further diagnostic evaluation.

Study Design and Setting This prospective observational study was conducted over a 12-month period in the General Medicine outpatient department of Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, Jammu and Kashmir, India. Study Population Adult female patients aged 18–65 years presenting with lower urinary tract symptoms were screened for eligibility. A total of 180 patients meeting the inclusion criteria were enrolled after obtaining written informed consent. Inclusion Criteria Participants were included if they met all the following criteria: 1. Presence of one or more lower urinary tract symptoms, including dysuria, urinary frequency, urgency, nocturia, or suprapubic discomfort 2. Completely normal urine dipstick findings 3. Absence of systemic features suggestive of infection, such as fever, chills, or flank pain Exclusion Criteria Patients were excluded if they had: 1. Pregnancy 2. Antibiotic use within the preceding 14 days 3. Known chronic kidney disease 4. Known structural abnormalities of the urinary tract 5. Known urolithiasis or active gynecological infections 6. Medical conditions or treatments that could influence urinary symptoms, including diabetes mellitus, diabetes insipidus, thyroid disorders, neurogenic bladder (associated with stroke, Parkinsonism, spinal cord injury, or transverse myelitis), cognitive impairment, prior bladder or urethral surgery, hormone replacement therapy, or current use of medications such as anticholinergics, β-blockers, calcium channel blockers, or cholinergic agents Clinical and Laboratory Assessment All enrolled patients underwent a detailed clinical evaluation followed by urine dipstick testing. Dipstick analysis included assessment of leukocyte esterase, nitrite, blood, glucose, protein, ketones, bilirubin, urobilinogen, pH, and specific gravity. Only patients with completely normal dipstick results across all parameters were included in the study. Physician Consultation Following clinical and laboratory assessment, the treating physician: 1. Explained the low likelihood of urinary tract infection based on clinical presentation and normal dipstick findings. 2. Advised against antibiotic therapy. 3. Recommended further evaluation to determine the etiology of LUTS, which included ultrasonography of the kidney–ureter–bladder region with post-void residual urine measurement, urine microscopy or culture when indicated, gynecological assessment, and referral to urology for further investigations such as uroflowmetry, micturating cystourethrogram, or urodynamic studies, as clinically appropriate. Counselling and Perception Assessment After physician consultation, patients were referred sequentially to two independent counsellors. Patient perceptions were assessed using standardized questions: 1. “Are you convinced that you do not have a urinary tract infection?” 2. “Do you believe that antibiotics should have been prescribed?” 3. “Are you willing to undergo further evaluation to determine the cause of your symptoms?” The first and second counsellor documented baseline patient perceptions and providing additional counselling. This structured counselling emphasized: 1. The potential harms of unnecessary antibiotic use. 2. The concept and consequences of antimicrobial resistance. 3. The multifactorial, non-infectious causes of lower urinary tract symptoms. 4. The importance of etiological evaluation for appropriate management of LUTS. Counsellors were not involved in clinical decision-making. Statistical Analysis Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS, version 22.0; IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequencies and percentages. Changes in patient perceptions across counselling stages were analysed using the McNemar test. A two-tailed p-value < 0.05 was considered statistically significant.

A total of 180 female patients aged 18–65 years were included in the study. The mean age of the participants was 58.6 years, and the majority were postmenopausal (162 patients; 90%). All enrolled patients presented with one or more lower urinary tract symptoms and had completely normal urine dipstick findings, with no associated systemic symptoms. Baseline demographic and clinical characteristics are summarized in table 1.

Urinary frequency was the most reported symptom, followed by urgency and nocturia. Dysuria was reported by approximately one-third of patients. More than half of the participants (56.1%) reported more than one lower urinary tract symptom at presentation. The distribution of individual LUTS is detailed in table 2.

Despite normal dipstick findings and physician reassurance regarding the low likelihood of urinary tract infection, a substantial proportion of patients continued to attribute their symptoms to UTI. Following physician consultation, 78.9% of patients believed that antibiotic therapy should have been prescribed, and 71.1% were reluctant to undergo further diagnostic evaluation to determine the etiology of LUTS. These baseline perceptions were documented by the first counsellor and are presented in table 3.

