Urinary retention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Steven C. Campbell, M.D., Ph.D. Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.

Synonyms and keywords: Ischuria; urine retention

Overview

Historical Perspective

  • Obstructive uropathy ranked 11th (with the rate of 15 per million population) in terms of the cause of death due to kidney and urologic diseases.
  • It is also ranked 9th in terms of cost of all kidney and urological diseases in the USA.
  • The incidence and the economic implication is not known in our setting; however, it is nonetheless a common urological problem.[1]

Classification

  • Based on the duration of symptoms, it may be classified as either acute (500-800ml), acute on chronic (>800ml), or chronic (4L).[1]
  • Based on the mode of disease, it can be classified as traumatic or non-traumatic.

Pathophysiology

The main pathophysiology behind urine retention is:[1]

  • Increased urethral resistance secondary to bladder outlet obstruction. The resistance to the flow of urine can occur because of mechanical obstruction such as BPH(most common in men), stricture or fecal impaction.
  • Impaired bladder contractility, (less common cause) a decrease in tone of bladder muscles (smooth or striated).
  • Loss of normal bladder sensory or motor innervations to the detrusor muscle is caused by a multiple pathologies of nervous system, for example, spinal cord lesion (traumatic or neurological), diabetic neuropathy, cauda equina syndrome, cerebrovascular accident, myelitis, spinal stroke.
  • Postoperative AUR occurs during a prolonged procedure with the patient non catheterised and in men who have had mild symptoms of BPH preoperatively. It is also exacerbated by the use of opiates, with anticholinergic administration and the generalised increase in alpha-adrenergic activity that is present naturally after surgery, causing increased sphincter tone and constricting neck of bladder. Overdistension of the bladder is seen after a general anaesthetic or a large fluid challenge during procedures.


