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ULY CLINIC

19 Septemba 2025, 04:44:36

Urinary hesitancy

Urinary hesitancy is defined as difficulty initiating the urine stream, often accompanied by a decrease in the force of the stream. It may develop gradually and commonly goes unnoticed until urine retention leads to bladder distention or discomfort. Hesitancy can affect individuals of all ages and sexes but is most prevalent in older men with prostatic enlargement. In women, it can occur with pregnancy, or with tumors of the uterus, ovary, or vagina.

Pathophysiology

Mechanical obstruction – e.g., benign prostatic hyperplasia, urethral stricture, tumors compressing the bladder outlet.
Neurologic dysfunction – e.g., spinal cord lesions affecting sacral nerve roots.
Inflammatory processes – e.g., urinary tract infections causing swelling and irritation.
Drug-induced – anticholinergics, tricyclic antidepressants, or post-anesthesia effects.

History and Physical Examination

History

Onset and duration of hesitancy; previous episodes.
Other urinary complaints: reduced stream, interruption, frequency, urgency, nocturia, incontinence.
Past medical history: Prostate disease, UTIs, urinary tract obstruction.
Drug history: Anticholinergics, recent anesthesia, cold remedies.

Physical Examination

Inspect urethral meatus: inflammation, discharge, swelling.
Examine anal sphincter and perineal sensation.
Obtain clean-catch urine for urinalysis and culture.
Male patients: palpate prostate for size, consistency, tenderness.
Female patients: perform gynecologic examination if indicated.

Medical causes

Cause	Key Features	Associated Findings	Clinical Notes
Benign prostatic hyperplasia (BPH)	Gradual onset urinary hesitancy, weak stream	Reduced force/caliber, perineal discomfort, incomplete voiding, overflow incontinence, nocturia, occasional hematuria	Depends on lobe involvement; obstruction severity correlates with symptom progression
Prostate cancer (advanced)	Urinary hesitancy	Frequency, dribbling, nocturia, dysuria, bladder distention, perineal pain, constipation	Digital rectal exam: hard, nodular prostate; obstruction due to mass effect
Spinal cord lesion	Hesitancy, tenesmus, dribbling	Urinary frequency, urgency, dysuria, nocturia	Sacral nerve root damage; loss of voluntary sphincter control → overflow incontinence
Urethral stricture	Hesitancy, weak stream	Tenesmus, frequency, urgency, nocturia, overflow incontinence	Often post-traumatic or post-infectious; pyuria if infection present; severe obstruction → urinomas
Urinary tract infection (UTI)	Hesitancy	Dysuria, frequency, urgency, hematuria, cloudy urine, suprapubic or flank pain, fever, chills, malaise	Male UTIs may have urethral discharge; children may present with failure to thrive or palpable bladder

Other causes

Drugs: Anticholinergics (tricyclic antidepressants, some cold remedies) may cause hesitancy.
Post-anesthesia effects: Temporary neurogenic bladder dysfunction.

Special considerations

Monitor voiding pattern; frequently palpate for bladder distention.
Apply local heat to perineum or lower abdomen to relax muscles and facilitate urination.
Prepare patient for diagnostic tests: cystometrography, cystourethrography.

Patient counseling

Teach clean, intermittent self-catheterization if needed.
Encourage increased fluid intake and frequent voiding.
Reinforce monitoring for symptoms of infection or bladder retention.

Pediatric pointers

Male infants: Posterior urethral strictures are the most common cause of urinary obstruction.
May present with weak urine stream, fever from UTI, failure to thrive, or palpable bladder.

References

Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008:444–447.
Colyar MR. Well-Child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis; 2003.
Schuiling KD. Women’s Gynecologic Health. Burlington, MA: Jones & Bartlett Learning; 2013.
Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.
Roehrborn CG. Male lower urinary tract symptoms and benign prostatic hyperplasia: Epidemiology and risk factors. Rev Urol. 2005;7(Suppl 9):S3–S14.
Abrams P, Andersson KE. Lower urinary tract function and dysfunction. Neurourol Urodyn. 2007;26:740–742.