The underappreciated underactive bladder

Slow urinary flow is a common lower urinary tract symptom (LUTS) that frequently prompts men to consult their primary care physician. While bladder outlet obstruction (BOO) is well recognised, underactive bladder (UAB) remains underappreciate despite its significant impact on quality of life. This review highlights the pathophysiology, clinical features, and diagnostic challenges and approach to UAB in men. Improving recognition of UAB as a distinct condition separate from other LUTS aetiologies, it can facilitate earlier diagnosis and management. Slow urinary flow is highly prevalent, particularly in an ageing population. UAB is characterised by impaired detrusor muscle activity, leading to slow urinary flow, hesitancy, straining and incomplete bladder emptying. The overlap in symptoms with BOO often leads to misdiagnosis, delaying appropriate intervention. UAB has multiple underlying causes including, neurogenic, myogenic, iatrogenic and idiopathic factors. Diagnosis is further complicated by the limited availability of urodynamic studies, the gold standard for assessing detrusor underactivity. Current management options remain limited with no definitive treatments. Current strategies focus on behavioural modifications, pelvic floor exercises, timed voiding, sacral neuromodulation and intermittent catheterisation. Increased awareness of UAB among primary care physicians and urologists is essential for timely diagnosis and intervention. Recognition of UAB as a distinct clinical entity will lead to a reduction in potential complications and significant improvement in the quality of life of affected men.