Urinary hesitancy in men: difficulty starting to pee, causes and treatment

Hesitancy is the medical word for a delay or difficulty in starting to pass urine. Men often describe standing at the toilet and waiting, or having to push or strain before the flow begins. The NHS places it among the common changes to the way you pee that are seen with prostate problems, alongside a weak flow, stopping and starting, taking longer than usual to empty the bladder, a feeling of not fully emptying, dribbling after finishing and needing to pee more often or urgently, including at night.

The prostate is a small gland below the bladder that makes semen and controls the flow of pee from the bladder to the penis. The NHS explains that if it gets bigger it can put pressure on the tube that carries pee from the bladder, the urethra, causing problems with peeing. That is the main reason hesitancy is so often linked with the prostate in men.

An enlarged prostate, sometimes called benign prostate enlargement, is common and not usually serious. The NHS says it is most common in men over 50 and that the symptoms usually develop slowly and may gradually get worse as you get older.

Prostate cancer can cause similar symptoms. The NHS explains that prostate cancer often has no symptoms at first, because it usually starts to grow on the outer part of the prostate and does not press on the urethra until it has grown or spread. When it does, it can cause difficulty starting to pee, straining, a weak flow, stop-start peeing, urgency and needing to pee often or at night. These symptoms do not always mean cancer, and the NHS stresses that you can get them with an enlarged prostate.

Prostatitis is inflammation of the prostate. The NHS lists pain when peeing, difficulty or straining to pee, needing to pee more often, pain in the penis, scrotum, testicles or bottom, pain on ejaculation and a high temperature. It is usually caused by an infection such as a urinary tract infection, and it is treated with antibiotics.

The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you have blood in your pee, which may look pink, red or brown, pain when peeing or if you cannot pee at all. Being unable to pee is also listed as a reason for urgent help in prostatitis.

For suspected prostatitis, the NHS also advises urgent help if you have been taking antibiotics for 48 hours and your symptoms have not got better or have got worse. It says to go to A&E or call 999 if you suddenly feel confused, have slurred speech, have blue, grey, pale or blotchy skin, lips or tongue, a rash that does not fade when you roll a glass over it, or severe difficulty breathing, as these may mean a serious infection or sepsis.

The NHS says a GP will ask about your symptoms, such as how often you pee, and may examine your tummy and penis and feel inside your bottom with a gloved finger to check the size of the prostate. You will usually be asked to keep a record for at least 3 days of how much you drink and how often and how much you pee.

The tests a GP might do include testing a sample of urine and a blood test called a PSA test. The NHS explains that a PSA test cannot tell you whether you have prostate cancer but can show whether there are problems affecting your prostate, and that results usually take 1 to 2 weeks. If the result is higher than normal you will be offered other tests to see whether it is cancer or something less serious such as an enlarged prostate or prostatitis. A specialist may arrange a urine flow test, an ultrasound scan of the bladder or a cystoscopy, which looks inside the bladder with a camera.

The NHS says an enlarged prostate does not always need treatment and that it depends on your symptoms and how they affect you. If symptoms are not causing many problems doctors will usually recommend lifestyle changes first. These include cutting down on alcohol and caffeine, reducing how much you drink before bed or before going out while still drinking enough during the day, eating enough fibre to prevent constipation, keeping to a healthy weight and waiting a few moments after peeing before trying again to empty the bladder.

Medicines are offered for moderate or severe symptoms. They include tamsulosin, doxazosin or alfuzosin to help you pee, oxybutynin or tolterodine for frequency or urgency, and finasteride or dutasteride to stop the prostate growing in people at high risk of getting worse. Surgery may be offered if medicines have not helped or symptoms are severe. The most common operation is transurethral resection of the prostate (TURP), and other procedures use lasers, an electrical current, steam, a water jet or an implant that holds the urethra open. Support options include pads, a urinary catheter if you cannot empty your bladder, bladder training and pelvic floor exercises.

On the NHS most men begin with a GP, who arranges urine tests, a PSA test where appropriate and referral to a urology specialist if needed. Private urology clinics can offer faster flow tests, ultrasound and cystoscopy, and some people choose them for speed, but the basic assessment and the treatment options are the same. If you have a private PSA test or scan, take the results with you to your GP so that your records are complete.