Causes

Life Threatening Causes

Common Causes

Causes by Organ System

Cardiovascular Accelerated hypertension  , Antepartum eclampsia  , Aortic arches defect  , Cardiomyopathy, Cast syndrome  , Hellp syndrome  , Hypertension of pregnancy  , Malignant hypertension  , Pulmonary branches stenosis, Pulmonary venous hypertension 
Chemical/Poisoning Aclidinium bromide, Acrylamide  , Ajuga nipponensis makino, Alcohol, Arsine  , Autumn crocus  , Black widow spider envenomation  , Boric acid  , Brown snake poisoning  , Cathinone poisoning  , Cetirizine hydrochloride, Chemical poisoning , Chlo-amine, Chlorate salts  , Chloromethane  , Chlorpheniramine, Chlor-pro, Chlorpromazine, Chlor-trimeton, Chlor-tripolon, Doxepin toxicity  , Ethylene glycol  , Eugenol oil poisoning  , Golden chain tree poisoning  , Hair bleach  , Hair dye  , Jimsonweed poisoning  , Mayapple poisoning  , Muscarinic antagonists, Naked brimcap poisoning  , Orotidylic decarboxylase deficiency  , Plant poisoning, Protriptyline toxicity  , Sea snake poisoning  , Senna  , Solanum tuberosum, Solder, Sublimaze, Toxic mushrooms
Dental No underlying causes
Dermatologic Dobriner syndrome 
Drug Side Effect Aller-chlor, Al-r, Amantadine, Anthraquinone  , Antipsychotic agents, Apo-clonidine, Atropine, Benztropine, Bromaline elixir, Bromanate elixir, Bromatapp, Bucladin-s softab, Buprenex, Catapresan-100, Cinnarizine, Clemastine, Clobazam, Clomipramine toxicity  , Clonidine, Cyclizine, Cystocele  , Cytarabine, Cytosar-u, Desipramine, Detrol, Dexchlorpheniramine, Diamorphine, Diphenhydramine, Dixarit, Donepezil, Dothiepin, Edronax, Ezogabine, Fantonest, Fentanyl injection, Fesoterodine, Genatap elixir, General anesthetic, Glyphosate  , Hydrocodone bitartrate , Hydroxyzine, Imipramine toxicity  , Kloromin, Levomepromazine, Mouth wash, Muscarinic antagonists, Myphetapp, Nabilone, Nalmefene, Naropin with fentanyl, Nortriptyline, Novo-clonidine, Nu-clonidine, Ormazine, Perazine, Perphenazine, Pethidine, Phenelzine, Phenetron, Pipothiazine, Pizotifen, Pomalidomide, Prochlorperazine, Reboxetine, Retigabine, Tamine, Telachlor, Teldrin, Temegesic, Terodiline, Thioridazine hydrochloride, Thiothixene, Thorazine, Tolterodine, Vibazine
Ear Nose Throat No underlying causes
Endocrine Acute intermittent porphyria  , Duodenal atresia  , Durogesic, Rénon-delille syndrome
Environmental Exposure to cold
Gastroenterologic Acute intermittent porphyria  , Diarrhea  , Duodenal atresia  , Durogesic, Gastrointestinal bleeding  , Hepatorenal syndrome  , Megaduodenum, Perirectal abscess  , Prune belly syndrome  , Rectal operations
Genetic Chromosome 19p duplication syndrome  , Congenital giant megaureter, Eosinophilic cystitis  , Fowler-christmas-chapple syndrome  , Mckusick-kaufman syndrome  , Munk disease  , Transthyretin amyloidosis  , Variegate porphyria  , Waterhouse-friederichsen syndrome  , Weil syndrome 
Hematologic Acute intermittent porphyria  , Anemic , Chronic granulomatous disease  , D-plus hemolytic uremic syndrome , Gastrointestinal bleeding  , Haematocolpos, Hemolytic uremic syndrome  , Hemorrhagic shock, Postoperative spindle cell nodule
Iatrogenic Anaesthesia complications  , Epidural anesthetic, General anesthetic, Post-vaccinial encephalitis  , Radiotherapy, Rectal operations, Surgery complication, Urinary catheters
Infectious Disease Botulism, Cholera  , Herpes genitalis, Herpes zoster, Lassa fever, Leptomeningitis, Lichen sclerosis  , Marezine, Mycobacterium tuberculosis, Neisseria gonorrhoea, Nephritis  , Perirectal abscess  , Poliomyelitis, Prostatic abscess  , Spirochetes disease  , Tetanus  , Vibrio infection , Weil syndrome  , Yellow fever 
