What it is

This is the medical term used to describe patients who have problems emptying the bladder, that is, who have difficulty urinating.

Causes

Difficulty urinating is more common in men, although it can also occur in women. The main causes are: benign prostatic hyperplasia (enlarged or obstructive prostate), urethral stricture (narrowing of the urinary canal), bladder neck stricture (bladder that does not open properly), and detrusor hypocontractility (bladder that does not contract adequately). Inflammatory and infectious diseases can also lead to voiding difficulty.

Symptoms

Symptoms are characterized by a weak and intermittent urine stream, straining to initiate urination, hesitancy, and a sensation of incomplete bladder emptying. Some irritative symptoms such as urgency, painful urination, and increased urinary frequency may also occur. Waking up at night to urinate is one of the earliest and most common symptoms in patients with difficulty urinating.

Prevalence in Brazil

It is estimated that up to 75% of men and women over the age of 40 have some symptom related to the lower urinary tract, and notably, 25% of the Brazilian population has some degree of difficulty emptying the bladder. (ref: Soler A et al. Neurourol and Urodyn 2017 Nov 6. doi: 10.1002/nau.23446)

Diagnosis

Diagnosis is often clinical, based on a thorough conversation between the physician and the patient. Physical examination may identify signs of poor bladder emptying, such as a palpable bladder, abdominal tenderness, and an enlarged prostate on digital rectal exam. Additional tests help determine the cause of the difficulty urinating and guide treatment, which may be clinical or surgical. The main tests used in the evaluation of patients with voiding difficulty are:

free uroflowmetry: measures the “strength” of the urine stream
urodynamic study: distinguishes whether the difficulty urinating is due to a bladder contraction problem or an obstructive factor, such as prostatic hyperplasia or urethral stricture
ultrasound of the urinary tract and prostate: important for evaluating all organs involved in urine production and storage and for measuring post-void residual volume
retrograde and voiding urethrocystography: identifies urethral and bladder neck strictures
urinalysis and urine culture: identifies infectious conditions

Treatment

Treatment varies according to the etiology (cause) of the difficulty urinating. Men with an enlarged or obstructive prostate (prostatic hyperplasia) may be treated with medications that relax the prostate (alpha-blockers) or reduce its size (finasteride).

If medication fails or is not tolerated, surgical treatment is indicated, typically transurethral resection of the prostate (a minimally invasive surgery performed via endoscopy of the urinary tract).

Patients with urethral narrowing should be treated surgically through internal urethrotomy (endoscopic opening of the canal) or urethroplasty (open surgery to widen the narrowed area). Patients with bladders that do not open properly may be treated with medications to facilitate urine emptying (alpha-blockers), while those with bladders that do not contract adequately may try medication (beta-agonists), but often require catheters to help drain urine from the bladder.

By Einstein Editorial Board