Symptom Finder - Difficulty Urinating
DIFFICULTY URINATING
This condition is characterized by a weak or interrupted urinary stream. Initiation of urination is difficult or slow, and the finish is just the same. Difficulty urinating must be distinguished from dysuria, which is painful urination, and anuria or oliguria which is absent or reduced volume of urine. The pathophysiologic cause of difficulty urinating is obstruction. If we then visualize the urinary tree from the prepuce on up to the bladder, we can visualize the causes of obstruction at each level. These are illustrated in the figure given for dysuria.
Prepuce—Phimosis and paraphimosis
Meatus—Meatal stricture
Urethral—Urethral stricture, urethral calculus
Prostate—Prostatitis, prostatic hypertrophy, prostatic carcinoma, prostatic calculus
Bladder—Bladder neck obstruction due to stricture, median bar hypertrophy, calculus or neoplasm
Extrinsic lesions of the bladder or urethra—Uterine fibroids, pregnant retroverted uterus, or carcinoma of the vagina Lesions of the innervation of the bladder wall—This may be due to lower motor neuron disorders such as poliomyelitis, cauda equine tumors, or disks; tabes dorsalis; or diabetic neuropathy. It may also be due to upper motor neuron lesions such as MS, transverse myelitis, or spinal cord tumor.
Approach to the Diagnosis
The first thing to do is to establish that there is an obstruction to the flow of urine. This may now be done with ultrasonography, but catheterization may still be done in the acute situation. The history will be helpful in many cases. Difficulty voiding in a young person will most likely point to a urethral stricture or prostatitis from previous gonorrhea or urethral injury, whereas difficulty voiding in an older man would suggest prostatic hypertrophy. A history of hematuria would suggest the possibility of a vesicle or urethral calculus. Ask if the patient is on any drugs or has a history of diabetes. A complete physical including a rectal and pelvic examination (in women) is done next. An abnormal neurologic examination might point to diabetic neuropathy, MS, or spinal cord tumor.
The laboratory workup should include the CBC, urinalysis, chemistry panel, VDRL, and a urine culture and sensitivity. If these tests are negative, an urologist needs to be consulted for cystoscopy and cystometric testing.
Other Useful Tests
1. Anaerobic cultures
2. Prostate-specific antigen (PSA) titer
3. Intravenous pyelogram (IVP) and voiding cystogram
4. Gynecology consult
5. Neurology consult
6. Electromyography (EMG) and nerve conduction velocity testing
7. Plain films of the thoracolumbar spine
8. MRI of the thoracic or lumbar spine
9. Laparoscopy
10. CT scan of the abdomen and pelvis
11. Therapeutic trial of tamsulosin (benign prostatic hyperplasia
[BPH])
12. Voiding cystourethrography (recurrent UTIs in children
This condition is characterized by a weak or interrupted urinary stream. Initiation of urination is difficult or slow, and the finish is just the same. Difficulty urinating must be distinguished from dysuria, which is painful urination, and anuria or oliguria which is absent or reduced volume of urine. The pathophysiologic cause of difficulty urinating is obstruction. If we then visualize the urinary tree from the prepuce on up to the bladder, we can visualize the causes of obstruction at each level. These are illustrated in the figure given for dysuria.
Prepuce—Phimosis and paraphimosis
Meatus—Meatal stricture
Urethral—Urethral stricture, urethral calculus
Prostate—Prostatitis, prostatic hypertrophy, prostatic carcinoma, prostatic calculus
Bladder—Bladder neck obstruction due to stricture, median bar hypertrophy, calculus or neoplasm
Extrinsic lesions of the bladder or urethra—Uterine fibroids, pregnant retroverted uterus, or carcinoma of the vagina Lesions of the innervation of the bladder wall—This may be due to lower motor neuron disorders such as poliomyelitis, cauda equine tumors, or disks; tabes dorsalis; or diabetic neuropathy. It may also be due to upper motor neuron lesions such as MS, transverse myelitis, or spinal cord tumor.
Approach to the Diagnosis
The first thing to do is to establish that there is an obstruction to the flow of urine. This may now be done with ultrasonography, but catheterization may still be done in the acute situation. The history will be helpful in many cases. Difficulty voiding in a young person will most likely point to a urethral stricture or prostatitis from previous gonorrhea or urethral injury, whereas difficulty voiding in an older man would suggest prostatic hypertrophy. A history of hematuria would suggest the possibility of a vesicle or urethral calculus. Ask if the patient is on any drugs or has a history of diabetes. A complete physical including a rectal and pelvic examination (in women) is done next. An abnormal neurologic examination might point to diabetic neuropathy, MS, or spinal cord tumor.
The laboratory workup should include the CBC, urinalysis, chemistry panel, VDRL, and a urine culture and sensitivity. If these tests are negative, an urologist needs to be consulted for cystoscopy and cystometric testing.
Other Useful Tests
1. Anaerobic cultures
2. Prostate-specific antigen (PSA) titer
3. Intravenous pyelogram (IVP) and voiding cystogram
4. Gynecology consult
5. Neurology consult
6. Electromyography (EMG) and nerve conduction velocity testing
7. Plain films of the thoracolumbar spine
8. MRI of the thoracic or lumbar spine
9. Laparoscopy
10. CT scan of the abdomen and pelvis
11. Therapeutic trial of tamsulosin (benign prostatic hyperplasia
[BPH])
12. Voiding cystourethrography (recurrent UTIs in children