Musculoskeletal/Orthopedic Degenerative disc disease  , Detrusor muscle dyssynergia, Familial visceral myopathy  , Pelvic malignancies, Prolapse of invertebral disc, Prune belly syndrome  , Rhabdomyosarcoma, Tetanus 
Neurologic Autonomic neuropathy  , Cauda equina syndrome  , Chronic fatigue syndrome  , Diabetic neuropathy  , Intrapartum eclampsia  , Leptomeningitis, Multiple system atrophy  , Myelitis  , Neurogenic bladder, Poliomyelitis, Post-vaccinial encephalitis  , Pudendal nerve entrapment  , Transverse myelitis
Nutritional/Metabolic Dehydration  , Diabetic neuropathy  , Diarrhea  , Maté  , Oxalosis
Obstetric/Gynecologic Antepartum eclampsia  , Eclampsia  , Epidural anesthetic, Haematocolpos, Hellp syndrome  , Hyperemesis gravidarum  , Hypertension of pregnancy  , Intrapartum eclampsia  , Ohss  , Polycystic ovaries urethral sphincter dysfunction, Postpartum eclampsia  , Pregnancy, Rénon-delille syndrome , Septic abortion  , Uterine prolapse 
Oncologic Bladder cancer  , Metastatic prostate cancer, Pdeunculated bladder tumor, Pelvic malignancies, Phyllodes tumor , Postoperative spindle cell nodule , Prostate cancer, Rhabdomyosarcoma, Urethral cancer  , Urinary tumors
Ophthalmologic No underlying causes
Overdose/Toxicity Alcohol, Amitriptyline toxicity, Amoxapine toxicity  , Clomipramine toxicity  , Doxepin toxicity  , Fentanyl injection, Toxic mushrooms , Trimipramine toxicity 
Psychiatric Hysteria, Paruresis
Pulmonary Acute respiratory distress syndrome, Mycobacterium tuberculosis, Pulmonary branches stenosis, Pulmonary venous hypertension 
Renal/Electrolyte Acute renal failure  , Azotemia, Bright's disease, Bywaters' syndrome  , Chronic kidney disease  , Dehydration  , End-stage renal disease  , Eosinophilic cystitis  , Glomerulonephritis  , Goodpasture syndrome  , Hydronephrosis  , Impacted calculus in urethra, Kidney stones  , Nephritis  , Nephrotic syndrome  , Orotic aciduria    , Oxalosis, Retroperitoneal fibrosis
Rheumatology/Immunology/Allergy Acquired angioedema  , C1esterase deficiency, Cardiomyopathy, Catastrophic antiphospholipid syndrome  , Dobriner syndrome  , Goodpasture syndrome  , Hereditary angioedema, Polyarteritis nodosa 
Sexual Herpes genitalis
Trauma Cauda equina syndrome  , Damage to the bladder, Exposure to cold, Heat exhaustion  , Prolapse of invertebral disc, Shock, Urethral injury
Urologic Acute prostatis , Ammonical ulceration of the foreskin , Anuria  , Benign prostatic hypertrophy, Bladder cancer  , Bladder conditions, Bladder diverticulum  , Bladder neck stenosis, Bladder obstruction, Bladder papilloma  , Circumcision, Damage to the bladder, D-plus hemolytic uremic syndrome , Enlarged prostate, Hemolytic uremic syndrome  , Impacted calculus in urethra, Megacystitis , Metastatic prostate cancer, Neurogenic bladder, Obstruction in the urethra, Orotic aciduria    , Paruresis, Pdeunculated bladder tumor, Polycystic ovaries urethral sphincter dysfunction, Posterior urethral valve, Posterior valve, Prostate cancer, Prostate conditions, Prostate enlargement, Prostate hyperplasia, Prostatic abscess  , Prostatic enlargement, Retroperitoneal fibrosis, Ureter obstruction, Urethral cancer  , Urethral catheterization, Urethral injury, Urethral obstruction, Urethral stricture, Urinary catheters, Urinary foreign bodies, Urinary outflow obstruction, Urinary scar tissue, Urinary stones, Urinary strictures, Urinary tract infections  , Urinary tumors
Miscellaneous Urethral obstruction

