Urinary Stream (Decreased)
A perceived or observed decrease in the strength or flow of one's urine stream is a common complaint. This is often of concern to the patient because of the concern about both a serious medical problem and the slowing of urination and associated dribbling or incomplete emptying that accompanies the decreased stream intensity. Benign prostatic hypertrophy is by far the most common etiology of this complaint, and it is often accompanied by nocturia, urgency, frequency, dribbling, and incomplete emptying.
Differential Diagnosis
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Benign prostatic hyperplasia
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–Most common cause of decreased urinary stream in men >40
Urethral stricture
–May be congenital or acquired
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Chronic urethritis
–May be secondary to stricture or chronic infection
Prostate cancer
–More frequent in men >40
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Neuropathic bladder
–Spinal cord trauma
–Herniated disc
–Multiple sclerosis
–Spina bifida
–CVA
–Parkinson's disease
–Nerve injury secondary to pelvic surgery
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(e.g., prostatectomy)
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Bladder neck contracture
–May be congenital or acquired
(e.g., post-prostatectomy)
Urethral or bladder foreign body
Bladder stones
Bladder neck cancer
Urethral cancer
Urethral polyp
Posterior urethral valves
–Frequently presents with recurrent UTIs
Workup and Diagnosis
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History and physical examination, including abdomen, back, genitalia (palpate penis for areas of tenderness or induration), digital rectal examination, neurologic exam
–Note previous urinary tract instrumentation and STDs
–Exploration of urethra with catheter to check for obstruction and postvoid residual (normal <100 mL)
Initial labs include urinalysis (pyuria indicates secondary infection), urine culture and sensitivity, CBC (may reveal leukocytosis in infection, anemia in chronic disease), BUN/creatinine (elevated in acute renal failure, such as obstruction), and electrolytes
Consider PSA, which is elevated in prostate cancer and prostatitis; may be mildly elevated in BPH
Consider urine cytology and alkaline phosphatase (elevated in metastatic prostate cancer)
Uroflowmetry: Calculate urine flow rate during timed void (normal 20–25 mL/second; <10 indicates obstruction)
Consider renal ultrasound to rule out hydronephrosis and stones
Consider abdominal/pelvic CT scan to detect stones and workup cancer
Consider cystoscopy (to rule out cancer and anatomic problems), retrograde urethrography (to assess for strictures), voiding cystourethrogram (pressure/volume curves), transrectal ultrasound with needle biopsy (prostate CA), and/or intravenous pyelogram (stones and anatomic abnormalities)
Treatment
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Initial evaluation for urinary retention, which must be treated immediately with catheterization to prevent additional injury and relieve pain; thereafter, evaluation and treatment of infection and pain is indicated
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BPH: “Watchful waiting,” α-blockers, 5α-reductase inhibitors, TURP or other transurethral procedures, and/or open prostatectomy
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Urethral stricture: Dilation, lysis, open surgical repair
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Chronic urethritis/prostatitis: Long-term antibiotics
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Prostate cancer may require prostatectomy or no intervention, depending on stage of the cancer and patient issues (e.g., age, co-morbid conditions)
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Bladder cancer: Transurethral resection, intravesical chemotherapy; radical cystectomy for late disease, external radiation, and/or systemic chemotherapy
-
Neuropathic bladder: Parasympatholytic medications, intermittent or permanent catheterization, or surgical options (section of sacral nerve roots, ureteral diversion, and/or artificial sphincter)
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Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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- Oliguria
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- DYSURIA
- "Differential Diagnosis in Primary Care" (2007)
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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Urination pain
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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» Next page: Dysuria (In A Page: Pediatric Signs and Symptoms)
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