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Luis Abranches-Monteiro

By the ICS definition, Hesitancy is the term used when an individual describes difficulty in initiating micturition resulting in a delay in the onset of voiding after the individual is ready to pass urine [1]

Hesitancy per se does not point in any specific diagnostic direction. Any delay between the cortical decision and the start of voiding, can be described as a hesitancy.
The term is less appropriate regarding that a decision to void is taken without any hesitancy.

In some languages is described as “delay of initiation”, and seems more adequate, semantically.

This delay, can be thus originated anywhere between the brain and urethra.

The voiding reflex and voluntary control rest on cortico-sub-cortical and ponto-spinal pathways and the prompt detrusor and sphincteric answers.

Hence, hesitancy can be accompanied of intense desire to void or just in its absence. This difference can lead us to different anatomical defects, and should deserve more attention. Hesitancy should then be split into several versions.

Mechanical obstruction of bladder outlet and detrusor underactivity are responsible for hesitancy in a quite different ways.

The detrusor behaviour and urethral resistance influence the type of hesitancy and accompanying symptoms like “sensation of incomplete emptying” or the quality of flow. [2]

Mild hesitancy is very common in men of all ages and the prevalence increases with age. [3] Hesitancy is globally a well-tolerated urinary symptom, compared with others. [4]

Psychological aspects are of importance and may account for the frequent observation of hesitancy in healthy people in a laboratory setting. One series points to almost 15% of young women. [5]

It can be observed not only in chronic obstruction but also in acute iatrogenic obstruction after incontinence surgery. [6]

In summary, hesitancy is a term needing some refinements regarding the presence of desire to void. Used alone, cannot point to a specific cause, ranging from cortical pathways to mechanical urethral mechanisms.


Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A; Society., Standardisation Sub-committee of the International Continence, “The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society,” Neurourol Urodyn., Vols. 21(2):167-78., 2002;.
Gammie A, Kaper M, Dorrepaal C, Kos T, Abrams P., “Signs and Symptoms of Detrusor Underactivity: An Analysis of Clinical Presentation and Urodynamic Tests From a Large Group of Patients Undergoing Pressure Flow Studies.,” Eur Urol. , 2015 Aug 26. e-pub ahead of print.
Malmsten UG1, Molander U, Peeker R, Irwin DE, Milsom I., “Urinary incontinence, overactive bladder, and other lower urinary tract symptoms: a longitudinal population-based survey in men aged 45-103 years.,” Eur Urol. , pp. 58(1):149-56, 2010 Jul;.
Pöyhönen A1, Häkkinen JT, Koskimäki J, Hakama M, Tammela TL, Auvinen A., “Prevalence of hesitancy in 30-80-year-old Finnish men: Tampere Ageing Male Urological Study (TAMUS),” BJU Int. , pp. 1360-4., 2012 May;109(9):.
van Breda HM1, Bosch JL, de Kort LM., “Hidden prevalence of lower urinary tract symptoms in healthy nulligravid young women.,” Int Urogynecol J. , 2015 Jun 18. Epub ahead of print.
Patel BN, Kobashi KC, Staskin D., “Iatrogenic obstruction after sling surgery.,” Nat Rev Urol. , vol. 9(8):, pp. 429-34., 2012 Aug;.

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