Causes in Alphabetical Order


Epidemiology and Demographics

  • The incidence of urinary retention to 6.8/1,000 men, Age 40 to 83.
  • The incidence of acute urinary retention is 300 /1000 men, Age 80s.
  • Urinary retention in women though not rare but is very uncommon.
  • The incidence of urinary retention increases with age.
  • It commonly affects people older than 50 years of age.
  • Mostly has an acute presentation, but chronic forms also exist.
  • There is racial predilection to African Men.
  • Caucasians are less like to develop acute urine retention because of low risk of prostate cancer and benign prostatic hyperplasia.

Risk Factors

Common risk factors related to the development of urinary retention include:

  • Age > 50 years
  • Long surgical procedure
  • Administering large amount of intraoperative fluids
  • Regional anesthesia
  • Underlying bladder disease
  • Previous pelvic surgery
  • Neurological dysfunctioning

Some risk factors related to post partum course:[2]

  • Epidural analgesia
  • Episiotomy
  • Length of second stage of labor
  • Instrument delivery
  • Labor augmentation

Screening

  • There is insufficient evidence to recommend routine screening for urinary retention.

Natural History, Complications and Prognosis

In the longer term, obstruction of the urinary tract may cause:

  • Bladder stones
  • Loss of detrusor muscle tone (atonic bladder is an extreme form)
  • Hydronephrosis (congestion of the kidneys)
  • Hypertrophy of detrusor muscle
  • Diverticula in the bladder wall (leads to stones and infection)
  • Urinary track infection/UTI
  • pyelonephritis
  • Bladder rupture
  • Post obstructive diuresis (POD), a rare but potentially lethal complication associated with the treatment of urinary obstructions. Even in severe cases this condition can become pathologic, resulting in dehydration, electrolyte imbalances, and sometimes death if not adequately treated. Therefore all patients after acute obstruction should be monitored for 24 hours for any unusual symptoms.[3]
  • Acute retention, UTIs and complications of renal failure are uncommon in men with chronic PVRs. Conservative management for this group of patients is reasonable but outpatient management is understudy for future.[4]
  • Some complications associated with urinary catheters: Urethral trauma, Urinary tract infection, Retained balloon fragments, Bladder stone formation, Bladder fistula and Bladder perforation[5]


Prognosis is generally good if condition is treated timely and with proper counseling about different complications, patients with retention who denied surgical treatment can be safely followed for at least 5 years without renal deterioration.[6]

Diagnosis

Diagnostic Study of Choice

The diagnosis of urinary retention is made through history including information about current prescription medications and use of over-the-counter medications and herbal supplements, physical exam, and lab test (to find the specific cause). Urinary retention is difficult to diagnose due to concomitant comorbidities and potential cognitive impairments. There are no specific diagnostic criteria for urinary retention. Lab test include


Conclusion: Major criterion in the diagnosis of urinary retention is the drainage of a large volume of urine after catheterization with the relief of the pain.[1]

History and Symptoms

  • Urinary retention is difficult to diagnose due to concomitant comorbidities and potential cognitive impairments.
  • Urinary retention is characterised by poor urinary stream with intermittance, straining, a sense of incomplete voiding and urgency. As the bladder remains full, it may lead to incontinence, nocturia (need to urinate at night) and high frequency.
  • Common symptoms of the disease include unable to void, lower abdominal pain, back pain, and acute distress if the bladder is full.
  • Retention is a medical emergency, as the bladder may distend (stretch) to enormous sizes and possibly tear if not dealt with quickly. If the bladder distends enough it will begin to become painful. The water can also pass back up the ureters and get into the kidneys, causing hydronephrosis leading to scarring and may end in kidney failure. You should go straight to your emergency department as soon as possible if you are unable to urinate and you have a painfully full bladder.

Physical Examination

  • Patients with urinary retention generally appear in acute distress.
  • The presence of full bladder found by dull percussion and bladder palpation of lower abdomen is highly suggestive of the disease.
  • If enlarge prostate is the cause of obstruction it can be noted on digital rectal exam after patient is stabilized.


Laboratory Findings

  • Urea and creatinine determinations may be necessary to rule out backflow kidney damage.

The basic laboratory investigation includes

Electrocardiogram

There are no ECG findings associated with the disease.

X-ray

There are no x-ray findings associated with the disease.

Ultrasound

  • Abdominopelvic ultrasound will measure residual urine in chronic retention in addition to unveiling some of the complications following chronic retention, like hydronephrosis, bladder stones, and loss of corticomedullary differentiation associated with impaired urinary secretion.
  • Transrectal ultrasound assesses the prostate size, echogenicity, and capsule integrity.

CT scan/MRI

  • They are helpful in showing the bladder stones or complications associated with urinary retention like hydronephrosis or corticomedullary scarring.

Other Imaging Findings

  • Uroflowmetry may aid in establishing the type of micturition abnormality.
  • A post-void residual scan may show the amount of urine retained.
  • Determination of the serum prostate-specific antigen (PSA) may aid in diagnosing or ruling out prostate cancer.

Other Diagnostic Studies

Treatment

Medical Therapy

  • In acute urinary retention, urinary catheterization or suprapubic cystostomy instantly relieves the retention. Urethral catheterization is particularly useful in patients where the cause of urinary retention is temporary, such as infection or medication. It is contraindicated in patients with recent urologic surgery such as radical prostatectomy or urethral reconstruction. If there is difficulty for indwelling a catheter, the patient should be sent to the urologist immediately.
  • In the longer term, treatment depends on the cause. Benign prostatic hypertrophy may respond to alpha blocker and 5-alpha-reductase inhibitor therapy, or surgically with prostatectomy or transurethral resection of the prostate (TURP).[8][9]
  • Suprapubic catheterization is superior to urethral catheterization for short-term management.
  • Silver alloy-impregnated urethral catheters have been shown to reduce the risk of urinary tract infection.[10]
  • Chronic urinary retention from the neurogenic bladder can be managed with clean, intermittent self-catheterization.


