Difficulty starting or maintaining a urinary stream is called urinary hesitancy.

This problem affects people of all ages and occurs in both sexes, but it is most common in older men with enlarged prostate glands.

Urinary hesitancy usually comes on gradually. It sometimes goes unnoticed until urinary retention (complete inability to urinate) produces distention and discomfort in the bladder.

Almost all older men have some degree of difficulty in starting urination, dribbling, or decreased force of the urinary stream.

Urinary hesitancy can be caused by:

• Benign prostatic hyperplasia (enlarged prostate)
• Urinary tract infection, especially if chronic and recurrent
• Prostatitis (inflammation or infection of the prostate gland)
• Drugs (some cold remedies, some nasal decongestants, tricyclic antidepressants, and anticholinergics which may be used for incontinence)
• Shy or bashful bladder syndrome (unable to urinate when another person is in the room)
• Neurologic disorders

• Monitor, record, and report your urination patterns to your doctor.
• Apply heat to your lower abdomen (below your belly button and above the pubic bone). This is where the bladder lies. The heat relaxes muscles and aids urination.
• Massage or place light pressure over your bladder to stimulate emptying.
• Drink plenty of fluid, especially fruit juices like cranberry.
• For infections, antibiotics from your doctor will be needed. Symptoms that suggest a possible infection include burning or pain with urination, frequent urination, cloudy urine, and a sense of urgency (strong, sudden urge to urinate.)

If you have not been evaluated for this problem previously, you should call your doctor for urinary hesitancy, dribbling, or weak urine stream.

Call your doctor right away if you have fever, vomiting, side or back pain, shaking chills, or passing little urine for 1-2 days.

Call if you have blood in your urine, cloudy urine, frequent or urgent need to urinate, or a discharge from the penis or vagina.

Your doctor will take your medical history and perform a physical examination, paying special attention to your pelvis, rectum, abdomen, and lower back.

Medical history questions may include:

• How long have you had difficulty starting urine flow?
• Did it come on gradually or suddenly?
• Is it worse in the morning or at night?
• Is the force of your urine flow decreased?
• Do you have dribbling?
• Do you ever leak urine uncontrollably?
• Does anything help? Like heat or massage to the lower abdomen?
• Does anything make the hesitancy worse?
• Do you have other symptoms like fever, pain or burning when you urinate, cloudy or bloody urine, back or side pain?
• Do you have a history of bladder or kidney infection? Prostate enlargement or infection? Neurologic disorders?
• Have you had a recent injury, surgery, or diagnostic procedures on the pelvis or bladder?
• What medications do you take, including over the counter drugs?

Diagnostic tests that may be performed include:

• Urinalysis and culture
• Urethral swab for culture
• Transrectal ultrasound of the prostate (similar to a transvaginal ultrasound)
• Catheterization of the bladder to determine residual urine volume and to obtain urine for culture (a catheterized urine specimen)
• Cystometrography
• Voiding cystourethrogram

Treatment of urinary hesitancy varies depending on the underlying cause. If a bacterial infection is present, antibiotics may be prescribed. A surgical procedure may be required to relieve prostate obstruction (see TURP).

Bass PF. Urinary tract infections. Prim Care. 2003; 30(1): 41-61, v-vi.

Hua VN. Acute and chronic prostatitis. Med Clin North Am. 2004; 88(2): 483-494.