A pediatrician asked his colleague for help with considering a differential diagnosis for a college age male who presented with true urinary hesitancy for ~2 weeks. “It’s just not that common a problem in pediatrics,” the pediatrician noted. “The patient has never had any urinary or bowel problems previously, denies dysuria or other pain, or fever. He says he has a normal stream, volume and urinates 6-8 times/day. He denies getting up at night to void. He also denies any bowel problems nor any neurological issues like issues with sensation or problems walking. He also denies any sexual activity for several months,” the pediatrician related to his colleague. “He just says that he wants to void and can’t seem to start his stream in a reasonable amount of time,” the pediatrician said. The second pediatrician agreed that it was not a common problem and asked some more questions about the potential for an occult malignancy or soft neurological signs for a neurological problem which the attending pediatrician said that the patient denied. “I guess I would do a urinalysis and screen him for sexually transmitted infections today and then consult urology. They obviously see this problem more than us and maybe the young man needs to have urodynamics testing or even have a cystoscopy performed,” the colleague stated. “In the meantime you can also have him keep a symptom diary so that you or the urologist can have a better idea of his bowel and bladder patterns,” the colleague also offered.
“Hesitancy” denotes difficulty in initiating voiding when the child is ready to void,” according to the International Children’s Continence Society. It is not seen that often in pediatrics in isolation, but is commonly associated with other symptoms such as dysuria, frequency, abdominal or anal pain which may indicate common problems such as a urinary tract infection, vaginal/perineal irritation, or constipation. Communication problems can also confound the accuracy of the history as patients and families can have a difficult time describing the urinary problem they are experiencing or may be embarrassed to fully communicate their concerns. Symptom diaries are often helpful to more accurately discern the frequency, and pattern of the problem, along with other concurrent symptoms. Some patients are more comfortable writing about the problem than expressing it verbally and diaries can sometimes assist. Testing for common problems usually begins the evaluation, but consultation with an urologist or another specialist may be necessary.
One of the classic causes of urinary hesitancy is benign prostatic hypertrophy but this is not a common cause in the pediatric and young adult age group. Another cause is medications, but as this age group generally takes fewer medications, drugs are also a less common cause but should be considered in the differential diagnosis.
The differential diagnosis of urinary hesitancy in children and teenagers includes:
- Foreign body
- Bowel bladder dysfunction
- Abdominal/pelvic malignancy
- Bladder neck obstruction
- Dysfunctional voiding
- Detrusor urethral sphincter dyssynergy
- CNS space occupying lesions – abscess, malignancy
- Drugs – antidepressants and others which may cause urinary retention
- Sexually transmitted infections
- Behavioral including abuse
- Situational – public restrooms
Questions for Further Discussion
1. What are indications for referral to an urologist?
2. What is the difference between dysfunctional voiding and detrusor urethral sphincter dyssynergy?
- Symptom/Presentation: Urine
- Age: Young Adult
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Paner GP, Zehnder P, Amin AM, Husain AN, Desai MM. Urothelial neoplasms of the urinary bladder occurring in young adult and pediatric patients: a comprehensive review of literature with implications for patient management. Adv Anat Pathol. 2011 Jan;18(1):79-89.
Glassberg KI, Combs AJ, Horowitz M. Nonneurogenic voiding disorders in children and adolescents: clinical and videourodynamic findings in 4 specific conditions. J Urol. 2010 Nov;184(5):2123-7.
Austin PF, Bauer SB, Bower W, et.al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society. Neurourol Urodyn. 2016 Apr;35(4):471-81.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa