Urinary Symptoms: What They Mean and When to Worry

Types of urinary symptoms

Urinary hesitancy

Urinary hesitancy means a delay or difficulty in starting the stream, even when the bladder feels full. Causes include:

• Benign prostatic hyperplasia (BPH): the most common cause in men over 50. The enlarged prostate narrows the urethra.
• Prostatitis: with pain in the perineum and sometimes fever.
• Urethral stricture: scarring from infection, injury or catheters, causing a thin, spraying stream.
• Medicines: antihistamines, decongestants, anticholinergics, tricyclic antidepressants and opioids.
• Nerve problems: diabetes, multiple sclerosis, spinal problems, after surgery.
• Pelvic organ prolapse in women.
• Anxiety ("shy bladder") in public toilets.
• Constipation, pressing on the bladder outlet.

Hesitancy that progresses to inability to urinate is urinary retention, which needs urgent care.

Common causes of urinary symptoms

Urinary tract infection

A UTI causes burning, frequency, urgency, cloudy or smelly urine and lower belly pain. It is very common in women. Fever, back pain and vomiting suggest the infection has spread to the kidney (kidney infection).

Enlarged prostate

BPH causes a weak stream, hesitancy, dribbling, nocturia and urgency in older men. It is not cancer, and symptoms do not reliably predict cancer, but a doctor will usually check.

Overactive bladder

Overactive bladder causes sudden, strong urges, frequency and nocturia, with or without leaking, without infection.

Sexually transmitted infections

Chlamydia, gonorrhea and trichomoniasis cause urethritis, with burning and discharge.

Other causes

• diabetes (frequent urination with thirst)
• kidney stones (pain, blood in urine, urgency when the stone nears the bladder)
• interstitial cystitis (bladder pain and frequency without infection)
• vaginal atrophy after menopause (burning, frequency, recurrent UTIs)
• pregnancy
• bladder cancer (painless blood in the urine, especially in smokers)
• excess fluid, caffeine or alcohol

Symptoms in women and men

Women most often have UTIs, overactive bladder and stress incontinence linked to childbirth and menopause. Men under 50 more often have STIs or prostatitis, while men over 50 most often have prostate enlargement. Children with urinary symptoms should always be checked for UTI.

How doctors find the cause

1. History: which symptoms, how long, fluid intake, medicines, sexual history, and a bladder diary over 3 days.
2. Examination: abdomen, and a prostate exam in men or pelvic exam in women.
3. Urine dipstick and culture: infection, blood, sugar.
4. Bladder scan: measures urine left after voiding.
5. Blood tests: kidney function, glucose, and PSA in some men after discussion.
6. Specialist tests: urine flow rate, urodynamics, ultrasound, cystoscopy for blood in the urine.

Treatment and self-help

Treatment depends on the cause: antibiotics for UTIs and STIs, alpha-blockers or 5-alpha-reductase inhibitors for BPH, bladder training and medicines for overactive bladder, and pelvic floor exercises for leakage.

Helpful self-care:

• drink enough fluid, spread through the day, and cut back in the 2 hours before bed
• reduce caffeine, alcohol and fizzy drinks
• avoid constipation
• try double voiding: wait a minute after urinating and try again
• do pelvic floor exercises
• review medicines that worsen urinary symptoms with your doctor

Frequently asked questions

What causes urinary hesitancy?

In men over 50, the most common cause is an enlarged prostate. Other causes include prostatitis, urethral stricture, medicines such as antihistamines and decongestants, nerve problems from diabetes or spinal disease, constipation and anxiety. Hesitancy that is getting worse should be checked.

What are lower urinary tract symptoms?

Lower urinary tract symptoms (LUTS) is the medical term for urinary problems involving the bladder, prostate and urethra. They include storage symptoms (frequency, urgency, nocturia), voiding symptoms (weak stream, hesitancy, straining) and post-voiding symptoms (dribbling, incomplete emptying).

When are urinary symptoms an emergency?

Seek emergency care if you cannot pass urine and your lower belly is painful and swollen, if you have fever with back pain and vomiting, if you pass blood clots, or if urinary problems come with new leg weakness or numbness around the genitals.

Is frequent urination always a sign of infection?

No. Frequent urination can come from drinking more fluid, caffeine or alcohol, diuretics, overactive bladder, an enlarged prostate, diabetes, pregnancy or anxiety. Infection is likely when frequency comes with burning, urgency and cloudy or smelly urine.

Can urinary symptoms be a sign of cancer?

Sometimes. Painless blood in the urine can be a sign of bladder or kidney cancer, especially in smokers and people over 50. Prostate cancer usually causes no urinary symptoms in its early stages, but men with symptoms should discuss testing with their doctor.