Definition
Urinary retention is the inability to empty the bladder completely. It can be acute or chronic, with symptoms such as total inability to urinate or simply inability to empty the bladder completely.
A.Acute urinary retention can cause great discomfort or pain; it is sudden in onset and involves inability to urinate at all even when the bladder is full. It is the most common urologic emergency in men. The duration may be short, but it can also be potentially life-threatening, requiring immediate emergency intervention.
B.Chronic urinary retention presents with the inability to empty the bladder and is long term. Most of the time, chronic urinary retention is diagnosed with other associated genitourinary (GU) conditions such as urinary tract infection (UTI), urinary incontinence (UI), and overactive bladder (OAB).
Incidence
A.Urinary retention occurs less frequently in women than in men.
B.The overall incidence in men ages 40 to 83 years old is less than 7 per 1,000.
C.At age 70, the rate increases to 100 per 1,000.
D.By the age of 80 years, the incidence is up to 300 per 1,000.
Pathogenesis
Urinary retention can be caused by three different factors:
A.Detrusor underactivity (DU) is defined by the International Continence Society (ICS) as a contraction of reduced strength and/or duration resulting in prolonged or incomplete emptying of the bladder. Both neurogenic and myogenic factors are involved in DU and may be influenced by pharmacotherapy or by primary disorder inhibiting the detrusor and altering urethral sphincter relaxation.
B.Bladder outlet obstruction (BOO) caused by tumors (GU, gastrointestinal [GI], or intestinal), bladder neck stenosis, calculi, structural malformation, or previous surgical interventions are classified as mechanical–anatomical. Little is known of the functional (nonmechanical–nonanatomical) cause but may include dyssynergia of the bladder neck and sphincter detrusor or dysfunction of the ureteral sphincter.
C.Combination of these mentioned.
Predisposing Factors
There are multiple factors that could cause urinary retention for both men and women, including the following:
A.Neurologic:
1.Peripheral neuropathy:
a.Diabetes mellitus (DM).
b.Infections.
c.Guillain–Barré syndrome.
d.Radiations and postsurgical interventions of the pelvis.
2.Central nervous system (CNS):
a.Costovertebral angle (CVA).
b.Parkinson’s.
c.Hydrocephalus—normal pressure.
d.Multiple sclerosis (MS).
e.Shy–Drager syndrome.
3.Spinal cord:
a.Mass or trauma.
b.Cauda equina syndrome.
c.Spinal dysraphism.
B.Ureteral strictures.
C.Bladder calculi.
D.Medications:
1.Antihistamines.
2.Anticholinergics/antispasmodics for bowel and bladder.
3.Tricyclic antidepressants.
4.Decongestants.
5.Nifedipine.
6.Antiseizure medications (AEDs).
7.Nonsteroidal anti-inflammatory drugs (NSAIDs).
8.Opioids.
E.Constipation/fecal impaction.
F.Low nocturnal bladder capacity.
G.Combination of the nocturnal polyuria and low nocturnal bladder capacity.
H.OAB.
I.Ureteral disruption secondary to trauma.
J.Obstructions for men:
1.Benign prostatic hypertrophy (BPH): most common.
2.Phimosis.
3.Cancer of the prostate.
4.Stenosis of the penile meatal.
5.UTIs:
a.Acute prostatitis.
b.Abscess.
c.Balanitis.
K.Obstructions for women:
1.Uterine: Prolapse, cystocele/rectocele.
2.Uterine fibroid.
3.Ovarian cyst.
4.Ureteral sphincter dysfunction.
5.Pelvic malignancy.
6.Infections:
a.Genital herpes (local inflammation as well as sacral nerve involvement).
b.Varicella zoster.
c.Vulvovaginitis.
7.Inflammations or dermatitis.
L.Abdominal mass.
M.Diabetes especially with peripheral neuropathy.
N.Postoperative urinary retention.
O.Postpartum urinary retention.
Common Complaints
A.Acute symptoms:
1.Inability to urinate.
2.Dysuria with pain and urgency.
B.Dysuria with poor or weak stream.
C.Urinary frequency.
D.Urinary urgency.
E.Geriatrics:
1.May not present with classic symptoms.
2.Incontinence.
3.Mental confusion.
4.History of falls.
Other Signs and Symptoms
A.Asymptomatic.
B.Bladder spasms.
C.Suprapubic pain or suprapubic discomfort.
D.Depression.
E.Morning fatigue.
F.Frequent wakefulness.
