Urinating is a normal function of elimination that we do without even noticing unless there’s something wrong. We don’t realize how important it is until we have voiding problems or urinary tract symptoms.
In this article, we’re exploring the most common causes of difficulty urinating problems in males and females. How does it feel? How will the doctor make the diagnosis? Is there any treatment for it?
Urinary symptoms are different depending on various conditions affecting the urinary tract. We’re giving you 3 different scenarios and what would you feel in each one of them:
Patients with urinary retention have difficulty urinating. Their bladder does not empty adequately and remains half-full after voiding. There’s usually a sense of not completely emptying the bladder, but that’s not a rule of thumb. Urinary retention may or may not be readily noticeable. Some of these patients are asymptomatic or do not realize that they are not emptying the bladder properly.
- The sensation of incomplete emptying: The patient feels that the bladder is not completely emptied. This feels as if there’s still more to urinate, and they tend to push a bit to continue voiding.
- Difficulty to start urinating: Starting to urinate can be difficult, even when you feel a full bladder sensation. This is urinary hesitancy. You might need to push your abdominal muscles, and men may prefer to urinate after sitting in the toilet to facilitate the beginning of the flow.
- Recurrent infections in the urinary tract: Urinary retention acts as a breeding ground for multiple bacteria. In many patients, causes of urinary retention act as triggers for a urinary infection, especially in the case of kidney stones. In other instances, solving urinary retention with urinary catheter placement may also cause infections.
- Weak urinary stream: This is a significant symptom in patients with urinary retention. The urinary stream can be weak or slow. In any case, there’s a lower volume of urine, and the patient takes longer to empty the bladder.
- Intermittent urinary stream: Besides being slow or weak, the urinary stream is not continuous. Patients report an unsteady (on and off) urinary flow. They may also need to push to continue urinating or resume voiding several times.
- Nocturia: Patients wake up several times every night to urinate. It is also ubiquitous and sometimes one of the first problems that patients report.
In many cases, overflow incontinence is the last stage of a prolonged case of urinary retention. In this type of urinary incontinence, the bladder cannot hold more urine volume and triggers sphincters’ relaxation. This empties the bladder violently and unexpectedly. These are the most common symptoms (2):
- Sudden release of urine: It is the most important symptom of overflow incontinence. A significant volume of urine leaks and it may be difficult to hide it from view.
- Urine leakage while sleeping: These patients can also experience an episode of overflow incontinence in their beds.
- Symptoms of urinary retention: Overflow incontinence is often the end-stage of urinary retention. Thus, patients report symptoms described above, including a sensation of incomplete bladder emptying, slow urinary stream, and difficulty to start urinating.
Urinary tract infection (UTI) symptoms are more common among women. They have a shorter length of the urethra. Thus, microorganisms can easily migrate to the bladder.
Additionally, the proximity of the urinary opening to the anus and the vagina can increase infections. Men can also have urinary infections, especially after the elimination of kidney stones.
Symptoms of urinary infection are slightly different from those described above (3):
- Burning sensation while urinating: This is the most common type of painful urination, medically known as dysuria. It can also be caused by a kidney stone being eliminated through the urethra.
- Strong odor and cloudy appearance: The urine usually looks cloudy and has a very strong smell. In some cases, we can even see traces of pus or debris in the urine (more common in kidney infection).
- Urgency to urinate: Patients may report an increase in the urinary volume or frequent urination. They tend to hold back the urine to avoid experiencing a burning sensation while urinating. Thus, they usually have an urgency to urinate repeatedly throughout the day.
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Causes of difficulty urinating problems
Incomplete bladder voiding has different symptoms, as noted above. In most cases, it is only detected in severe cases. Sometimes patients need to reach the end stage to realize that something is going on.
Overflow incontinence is the end stage of bladder outlet obstruction, but it can also be triggered by nerve damage. Thus, as you can see, there is not a single line of cause and effect. Instead, we have different causes and risk factors coming into play to trigger a difficulty urinating.
We can summarize the most common causes of difficulty urinating in three main categories:
This is one of the most common causes of difficulty urinating, at least in men. It can be partial or complete. Indeed, complete urinary retention is a medical emergency. It sometimes requires draining the bladder and then taking care of the blockage. But most cases are partial and can be due to three main reasons (1):
This is neurogenic bladder. In this condition, the bladder does not contract as it should. Thus, it is not possible to completely empty its contents. It can be due to a muscular or, more commonly, a neuronal problem in the bladder. In any case, patients do not urinate fully and have different degrees of urinary retention.
In women, the vaginal tissue stays in place by ligaments. As they age, those ligaments lose their elasticity and become lax. They give away, and the vagina drops or becomes descended. This presses upon the urethra and leads to difficulty urinating. The blockage of the urine passage can be different depending on each patient.
As the name implies, it is a problem in the voiding function. It is usually caused by a bladder muscle that does not relax during voiding. Thus, it does not let the urine pass properly to be eliminated. These muscles are affected by neurological diseases such as herniated discs, a spinal cord injury, or an infectious neurological process. In some cases, a pelvic surgery may cause the same problem as an unwanted side effect.
