Marcus Drake recently served as senior author of a short but thought-provoking article in European Urology Focus that raises important questions about this long-held assumption.1 The authors review the surprisingly limited evidence linking the symptom of straining to void with objectively confirmed BOO.
They cite several studies that challenge this assumption, particularly one by Reynard et al., which demonstrated poor agreement between a patient’s complaint of straining and objectively measured abdominal straining.2 The study also found no significant association between the symptom of straining and urodynamically confirmed BOO, as well as little or no improvement in urinary flow resulting from abdominal straining. The authors conclude that straining is neither a sensitive nor specific marker of obstruction.
They also note that patients may interpret the term “straining” differently. Some understand it to mean actively pushing with the abdominal muscles, while others use it to describe the effort required to void or difficulty initiating urination. In addition, many men with objectively proven BOO never report straining.
Jensen et al., as cited in the article, described five subtypes of straining: (1) during filling cystometry; (2) to initiate voiding, before the onset of a detrusor contraction; (3) before the onset of urine flow; (4) before or during maximum flow; and (5) after maximum flow has been reached (terminal straining).3
The authors conclude that straining to void is a common but nonspecific behavior in patients with lower urinary tract symptoms. Although it is frequently assumed to indicate BOO, current evidence suggests that straining occurs in both obstructed and unobstructed individuals and often persists after surgical relief of obstruction. The maneuver may help initiate, enhance, or complete voiding for physiological or behavioral reasons. Consequently, straining should not be considered a reliable indicator of BOO and should be interpreted alongside objective urodynamic assessment.
The practical implication is that clinicians should be cautious about equating a patient’s report of straining with the presence of BOO. As this review highlights, the symptom itself is heterogeneous, and its clinical significance should be interpreted alongside other findings rather than used in isolation to infer obstruction.
Written by: Alan Wein, MD, PhD, FACS, Professor of Clinical Urology, Department of Urology, Desai Sethi Urology Institute (DSUI), University of Miami Miller School of Medicine, University of Miami Health Systems, Miami, FL
References:
- Garcia-Reyes PB, et al. (Marcus Drake, senior author). Straining to pass urine in men with lower urinary tract symptoms. European Urology Focus. https://doi.org/10.1016/j.euf.2026.06.001
- Reynard JM, et al. The significance of abdominal straining in men with lower urinary tract symptoms. British Journal of Urology. 1995;75:148-153.
- Jensen KME, et al. Abdominal straining in benign prostatic hyperplasia. Journal of Urology. 1983;129:44-47.