Urinary hesitancy

Urinary hesitancy: Excerpt from Handbook of Signs & Symptoms (Third Edition)

Hesitancy — difficulty starting a urine stream generally followed by a decrease in the force of the stream — can result from a urinary tract infection, a partial lower urinary tract obstruction, a neuromuscular disorder, or use of certain drugs. Occurring at all ages and in both sexes, it’s most common in older men with prostatic enlargement. It also occurs in women with gravid uterus, tumors in the reproductive system, such as uterine fibroids, or ovarian, uterine, or vaginal cancer. Hesitancy usually arises gradually, commonly going unnoticed until urine retention causes bladder distention and discomfort.

History and physical examination

Ask the patient when he first noticed hesitancy and if he’s ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he’s ever been treated for a prostate problem or urinary tract infection or obstruction. Obtain a drug history.

Inspect the patient’s urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch sample for urinalysis and culture. In a male patient, the prostate gland requires palpation. A female patient requires a gynecologic examination.

Medical causes

Benign prostatic hyperplasia (BPH)

Signs and symptoms of BPH depend on the extent of prostatic enlargement and the lobes affected. Characteristic early findings include urinary hesitancy, reduced caliber and force of urine stream, perineal pain, a feeling of incomplete voiding, inability to stop the urine stream and, occasionally, urine retention. As obstruction increases, urination becomes more frequent, with nocturia, urinary overflow, incontinence, bladder distention, and possibly hematuria.

Prostatic cancer

In patients with advanced cancer, urinary hesitancy may occur, accompanied by frequency, dribbling, nocturia, dysuria, bladder distention, perineal pain, and constipation. Digital rectal examination commonly reveals a hard, nodular prostate.

Spinal cord lesion

A lesion below the micturition center that has destroyed the sacral nerve roots causes urinary hesitancy, tenesmus, and constant dribbling from retention and overflow incontinence. Associated findings are urinary frequency and urgency, dysuria, and nocturia.

Urethral stricture

Partial obstruction of the lower urinary tract secondary to trauma or infection produces urinary hesitancy, tenesmus, and decreased force and caliber of the urine stream. Urinary frequency and urgency, nocturia, and eventually overflow incontinence may develop. Pyuria usually indicates accompanying infection. Increased obstruction may lead to urine extravasation and formation of urinomas.

Urinary tract infection

Urinary hesitancy may be associated with urinary tract infection. Characteristic urinary changes include frequency, possible hematuria, dysuria, nocturia, and cloudy urine. Associated findings include bladder spasms; costovertebral angle tenderness; suprapubic, low back, pelvic, or flank pain; urethral discharge in males; fever; chills; malaise; nausea; and vomiting.

Other causes

Drugs

Anticholinergics and drugs with anticholinergic properties (such as tricyclic antidepressants and some nasal decongestants and cold remedies) may cause urinary hesitancy. Hesitancy may also occur in those recovering from general anesthesia.

Special considerations

Monitor the patient’s voiding pattern, and frequently palpate for bladder distention. Apply local heat to the perineum or the abdomen to enhance muscle relaxation and aid urination. Also, teach how to perform a clean, intermittent self-catheterization. Prepare the patient for tests, such as cystometrography or cystourethrography.

Pediatric pointers

The most common cause of urinary obstruction in male infants is posterior strictures. Infants with this problem may have a less forceful urine stream and may also present with fever due to urinary tract infection, failure to thrive, or a palpable bladder.

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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