Hesitancy is where the person feels that the bladder is full and wants to pass urine, but then has to wait a long time before the urine stream starts to flow.
- The underlying problem is inability of the bladder outlet (sphincter) to open quickly and easily, or inability of the bladder muscle (detrusor) to contract efficiently, or a combination of the two.
- In men over the age of 40-50 the most common cause is narrowing (obstruction) of the bladder outlet due to enlargement of the prostate. This may be due to prostate cancer or non-cancerous enlargement (benign prostatic hyperplasia – BPH).
- In younger men (around 30-40 years) the cause may be inflammation or infection of the prostate (prostatitis) or narrowing (stenosis) of the bladder neck.
- In young men under the age of 20-30, and also sometimes in women, the cause may be psychological, when they feel anxious or stressed and find it difficult to start urinating, especially in the presence of others. This is known as bashful bladder or anxious bladder.
- Conditions that affect the nerve supply of the bladder can cause hesitancy, e.g. spinal cord injury, Parkinson’s disease, stroke, and diabetes mellitus.
- Certain medicines can cause hesitancy, e.g. pseudo-ephedrine, which stimulates contraction of the smooth muscle in the sphincter, or antidepressants, which impair contraction of the detrusor.
You need not be too concerned about hesitancy:
- if it is your only urinary complaint,
- if it is clearly made worse by stress, anxiety or in unfamiliar surroundings,
- and if it has been present for a long time without becoming worse.
There is not much one can do, except trying to relax, or learning to live with the condition.
When to see a doctor
You should see a doctor:
- if the hesitancy is becoming worse or
- if you have other urinary symptoms such as
- having to pass urine very often during the day (frequency) or night (nocturia),
- feeling a very strong urge to pass urine immediately when the bladder is full (urgency),
- pushing or straining to start the urine flow,
- a weak stream (stranguria),
- stopping and starting of the urinary stream (intermittency),
- feeling that the bladder is not empty after urination,
- pain on passing urine (dysuria),
- involuntary leakage of urine (incontinence) or
- blood in the urine (hematuria).
In men with hesitancy plus some of these symptoms, there is a risk of developing retention (complete inability to pass urine) which usually requires the doctor to insert a tube (catheter) into the bladder.
What to expect at the doctor
The doctor will ask you questions about your bladder complaints, and may ask you to fill in a questionnaire on bladder symptoms. The doctor may perform a neurological examination to find out if there is any damage to the nerves supplying the bladder, examine your abdomen and genital organs and perform a rectal examination. You will also be asked to provide a urine sample, so do not empty your bladder before going to the doctor. Depending on the findings, you may be referred to a specialist in urinary tract diseases (an urologist) for further investigation.
Depending on what causes the symptom of urinary hesitancy, the treatment may vary from simple reassurance to stopping medication that affects the bladder, or giving medication that will relax the bladder outlet muscles or shrink the prostate size. Prostatitis can be treated with antibiotics or anti-inflammatory drugs. BPH can be treated with drugs or various forms of surgery. Cancer of the prostate can be treated with surgery, radiotherapy or hormone treatment. Neurological diseases are often more difficult to treat, but many forms of management are available.