Differential Diagnosis

• Single most likely diagnosis
  • Post-traumatic urinary retention or psychogenic urinary retention: The patient's history of being unable to urinate in front of people while in jail, followed by persistent urinary difficulties, suggests a psychological component to his condition. The need to stroke his penis to help initiate urination further supports this, as it may be a coping mechanism or a sign of a psychological barrier to normal urination.
• Other Likely diagnoses
  • Urinary hesitancy or obstructive uropathy: The patient's report of a weak stream and difficulty initiating urination could be indicative of an obstructive process, such as benign prostatic hyperplasia (less common in a 20-year-old but possible), urethral stricture, or bladder neck contracture, especially given his history of urinary retention.
  • Overactive bladder or detrusor overactivity: Although the patient denies pain or fevers, his symptoms of weak stream and needing to stroke his penis to urinate could also be related to an overactive bladder, where the bladder muscle contracts too often or at inappropriate times, leading to urinary urgency and frequency, and potentially weak stream due to incomplete bladder emptying.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Neurogenic bladder: This condition, resulting from a neurological condition affecting bladder control, could present with urinary retention or obstructive symptoms. Although less likely given the patient's age and lack of other neurological symptoms, it's crucial to consider due to its potential impact on quality of life and the possibility of underlying neurological disease.
  • Urethral stricture or bladder cancer: Both conditions could present with obstructive urinary symptoms. While bladder cancer is rare in young adults, and urethral stricture might be less common without a history of trauma or infection, these conditions are critical to rule out due to their significant health implications.
• Rare diagnoses
  • Fowler's syndrome: A rare condition characterized by urinary retention in young women, but it has been reported in men as well. It's associated with polycystic ovary syndrome (PCOS) in women but can occur without any underlying condition in men, making it a rare consideration in this case.
  • Multiple system atrophy: A rare neurodegenerative disorder that can affect bladder control, among other systems. It typically presents in older adults, making it an unlikely diagnosis in a 20-year-old but should be considered in the differential for completeness, especially if other neurological symptoms are present or develop.