Difficulty urinating is one of the most common complaints in a urology practice: you wait for the stream to start, you strain, the stream is weak or stops and starts, and when you finish you still feel that your bladder is not empty. Many people accept it as a normal part of getting older and put up with it for years.
Behind these symptoms, however, there is a specific cause – most often an obstruction to the outflow of urine or a weakened bladder muscle – and it can almost always be treated. The extreme form is urinary retention: the bladder is full, but emptying it is impossible or very incomplete.
What difficulty urinating is
Normal urination requires the bladder muscle to contract strongly enough and the outlet – the bladder neck, the prostate in men and the urethra – to relax and be open. A problem at any point leads to a weak stream and residual urine (urine left in the bladder after urinating).
Retention comes in two forms. Acute retention comes on suddenly: the bladder becomes overfilled, there is severe pain low in the abdomen and you cannot urinate at all. Chronic retention develops gradually and is often painless – the bladder empties only partly, stretches and loses strength, and in advanced cases urine leaks out involuntarily (overflow), especially at night. When the pressure in the overfilled bladder is passed back up, the kidneys become swollen (hydronephrosis) and their function deteriorates.
Symptoms
- a delay before you start urinating, needing to wait or strain;
- a weak, thin or interrupted stream;
- dribbling after you finish and a feeling of incomplete emptying;
- frequent urination in small amounts and at night, because the bladder does not empty completely;
- repeated infections caused by urine that stays in the bladder.
Do not wait for a booked appointment – go to an emergency department or call 112 (the European emergency number) if you have not been able to urinate for several hours and your bladder is full and painful, if you have a high temperature and shivering, blood with clots, or if you also develop weakness or numbness in the legs and around the anus. In these cases the bladder must be emptied with a catheter within hours.
Causes and risk factors
In men over 50 the leading cause is an enlarged prostate, which presses on the urethra. Next come urethral stricture – a scar-tissue narrowing after inflammation, injury or a catheter – bladder neck sclerosis (scarring and narrowing of the bladder outlet), bladder stones, acute inflammation of the prostate and, less often, tumours.
A weakened bladder is the second group of causes: long-standing diabetes, spinal cord injuries, neurological diseases and the natural weakening that comes with age. Urination is also made worse by medicines – antihistamines, decongestant cold remedies, some antidepressants, antispasmodics and opioid painkillers. Acute retention is often triggered by alcohol, getting very cold, holding urine for a long time, constipation or general anaesthesia. In women the more common causes are pelvic organ prolapse, conditions after childbirth and surgery, and neurological diseases.
Diagnosis
At his private practice in Plovdiv and at Vita Med Medical Centre, Karlovo, Dr Penev carries out a consultation for urinary problems, which begins with a detailed history: when the symptoms started, what medicines you take, whether you have had operations or infections. A standardised questionnaire assesses how severe the symptoms are, and in men the physical examination includes a rectal examination of the prostate.
An ultrasound scan shows the kidneys, the bladder wall, the size of the prostate and, most importantly, the residual urine. Uroflowmetry measures the strength and shape of the stream and shows objectively how obstructed the outflow is. A urine test is done and, if needed, kidney function and PSA. If a narrowing of the urethra is suspected, a cystoscopy is performed, and in more complex cases a urodynamic study, which distinguishes a weak bladder from an obstruction at the outlet.
Treatment
For acute retention
The first step is to empty the bladder with a catheter through the urethra or, when that is not possible, through the abdominal wall. The catheter stays in for a few days, you start an alpha-blocker, which relaxes the prostate and the bladder neck, and then a trial without the catheter is done. If it succeeds, treatment continues with medication; if retention recurs, surgery is discussed. You will find practical advice for this period in the article on living with a urinary catheter.
For long-term symptoms
For milder symptoms it helps to spread your fluid intake through the day, drink less alcohol and caffeine, treat constipation and review the medicines you take. Medicines for an enlarged prostate relax the bladder outlet or, over time, reduce the size of the gland. When they are not enough or there are complications – repeated retention, stones, infections, worsening kidney function – endoscopic prostate operations are performed at the Department of Urology at Kaspela University Hospital (UMBAL Kaspela), Plovdiv, and urethral strictures are widened or cut open. For a weak bladder that does not recover, intermittent self-catheterisation may be the solution.
When to see a urologist
Book an appointment if your stream is getting weaker or stops and starts, if you have to strain to urinate, if your bladder still feels full when you finish, if you get up more than once at night or if infections keep coming back. An early diagnosis allows treatment with the gentlest methods, before the bladder has lost its strength.
Prevention
You can reduce the risk of retention: urinate when you feel the urge instead of holding on for a long time; avoid alcohol and cold remedies if you know you have an enlarged prostate; avoid getting very cold; treat constipation and keep your blood sugar under control. For men over 50, a yearly preventive check-up picks up the problem early.
Difficulty urinating is not an inevitable part of ageing but a symptom with a cause that in most cases can be treated successfully. If you recognise the symptoms described here, book an appointment with Dr Penev for a consultation and ultrasound in Plovdiv or Karlovo, plus uroflowmetry if needed.
Frequently asked questions
How long does the catheter stay in after acute urinary retention?
Usually from a few days to one or two weeks; meanwhile you start a medicine that relaxes the prostate and the bladder neck. The catheter is then removed and we check whether you can urinate normally again; if the retention comes back, surgical treatment is discussed.
Can difficulty urinating be caused by stress or anxiety?
Tension can make it harder to relax the pelvic floor and delay the start of urination, especially in public toilets. However, this is a diagnosis of exclusion – first we need to check that there is no obstruction to the outflow of urine or another condition.
Why is it harder to urinate after alcohol or when I have a cold?
Alcohol, cold and many cold remedies tighten the bladder neck and the prostate or weaken the bladder muscle. In men with an enlarged prostate, exactly these triggers often bring on acute retention, so it is best to take such products only after consulting a doctor.
Can women have urinary retention?
Yes, although much less often. In women the causes include pelvic organ prolapse, conditions after childbirth or gynaecological surgery, neurological diseases and side effects of medicines. An examination and an ultrasound scan measuring the residual urine clarify the cause.
What is double voiding and does it help?
It is a technique where, after you finish urinating, you wait about half a minute and try again to empty what is left. It helps when there is a moderate amount of residual urine and is recommended as an addition to the main treatment, not instead of it.
The information on this website is for general education and does not replace an examination and consultation with a doctor. If you have urgent symptoms, seek medical help immediately or call 112.