• Clinical science

Urinary retention

Summary

Urinary retention is the inability to voluntarily empty the bladder. The causes can be either mechanical (e.g., benign prostatic hyperplasia, tumors, urethral strictures) or functional (e.g., detrusor underactivity due to peripheral neuropathy, anticholinergic drugs). Patients with acute urinary retention (AUR) present with a sudden, painful inability to void and a tender, distended bladder on palpation. Patients with chronic urinary retention (CUR) are typically unable to void completely but do not experience pain. AUR is usually diagnosed clinically and is considered a urological emergency. Therefore, urgent bladder catheterization should precede diagnostics. These include renal function tests to assess for renal damage (obstructive nephropathy) and ultrasound of the kidneys, ureter, and bladder to identify the underlying cause and possible complications (e.g., hydroureteronephrosis). Further evaluation depends on the patient history and physical examination. Treating the underlying cause (e.g., alpha adrenergics and/or TURP for BPH) is essential to prevent recurrence and complications due to urinary retention, such as UTI, nephrolithiasis, and renal failure.

Etiology

Mechanical obstruction

Functional obstruction

References:[1][2][3][3][4][5][6][7]

Clinical features

Acute urinary retention Chronic urinary retention
Etiology
Clinical features
  • More common in men, esp. > 70 years of age
  • Sudden onset
  • Painful inability to void
  • Suprapubic pain/discomfort
  • Palpable bladder
  • Patient is restless and distressed.

Physical examination

  • Abdominal and pelvic examination: urethra (for discharge/meatal stenosis), prepuce (retractability), vaginal examination (evaluation for a pelvic mass)
  • Digital Rectal Exam (DRE): to evaluate prostate size and tenderness, detect a rectal mass or fecal impaction, assess sphincter tone.
  • Complete neurological examination

Complications

References:[8][9][10][11]

Subtypes and variants

Urethral stricture

  • Definition: narrowing of the urethra with possible restriction of urinary flow
  • Etiology
    • Traumatic or iatrogenic (instrumentation/catheterization)
    • Post-infectious (e.g., urethritis)
    • Congenital
    • Idiopathic
  • Clinical features[12]
  • Diagnostics
  • Treatment
    • Internal urethrotomy: endoscopic transurethral approach; incision at 12 o'clock position to release strictures/scar tissue
    • Urethroplasty: open reconstruction with excision of the fibrotic urethra and reanastomosis ; indicated if urethrotomy fails
    • Permanent urethral stents: placed endoscopically; indicated in patients with short-length strictures

References:[13]

Diagnostics

AUR is a urological emergency and urgent bladder catheterization should precede any further investigations. If the diagnosis is uncertain, abdominal ultrasound/bladder scan should be performed first to assess bladder volume. In patients with postoperative AUR, further investigations are usually not needed.

Laboratory studies

Imaging

  • Ultrasound of the kidney, ureter, and bladder: indicated in all patients with urinary retention
    • AUR: bladder distended with > 400 mL of urine
    • CUR: post-void residual volume > 300 mL; bladder wall thickening (in chronic obstructive urinary retention)
    • In both: evaluate for hydroureteronephrosis (due to BOO); diagnose bladder calculi or BPH, if present

Further investigations

AUR is a urological emergency and requires urgent bladder catheterization before any further investigations are performed!
References:[14][1][15][16][17][18][19]

Treatment

Urgent complete bladder catheterization

In all patients with acute or acute on chronic urinary retention (before further diagnostics)

Treatment of the underlying cause

In all patients with acute or chronic urinary retention:

See “ Posterior urethral valves”, “Genitourinary trauma”, and “Treatment of lower urinary tract obstruction” in “ Urinary tract obstruction” for information on the management of other causative factors.

References:[1][8][20][21][2][22][23]

