Discussion
Viral infections of the lower urinary tract are specially detected in immuno-compromised patients and are the major cause of hemorrhagic cystitis in the solid organ and stem cell transplant recipients (9-1,2,3). To define viral cystitis, the viral pathogen should be evaluated from a urine sample and the patient must have hematuria, abdominal pain, urgency, frequency, pyuria and/or hematospermia (9). To date, COVID-19 was only be isolated from urine samples by Sun et al (8). Then Lie et al found that while urine occult blood, proteinuria, and the urine potential of hydrogen were higher in COVID-19 patients than in healthy controls, the urine specific gravity value was lower in patients than in healthy controls (1). In addition, they reported that the positive rates of glucosuria and proteinuria in the severe and critical groups were higher than those in the moderate group, as a result, they also suggested that urine findings could be useful for the evaluation of the illness (1).
Mumm et al suspected that if the patients had any urinary symptoms after they had treated a patient with COVID-19 presented as urosepsis (5). Then they evaluated 57 COVID-19 patients retrospectively and found that seven male patients had a urinary frequency (5). After this study’s findings, Luciani et al reported three cases of COVID-19 who had gross hematuria (6). They recommended that clinicians should be aware that COVID-19 patients, especially those who had a history of urinary tract disease, could apply to the hospital with urinary tract symptoms (6).
In this study we evaluated COVID-19 patients for LUTS with validated instruments retrospectively for the first time. We excluded all medical and surgical conditions that might affect urinary tract symptoms and cause LUTS from the study. We found that the male patients did not have significant voiding symptoms during the illness or after the treatment, and these symptoms did not affect their quality of life. However, the storage symptoms were seen before the early time of illness and during COVID 19. With the discharge from hospital, these symptoms had disappeared. It could be explained that the storage symptoms might have occurred after the patient had been infected by the virus, so the storage symptoms may be one of the first symptoms of COVID-19 along with a fever or cough. In the female patients it could be said that the obstructive symptoms were similar before, during and after the illness. As with the male patients, the female patients had overactive bladder symptoms at the start of the illness and during hospitalized time, however these symptoms were cured at the time of resting at the home. When the medical reports of the patients were examined, any intravenous fluid supply or oral hydration therapy which could cause the urinary frequency, were not given as an medical order to any patients. The other possible reason of storage symptoms were the psychogenic LUTS or overactive bladder described by Sakakibara et al (13). It was found that the patients under the depressive condition could complain about the voiding symptoms, so infected with COVID-19, hospitalized and the fear of death could cause depressive moods to all patients. Also, we found that stress incontinence was higher during the active infection period rather than before and after the illness for the first time in the literature. This result could be explained that the cough is one of the main symptoms of COVID-19, so the increased cough could be expected to cause this incontinence. With the recovery from COVID-19, the cough would be less and so the stress incontinence would be detected less as a result.
The retrospective design with a small number of participants and the time of questionnaire completion are the major limitations of the study. Another limitation was that there were no urine biochemical results, voiding diary datas or uroflowmetry of the patients because the clinicians were not aware of the importance of urine results in the early days of the pandemic. The last limitation was there was no control group to compare the incidence of the symptoms.
In conclusion, we have tried to show the urinary symptoms of COVID-19 patients with validated tools for the first time in the literature. According to our results, LUTS, especially storage symptoms, might be one of the early symptoms of COVID-19 and the clinicians should evaluate LUTS with other known symptoms of the virus when a patient is suspected of having COVID-19.