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Difficulty Urinating (Urinary Hesitancy/Retention): Causes, Evaluation & Management

Dysuria, hesitancy, weak stream, or incomplete emptying signal lower urinary tract dysfunction. Prompt assessment prevents complications (infection, renal damage).

Common Etiologies

Obstructive

  • Benign Prostatic Hyperplasia (BPH) – most common in men >50
  • Urethral stricture (trauma, infection, iatrogenic)
  • Bladder neck contracture (post-surgery)
  • Stones, tumors, fecal impaction

Neurogenic

  • Spinal cord injury, multiple sclerosis, diabetic neuropathy, Parkinson's
  • Cauda equina syndrome (surgical emergency)

Pharmacologic

  • Anticholinergics, antihistamines, sympathomimetics (decongestants), tricyclics, opioids, alpha-agonists

Infectious/Inflammatory

  • UTI, prostatitis, urethritis (STI)

Functional/Psychogenic

  • Detrusor underactivity, pelvic floor dyssynergia, anxiety-related retention

Evaluation Algorithm

  1. History: onset, duration, medications, neurologic symptoms, voiding diary
  2. Exam: DRE (prostate), neuro check, bladder scan (post-void residual)
  3. Labs: UA/UC, PSA (if indicated), creatinine, glucose
  4. Urodynamics if unclear

Management

Catheterization for acute retention. Then: alpha-blockers (tamsulosin) for BPH, antibiotics for infection, medication review, intermittent self-catheterization, or surgery (TURP, UroLift). Pelvic floor PT for dyssynergia.

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