After structured educational counselling, a statistically significant reduction in antibiotic expectation and an improvement in acceptance of further investigations were observed. The proportion of patients who believed antibiotics were necessary decreased to 46.7%, while reluctance to pursue further evaluation declined to 34.4% (p < 0.001). However, a notable proportion of patients continued to associate LUTS exclusively with UTI. Post-counselling perceptions documented by the second counsellor are shown in table 4.

Table 1: Baseline characteristics of study participants (N = 180)

Table 2: Distribution of lower urinary tract symptoms

Patient perceptions and counselling outcomes

Table 3: Patient perceptions after physician consultation (documented by first counsellor)

Table 4: Patient perceptions after structured counselling (documented by second counsellor)

Lower urinary tract symptoms in women have gained increasing clinical attention in recent years, largely due to the rising life expectancy of women and the substantial impact of these symptoms on quality of life. Although LUTS are common across all adult age groups, their prevalence and severity are notably higher in postmenopausal women. This pattern was also observed in the present study, where most women presenting with LUTS were postmenopausal. While estrogen deficiency has historically been considered the primary contributor to urinary symptoms in this population, contemporary research has demonstrated that LUTS frequently result from a combination of functional and structural abnormalities identifiable through imaging and urodynamic assessment [6].

In the current study, urinary frequency, urgency, and nocturia emerged as the most frequently reported symptoms, affecting 62.2%, 53.3%, and 41.1% of participants, respectively. These findings are consistent with previous reports. Espuña Pons and Puig Clota identified urinary frequency as the predominant symptom, followed by urgency and nocturia, while Malla et al. similarly reported frequency and nocturia as the most prevalent complaints among women with LUTS [12,13]. The concordance of symptom patterns across diverse populations underscores the nonspecific nature of LUTS and highlights the diagnostic challenges associated with symptom-based assessment alone.

A key finding of this study is the high prevalence of misinterpretation of LUTS as urinary tract infection, even when urine dipstick results were entirely normal. This observation aligns with earlier studies demonstrating that symptom-driven assumptions frequently lead to overdiagnosis of UTI and unnecessary antibiotic use [14]. Although normal dipstick findings significantly lower the probability of UTI, objective laboratory evidence alone proved insufficient to dispel deeply held patient beliefs regarding infection, as reflected by persistent expectations for antibiotic therapy [8].

Reluctance to undergo further diagnostic evaluation observed in this study further reflects a limited understanding of the multifactorial etiology of LUTS. Similar resistance to diagnostic uncertainty and alternative explanations for symptoms has been described in previous research, suggesting that patients often prefer a single, familiar diagnosis over broader etiological exploration [14]. Such perceptions may inadvertently hinder appropriate evaluation and delay targeted management of non-infectious causes of LUTS.

The continued demand for antibiotics despite counselling highlights broader deficiencies in public awareness regarding infections and antimicrobial resistance. This issue is particularly concerning in regions where antibiotics are easily accessible without prescription, facilitating self-medication and accelerating the development of resistance [15,16]. Although structured counselling in the present study resulted in a significant reduction in antibiotic expectations and improved acceptance of further investigations, a substantial proportion of patients remained unconvinced, emphasizing the limitations of isolated, short-term educational interventions.

Previous studies have demonstrated that educational initiatives directed at both healthcare providers and patients can reduce inappropriate antibiotic prescribing and dispensing in primary care settings [17]. The partial but meaningful improvement observed after repeated counselling in this study supports the value of patient education while simultaneously indicating the need for sustained, multifaceted strategies. Integrating structured counselling into routine outpatient care, along with broader community-based educational efforts, may be necessary to achieve durable changes in patient perceptions and antibiotic-seeking behavior.

Limitations

This study has certain limitations, including its single-center design, which may limit generalizability. Urine culture was not performed in all patients, and patient perceptions were assessed using non validated questions. Social desirability bias may have influenced responses following counselling. Long-term behavioral outcomes, such as future self-medication practices, were not evaluated.

Misinterpretation of LUTS as UTI despite normal urine dipstick findings is common and significantly contributes to inappropriate antibiotic expectations and resistance to further diagnostic evaluation. Physician reassurance alone is often insufficient. Repeated, structured counselling and patient-centered education are critical to rational management of LUTS and effective antimicrobial stewardship. Acknowledgements The authors acknowledge the dedication and professionalism of the junior residents of the Department of General Medicine, SKIMS, Soura, for their active participation in patient counselling and data collection. Conflicts of Interest There was no conflict of interest. Financial Support Nil

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