  • 1. Selius BA, Subedi R. Urinary Retention in Adults: Diagnosis and Initial Management. Am Fam Physician. 2008; 77(5): pp. 643–650. url: http://www.aafp.org/afp/2008/0301/p643.html.
  • 2. Miyamae K, Otsuka T, Otsuka Y, Nagayoshi M, Hamada Y. Clinical study of bladder tamponade resulting from clots of blood [Article in Japanese]. Nippon Hinyokika Gakkai Zasshi. 2006; 97(5): pp. 743–747. pmid: 16898598.
  • 3. Crain EF, Gershel JC, Cunningham SJ. Clinical Manual of Emergency Pediatrics. Cambridge University Press; 2010.
  • 4. Tammela T. Urinary bladder tamponade (blood clots in the bladder). http://www.ebm-guidelines.com/go/ebm/ebm00239.html. Updated March 21, 2016. Accessed March 14, 2017.
  • 5. Ali RA. Management of diabetic neuropathy. Malays J Med Sci. 2003; 10(2): pp. 27–30. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3561884/.
  • 6. Verhamme KMC, Miriam M, Stricker BHCh, Bosch R. Drug-Induced Urinary Retention: Incidence, Management and Prevention. Drug Saf. 2008; 31(5): pp. 373–388. doi: 10.2165/00002018-200831050-00002.
  • 7. Barrisford GW, Steele GS. Acute urinary retention. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/acute-urinary-retention. Last updated September 21, 2015. Accessed March 14, 2017.
  • 8. Kalejaiye O, Speakman MJ. Management of Acute and Chronic Retention in Men. Eur Urol Suppl. 2009; 8(6): pp. 523–529. doi: 10.1016/j.eursup.2009.02.002.
  • 9. Map of Medicine. Acute urinary retention (AUR) in adult males. url: http://www.htmc.co.uk/resource/data/htmc1/docs/Acute%20Urinary%20Retention%20in%20Adult%20Males.pdf Accessed March 14, 2017.
  • 10. Stoffel J, Lightner D, Peterson A, et al. non-neurogenic chronic Urinary Retention: consensus Definition Management Strategies, and Future Opportunities. url: https://www.auanet.org/common/pdf/education/clinical-guidance/Non-Neurogenic-Chronic-Urinary-Retention-White-Paper.pdf Accessed March 14, 2017.
  • 11. Stoffel JT, Peterson AC, Sandhu JS, Suskind AM, Wei JT, Lightner DJ. AUA White Paper on Nonneurogenic Chronic Urinary Retention: Consensus Definition, Treatment Algorithm, and Outcome End Points. J Urol. 2017; 198(1): pp. 153–160. doi: 10.1016/j.juro.2017.01.075.
  • 12. Rourke K, Hickle J. The Clinical Spectrum of the Presenting Signs and Symptoms of Anterior Urethral Stricture: Detailed Analysis of a Single Institutional Cohort. Urology. 2012; 79(5): pp. 1163–1167. doi: 10.1016/j.urology.2012.01.044.
  • 13. Broghammer JA. Urethral Strictures in Males. In: Urethral Strictures in Males. New York, NY: WebMD. http://emedicine.medscape.com/article/450903. Updated November 21, 2015. Accessed March 15, 2017.
  • 14. Aliasgari M, Soleimani M, Hosseini moghaddam SM. The effect of acute urinary retention on serum prostate-specific antigen level. Urol J. 2005; 2(2): pp. 89–92. pmid: 17629877.
  • 15. Mustonena S, Ala-Houhalab IO, Vehkalahtic P, Laippalad P, Tammelaa TLJ. Kidney ultrasound and Doppler ultrasound findings during and after acute urinary retention. Eur J Ultrasound. 2001; 12(3): pp. 189–196. doi: 10.1016/S0929-8266(00)00115-4.
  • 16. Lukacz ES, Sampselle C, Gray M, et al. A healthy bladder: a consensus statement. Int J Clin Pract. 2011; 65(10): pp. 1026–1036. doi: 10.1111/j.1742-1241.2011.02763.x.
  • 17. Kumar V, Dhabalia JV, Nelivigi GG, Punia MS, Suryavanshi M. Age, gender, and voided volume dependency of peak urinary flow rate and uroflowmetry nomogram in the Indian population. Indian J Urol. 2009; 25(4): pp. 461–466. doi: 10.4103/0970-1591.57912.
  • 18. Dorsher PT, Mcintosh PM. Neurogenic bladder. Adv Urol. 2012. doi: 10.1155/2012/816274.
  • 19. Shenot PJ. Neurogenic Bladder. http://www.msdmanuals.com/professional/genitourinary-disorders/voiding-disorders/neurogenic-bladder. Updated September 1, 2016. Accessed February 22, 2017.
  • 20. Willette PA, Coffield S. Current trends in the management of difficult urinary catheterizations. West J Emerg Med. 2012; 13(6): pp. 472–478. doi: 10.5811/westjem.2011.11.6810.
  • 21. Basler J. Hemorrhagic Cystitis. In: Hemorrhagic Cystitis. New York, NY: WebMD. http://emedicine.medscape.com/article/2056130. Updated October 5, 2016. Accessed February 22, 2017.
  • 22. Koc S, Hagglund H, Ireton RC, Perez-Simon JA, Collins SJ, Appelbaum FR. Case Report: Successful treatment of severe hemorrhagic cystitis with cystectomy following matched donor allogeneic hematopoietic cell transplantation. Bone Marrow Transplant. 2000; 26(8): pp. 899–901. url: http://www.nature.com/bmt/journal/v26/n8/full/1702611a.html.
  • 23. West DA, Cummings JM, Longo WE, Virgo KS, Johnson FE, Parra RO. Role of chronic catheterization in the development of bladder cancer in patients with spinal cord injury. Urology. 1999; 53(2): pp. 292–297. pmid: 9933042.
last updated 07/26/2019
{{uncollapseSections(['KzaUFM', 'qzaCFM', '7za48M', 'j1c_gY0', 'GzaB8M', '8zaOuM'])}}