Urinary retention is considered an absolute contraindication to the use of the following medications:

Surgery

  • One study describes five men who suffered acute urinary retention and who were all advised by their urologists that they must undergo surgery (transurethral resection of the prostate, TURP). Instead all five men were treated with catheter removal followed by repetitive prostatic massage, extensive microbial diagnosis, and antibiotics, as well as alpha-blockers, and in two cases finasteride. During treatment, statistically significant improvements occurred in global symptom severity scores, urethral white blood cell (WBC) counts, WBC counts of the expressed prostatic secretions (EPS), EPS red blood cell (RBC) counts, urinary WBC counts, and urinary RBC counts. The treatment enabled catheter removal in all 5 men (100%) as well as successful urination in all 5 men (100%). Surgery was able to be postponed indefinitely in all five men.[11]

Prevention

  • There are no established measures for the prevention of urinary retention.
  • Effective strategies to decrease the risk of urinary retention include:
  1. Pelvic floor strengthening exercises
  2. General genital/pelvic hygiene
  3. Good diet
  4. Good bathroom habits/routine
  5. Taking medication as directed by the physician.
  • There is no vaccine available for the prevention of this disease.

Related Chapters

References

  1. ↑ 1.0 1.1 1.2 1.3 Muhammed, Ahmed; Abubakar, Abdulkadir (2012). "Pathophysiology and management of urinary retention in men". Archives of International Surgery. 2 (2): 63. doi:10.4103/2278-9596.110018. ISSN 2278-9596.
  2. ↑ Kawasoe I, Kataoka Y (2020). "Prevalence and risk factors for postpartum urinary retention after vaginal delivery in Japan: A case-control study". Jpn J Nurs Sci. 17 (2): e12293. doi:10.1111/jjns.12293. PMID 31465155.
  3. ↑ Halbgewachs C, Domes T (2015). "Postobstructive diuresis: pay close attention to urinary retention". Can Fam Physician. 61 (2): 137–42. PMC 4325860. PMID 25821871.
  4. ↑ Bates TS, Sugiono M, James ED, Stott MA, Pocock RD (2003). "Is the conservative management of chronic retention in men ever justified?". BJU Int. 92 (6): 581–3. doi:10.1046/j.1464-410x.2003.04444.x. PMID 14511038.
  5. ↑ Halbgewachs C, Domes T (2015) Postobstructive diuresis: pay close attention to urinary retention. Can Fam Physician 61 (2):137-42. PMID: 25821871
  6. ↑ Abello A, DeWolf WC, Das AK (2019). "Expectant long-term follow-up of patients with chronic urinary retention". Neurourol Urodyn. 38 (1): 305–309. doi:10.1002/nau.23853. PMID 30407653.
  7. ↑ Serlin DC, Heidelbaugh JJ, Stoffel JT (2018). "Urinary Retention in Adults: Evaluation and Initial Management". Am Fam Physician. 98 (8): 496–503. PMID 30277739.
  8. ↑ Marshall JR, Haber J, Josephson EB (January 2014). "An evidence-based approach to emergency department management of acute urinary retention". Emerg Med Pract. 16 (1): 1–20, quiz 21. PMID 24804332.
  9. ↑ Verzotti G, Fenner V, Wirth G, Iselin CE (November 2016). "[Acute urinary retention: a mechanical or functional emergency]". Rev Med Suisse (in French). 12 (541): 2060–2063. PMID 28700149.
  10. ↑ Selius BA, Subedi R (2008). "Urinary retention in adults: diagnosis and initial management". Am Fam Physician. 77 (5): 643–50. PMID 18350762.
  11. ↑ Hennenfent BR, Lazarte AR, Feliciano AE. Repetitive prostatic massage and drug therapy as an alternative to transurethral resection of the prostate. MedGenMed. 2006 Oct 25;8(4):19. PMID: 17415302.

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