This is not the same as vaginal prolapse, but they are sometimes simultaneously in the same patient. We also call this problem is also a fallen or descended bladder. What happens is that the vaginal wall weakens and does not hold up the weight of the bladder anymore. This occurs as the woman ages. The result is that the bladder descends and locates where the vagina is. Besides old age and tissue degeneration, other causes of the prolapsed bladder include childbirth, chronic constipation, heavy weight lifting, and low estrogen levels in women. In this case, obesity is a risk factor, so obese women are more likely to have this problem (4).
A urinary infection is another common cause of voiding problems. It is more common in women because they have a short urethra. However, men would also have a urinary infection, especially if they have kidney stones. Another cause of urinary infections is sexual intercourse, especially in individuals with multiple sexual partners (3).
Other urinary problems
There are multiple causes of urination problems, and some of them do not fall in any of the categories above. For example, we can see a patient who simply has kidney stones. They obstruct the urinary tract and cause urinary symptoms. We can also have a patient with benign prostatic hyperplasia (BPH), prostate cancer, and bladder cancer. The prostate gland surrounds the urethra and blocks the passage of urine in case of prostate enlargement. Thus, a doctor should evaluate each case, and the causes can be severe and difficult to solve or relatively mild and easy to treat. There are multiple other causes or urinary issues, and some of them are congenital, like urethral stricture.
Evaluation & diagnosis
Diagnosing urinary problems should be done after considering signs and symptoms, evaluating the patient, and confirming with tests. It is essential to take a complete history of the disease.
For example, the main suspect in a sudden onset of dysuria is a urinary infection. If the patient is a female senior who feels a pressing sensation in the pelvis and has chronic urinary retention, it may be due to vaginal prolapse. On the contrary, if we’re talking about a senior male with higher urinary frequency and slow urinary stream, we may think of benign prostate hyperplasia.
Up to this point, we only have a clinical suspicion. It should be confirmed with a physical exam and a series of tests. In the physical exam, doctors may press in the abdomen to evaluate irritability. They may also perform a digital rectal exam to assess an enlarged prostate. Tests are also necessary, including a urinalysis, an ultrasound scan of the prostate or vagina, an MRI if a neurologic problem is suspected, or a cystourethrogram to evaluate the structural issues of the bladder (5).
As you can see above, there are different patients and different conditions. Each one of them has a distinct cause. Thus, you can’t solve all urinary problems with the same treatment.
Treatments should attack the underlying cause. In the case of a urinary infection, it will be the infectious agent. In the case of urinary retention, it can be a kidney stone, benign prostatic hyperplasia, or vaginal prolapse. Sometimes treatment includes surgical procedures. In other cases, it is oral treatment held for a limited time.
- Urinary infection: They are commonly solved using oral treatment with antibiotics. Sometimes that’s not enough, and it is essential to treat an underlying cause, such as kidney stones or a sexually transmitted disease (3).
- Prolapsed bladder or a prolapsed vagina: There are different degrees of severity. In some cases, prolapse responds to estrogen replacement therapy. In other cases, doctors can place a device that holds every organ in place to ensure their position (4).
- Acute urinary retention: In some cases, there is absolutely no urine output, and it can be very dangerous. If that’s the case, doctors may need to use catheterization or surgical draining of the urine (6).
- Dysfunctional voiding: When the problem is caused by muscles or nerves not working correctly (as in overactive bladder), some devices can be used for the treatment. For example, there’s an implant device that stimulates the sacral nerve and triggers bladder voiding. Electrical stimulation and biofeedback may also work in these cases. Pelvic floor muscle therapy with Kegels and other exercises may also help recover the bladder’s muscle function (7).
- BPH and prostate cancer: In the case of benign prostatic hyperplasia, the problem is usually solved with medications that relax the prostate muscles. By doing so, they relieve the blockage and favor the reestablishment of the urine flow. But sometimes BPH grows too much, and the prostate gland needs to be taken out. The same happens in prostate cancer, and surgical resection of the prostate can be followed by radiotherapy, chemotherapy, and other treatments (5).
Voiding problems are common urination problems that arise in different cases.
Depending on the patient, it can be a prostate health problem, a vaginal prolapse, kidney stones, a urinary infection, or a dysfunction of the muscle or nerves. That’s why a complete history should be taken and then confirmed with tests and a physical exam.
After making the diagnosis, the treatment will be directed towards the cause of the voiding problems. BPH patients may receive a medication to relax the prostate and let the urine pass. Vaginal prolapse patients may be treated with estrogen therapy to strengthen their ligaments. Patients with kidney stones and a urinary infection usually receive oral antibiotics treatment.
Throughout this process, it is very important to follow your doctor’s advice. Do not neglect your problem or get used to the changes. You may be missing the opportunity of improving your quality of life with easier measures before your voiding problems are more intense and difficult to solve.