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Urinary Retention

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Urinary Retention, Bladder Distention

  • Definitions
  1. Urinary Retention
    1. Inability to voluntarily pass adequate volume of urine
  • Epidemiology
  1. Incidence
    1. Women: 7 per 100,000
    2. Men: 4-7 per 1000 (ages 40-83 per year in U.S.)
      1. More common in men over age 70-80 years (up to 30%)
  • Causes
  • Neurologic in both Men and Women
  1. Peripheral Neuropathy (or autonomic)
    1. Diabetes Mellitus
      1. Diabetic cystopathy and detrussor underactivity develops in 25-60% of diabetes patients
      2. Kebapci (2007) Neurourol Urodyn 26(6): 814-9 [PubMed]
    2. Infection (Lyme Disease, Syphilis, Herpes Zoster virus, Poliomyelitis)
    3. Guillain-Barre Syndrome
    4. Post-radical pelvic surgery or radiation
    5. Autonomic Neuropathy
  2. Central causes (CNS)
    1. Cerebrovascular Accident
      1. CVA more commonly causes Urinary Incontinence
      2. Brainstem lesions may instead cause Urinary Retention (often resolves during acute recovery period)
    2. Multiple Sclerosis
      1. Up to 25% of patients with MS intermittently catheterize
      2. Mahajan (2010) J Urol 183(4): 1432-7 [PubMed]
    3. Normal Pressure Hydrocephalus
    4. Shy-Drage Syndrome
    5. Parkinsonism
    6. Brain neoplasm
  3. Spinal cord
    1. Spinal cord Trauma
      1. Urinary Retention may resolve after 1-12 months of initial spinal cord shock
    2. Spinal cord mass (spinal cord hematoma)
    3. Cauda Equina Syndrome (related to spinal stenosis, intervertebral disc)
    4. Spinal Dysraphism (e.g. Myelomeningocele, Spina Bifida Occulta)
    5. Transverse Myelitis
  • Causes
  • Miscellaneous in both Men and Women
  1. Iatrogentic
    1. Medication adverse effects (12% of chronic Urinary Retention)
      1. Frequent cause of acute on chronic Urinary Retention (resulting in emergency visit)
      2. See Medication Causes of Urinary Retention
    2. Postoperative Urinary Retention (2-14% of inpatient surgeries)
      1. Higher risk in advanced age and Urinary Tract Infection
      2. Alpha Adrenergic Antagonist (e.g. Flomax) prior to surgery reduced retention risk
  2. Obstruction
    1. Urethral stricture
    2. Bladder calculi
    3. Bladder Cancer
    4. Hematuria with clot formation within Bladder
    5. Foreign body
    6. Pelvic mass
      1. Tumor
      2. Abdominal Aortic Aneurysm
      3. Fecal Impaction
  3. Trauma
    1. Urethral disruption in pelvic Trauma
  4. Infection
    1. Urinary Tract Infection
    2. Herpes Zoster (affecting lumbosacral Dermatome)
    3. Urethritis
    4. Periurethral abscess
  5. Rare infections in U.S.
    1. Bilharziasis cystitis (shistosomiasis)
    2. Echinococcosis
    3. Tuberculous cystitis
  • Causes
  • Men
  1. Urinary Obstruction
    1. Benign Prostatic Hyperplasia (most common, 53% of obstructive causes)
    2. Phimosis or Paraphimosis
    3. Prostate Cancer
    4. Penile meatal stenosis
  2. Genitourinary Infection or inflammation
    1. Balanitis or Posthitis
    2. Acute Prostatitis or prostatic abscess
  • Causes
  • Women
  1. Urinary Obstruction
    1. Pelvic Organ Prolapse (Cystocele, Rectocele or Uterine Prolapse)
    2. Uterine Fibroid
    3. Ovarian Cyst
    4. Pelvic malignancy
    5. Urethral sphincter dysfunction
    6. Pregnancy
      1. Postpartum (10%)
      2. Antepartum (0.5%): Most common at 9-16 weeks gestation
        1. More common if over age 35 years, retroverted gravid Uterus, preterm delivery
  2. Genitourinary infection or inflammation
    1. Vulvovaginitis
    2. Vaginal dermatitis
      1. Vaginal Lichen Planus
      2. Vaginal Lichen Sclerosis
      3. Behcet Syndrome
      4. Vaginal Pemphigus
  • Symptoms
  1. Acute Urinary Retention (urologic emergency)
    1. Significant pain and distress
    2. Suprapubic Pain
    3. Abdominal Bloating
    4. Urine urgency
    5. Mild urine Incontinence
  2. Chronic Urinary Retention
    1. Often asymptomatic
  • Exam
  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. Digital Rectal Exam
    1. Prostate size (and tenderness in the case of Acute Prostatitis)
    2. Fecal Impaction or rectal mass
    3. Anal sphincter tone
  4. 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
  • Imaging
  1. First-Line
    1. Renal Ultrasound and Bladder Ultrasound
    2. Consider CT Abdomen
  2. Additional imaging as indicated
    1. Brain imaging (CT Head or MRI Head)
    2. Lumbosacral MRI
  • Diagnostics
  1. Cystoscopy
  2. Urodynamic studies
  • Management
  • Acute Urinary Retention
  1. Emergent Bladder decompression
    1. Precaution: Anticipate Hematuria and Hypotension with decompression
    2. First-line: Urethral Catheterization (16 Fr Urethral Catheterization, or coude catheter in BPH)
    3. Refractory: Suprapubic Catheterization
  2. Additional measures
    1. Try to stop Medication Causes of Urinary Retention
    2. Consider starting alpha blocker (e.g. Tamsulosin or Flomax)
      1. Benign Prostatic Hyperplasia
    3. Leave Urinary Catheter in for 3-7 days
    4. Perform post-void residual urine measurement
      1. Replace catheter if >300 ml post-void residual or persistent urinary tract symptoms
    5. Follow-up urology within 2-3 weeks for discussion of intermittent catheterization
  • Management
  • Chronic Urinary Retention in High Risk Patients
  1. Indications
    1. Hydronephrosis or hydroureter
    2. Stage 3 Chronic Kidney Disease
    3. Recurrent culture proven UTI or urosepsis
    4. Urinary Incontinence (esp. with perineal skin breakdown or Decubitus Ulcers)
  2. Initial Management
    1. Urinary Catheterization
    2. Reduce risk (e.g. treat UTI, consider surgical options such as TURP)
    3. Urodynamics to evaluate Bladder outlet obstruction
  3. Reassess
    1. Re-evaluate risk with exam, Ultrasound, Urine Culture
    2. Consider repeat urodynamics
    3. If improved and risk lowered, go to next step under low risk patients as below
  • Management
  • Chronic Urinary Retention in Low Risk Patients
  1. Symptomatic (moderate to severe symptoms, e.g. AUA Symptom Index for BPH)
    1. See Overflow Incontinence
    2. Consider medication, behavioral and/or surgical management
    3. Urodynamics distinguishes Bladder outlet obstruction from low detrussor contractility
  2. Asymptomatic or mild symptoms
    1. Routine surveillance with periodic renal and Bladder Ultrasound and GFR testing