II. Epidemiology

  1. Incidence: 4-7 per 1000 men ages 40-83 per year in U.S.
  2. More common in men over age 70 years

III. Causes: Neurologic in both Men and Women

  1. Peripheral Neuropathy
    1. Diabetes Mellitus
    2. Infection (Lyme Disease, Syphilis, Herpes Zoster virus)
    3. Guillain-Barre Syndrome
    4. Post-pelvic surgery or radiation
  2. Central causes (CNS)
    1. Cerebrovascular Accident
    2. Multiple Sclerosis
    3. Normal Pressure Hydrocephalus
    4. Shy-Drage Syndrome
    5. Parkinsonism
  3. Spinal cord
    1. Spinal cord Trauma or mass
    2. Cauda Equina Syndrome (related to spinal stenosis, intervertebral disc)
    3. Spinal Dysraphism (e.g. Myelomeningocele)

IV. Causes: Miscellaneous in both Men and Women

  1. See Medication Causes of Urinary Retention
  2. Urethral stricture
  3. Bladder calculi
  4. Abdominal mass (tumor, AAA, Fecal Impaction)
  5. Urethral disruption in pelvic Trauma

V. Causes: Men

  1. Urinary Obstruction
    1. Benign Prostatic Hyperplasia
    2. Phimosis or paraphimosis
    3. Prostate Cancer
    4. Penile meatal stenosis
  2. Genitourinary Infection or inflammation
    1. Balanitis
    2. Acute Prostatitis or prostatic abscess

VI. Causes: Women

  1. Urinary Obstruction
    1. Cystocele, Rectocele or Uterine Prolapse
    2. Uterine Fibroid
    3. Ovarian Cyst
    4. Pelvic malignancy
    5. Urethral sphincter dysfunction
  2. Genitourinary infection or inflammation
    1. Vulvovaginitis
    2. Vaginal dermatitis (e.g. vaginal Lichen Planus, vaginal Lichen Sclerosis)

VII. Examination

  1. Bladder exam
    1. Bladder is percussable when urine volume >150 ml
    2. Bladder is palpable when urine volume >200 ml
  2. Genitourinary exam
  3. Neurologic Exam: Evaluate for neurogenic Bladder
    1. Reflexes
      1. Bulbocavernosus Reflex
      2. Anal reflex (Anal Wink)
    2. Muscle tone
      1. Anal sphincter tone
      2. Pelvic floor voluntary contractions
    3. Sensation
      1. S2 Nerve sensation: Evaluate for saddle anesthesia
      2. S3-S5 Nerve sensation: Evaluate for perianal anesthesia

IX. Imaging

  1. First-Line
    1. Renal and Bladder Ultrasound
    2. Consider CT Abdomen
  2. Additional imaging as indicated
    1. Brain imaging (CT Head or MRI Head)
    2. Lumbosacral MRI

X. Diagnostics

  1. Cystoscopy
  2. Urodynamic studies

XI. Management

  1. Emergent Bladder decompression
    1. Precaution: Anticipate Hematuria and Hypotension with decompression
    2. First-line: Urethral Catheterization
    3. Refractory: Suprapubic Catheterization
  2. Identify cause and treat specific etiologies
    1. Example: Benign Prostatic Hyperplasia

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