What is the initial workup for a patient presenting with urinary hesitancy?

From the Guidelines

The initial workup for a patient presenting with urinary hesitancy should begin with a thorough history and physical examination, focusing on urinary symptoms, medication use, and neurological status, as recommended by the most recent guidelines 1. The key components of this initial evaluation include:

• A detailed urinary symptom assessment (frequency, urgency, nocturia, stream quality, and post-void dribbling)
• Medical history review for conditions like diabetes or neurological disorders
• Medication review for anticholinergics or alpha-agonists that may affect urination
• Physical examination, including abdominal, genital, rectal, and prostate examinations, with particular attention to prostate size and consistency in men Laboratory tests should include:
• Urinalysis to rule out infection
• Blood tests for renal function (BUN, creatinine)
• PSA testing in appropriate male patients
• Post-void residual volume measurement using bladder ultrasound or catheterization to assess bladder emptying efficiency, with volumes over 100mL suggesting significant retention Additional studies may include uroflowmetry to measure urine flow rate and pattern, with normal peak flow rates being 15-20 mL/second in men and 20-25 mL/second in women, as supported by recent guidelines 1. This systematic approach helps identify the underlying cause of urinary hesitancy, whether it's benign prostatic hyperplasia, urethral stricture, neurogenic bladder, medication effect, or other conditions, allowing for appropriate treatment planning, in line with the recommendations from the American Urological Association 1. It's also important to consider the patient's risk factors for malignancy, such as gross hematuria, male gender, age >35 years, smoking, and occupational exposure to chemicals, as highlighted in recent studies 1.

From the Research

Initial Workup for Urinary Hesitancy

The initial workup for a patient presenting with urinary hesitancy involves a thorough evaluation to determine the underlying cause. Key components of this workup include:

• A detailed history to identify potential causes, such as obstructive, infectious, inflammatory, pharmacologic, or neurologic factors 2
• A focused physical examination with neurologic evaluation to assess for any abnormalities 2
• Measurement of postvoid residual (PVR) volume of urine to assess for urinary retention 2
• Diagnostic testing, such as urinalysis and imaging studies, to rule out underlying conditions such as benign prostatic hyperplasia (BPH), prostatitis, or neurogenic bladder 3, 4, 5, 6

Common Causes of Urinary Hesitancy

Common causes of urinary hesitancy include:

• Benign prostatic hyperplasia (BPH), which is the most common cause of urinary retention in men 3, 4, 5, 6
• Prostatitis, cystitis, urethritis, and vulvovaginitis, which can cause infectious and inflammatory symptoms 3
• Neurologic causes, such as cortical, spinal, or peripheral nerve lesions, which can affect bladder function 3, 2
• Pharmacologic causes, such as medications with anticholinergic or alpha-adrenergic agonist properties, which can affect bladder function 3, 2

Diagnostic Criteria

Diagnostic criteria for urinary retention include:

• Acute urinary retention, which is defined as the inability to voluntarily pass an adequate amount of urine 2
• Chronic urinary retention, which is defined as a postvoid residual (PVR) volume greater than 300 mL measured on two separate occasions and persisting for at least six months 2