G.Insomnia.
Potential Complications
A.UTIs.
B.Chronic kidney disease (CKD).
C.Poor quality of life.
Subjective Data
A.Review the onset, course, and duration of symptoms.
B.Review all medications, over-the-counter (OTC) medicines, and herbal products with notation of the medication/classes that cause urinary retention (see the section Predisposing Factors
).
C.Does the patient have a fever and chills or back or flank pain (unilateral or bilateral)?
D.Has the patient had any recent surgical procedures?
E.Is there any history of previous UTIs? How often and how were they treated? Were any tests performed in a workup by a urologist?
F.Males: Review the strength of the urinary flow, dribbling, and hesitancy.
G.Females:
1.Postmenopausal woman: Review whether she has a known prolapse and/or vaginal atrophy.
2.Does she use any systemic or local estrogen medications?
3.Is she postpartum?
H.Is there any history of other medical diseases noted in predisposing factors?
I.Review for the presence of neurologic disorders, including spinal cord injury or MS.
J.Review if there are other active problems or a history of genital problems such as herpes.
Physical Examination
A.Both sexes:
1.Check temperature (if an infection is suspected), pulse, blood pressure (BP), and respirations.
2.Inspect for evidence of cardiac overload: Pedal edema.
3.Auscultate the lungs for evidence of fluid overload: Rales.
4.Perform neurologic examination to determine the presence of sensation and neurogenic bladder. Check anal reflex and sphincter tone.
5.Palpate the abdomen, suprapubic, and back for masses, fullness over bladder, inguinal nodes, and CVA tenderness (bladder is percussible with 150 mL and palpable <200 mL of urine).
6.Assess cognitive and functional status, including mobility, transfers, manual dexterity, and ability to toilet in the elderly.
7.Screen for depression.
8.Assess for falls and possible healing fractures.
9.Evaluate for obesity.
B.Females:
1.Inspect perineal skin for irritation, thinning, vaginal atrophy, herpetic lesion, or vaginal discharge.
2.Remove the top blade of the speculum and evaluate the vaginal wall support.
3.Ask the woman to cough to reevaluate the vaginal wall support.
4.Palpate:
a.Perform a bimanual pelvic exam for prolapse, masses, or tenderness.
b.Perform a rectal exam for sphincter tone, masses, and fecal impaction.
C.Males:
1.Inspect:
a.Inspect the glans of the penis for abnormalities in urethral meatus. (Hypospadias may cause postvoid dribbling.)
b.Uncircumcised men should be evaluated for phimosis and balanitis.
c.Inspect for active herpetic lesions.
2.Palpate:
a.Perform a rectal exam for sphincter tone, masses, fecal impaction, prostate size, and contour.
b.Palpate the scrotum to evaluate masses.
c.Evaluate the presence of an inguinal hernia since straining with a partial urinary obstruction can worsen an inguinal hernia.
Diagnostic Tests
The history, physical examination, and urinalysis may be sufficient to guide initial therapy and to rule out other causative factors. Other tests include the following:
A.Urine culture and sensitivity if infection is suspected.
B.Urine cytology if hematuria or pelvic pain is present.
C.A prostate-specific antigen (PSA) should be considered; however, it is expected to be elevated with acute urinary retention.
D.Cystoscopy/ureteroscopy.
E.Urodynamic testing is strongly recommended.
F.Postvoid residual (PVR) measurement.
G.CT scans.
H.Electromyography.
I.Depression screen.
J.Neurological evaluation may be needed to include, but is not limited to, CT studies.
K.Chemistry study with hemoglobin (Hgb) A1c.
L.Nocturnal pulse oximetry study.
M.Sleep study may be indicated, especially in those positive for nocturnal hypoxemia.
N.Ultrasound of the kidneys with Doppler.
Differential Diagnoses
A.Urinary retention.
B.Urinary obstruction:
1.Bladder calculi.
2.Ureteral stricture.
C.Medication(s) side effect.
D.Neurologic etiology.
E.Male-related etiologies as noted in the predisposing factors.
F.Female-related etiologies as noted in the predisposing factors.
G.Fecal impaction.
H.Abdominal mass.
I.CKD.
Plan
A.Initial management of acute urinary retention is prompt bladder decompression with a urethral catheter. Urethral catheterization is contraindicated in patients who have had recent urologic surgery (radical prostatectomy or urethral reconstruction). A suprapubic catheter may be necessary if a urethral catheter cannot be passed because of obstruction.