Mary K. Powers, MD
Raju Thomas, MD, MHA, FACS
BASICS
DESCRIPTION
• Urinary retention is the inability to properly empty the urinary bladder. It can be further classified as acute and chronic.
– Acute retention of urine is defined by the International Continence Society (ICS) as a painful, palpable or percussable bladder, when the patient is unable to pass any urine (1).
– Chronic retention of urine is defined by the ICS as a non-painful bladder, which remains palpable or percussable after the patient has passed urine. Such patients may be incontinent (1).
• Females can void with low detrusor pressures and valsalva, making diagnosis more complicated than the old adage “high pressure, low flow”
EPIDEMIOLOGY
Incidence
Occurs in 2.7–23% of women, most commonly after anti-incontinence surgery
Prevalence
Usually self-limited
RISK FACTORS
• Anti-incontinence surgery (eg, urethral slings)
• Diabetes
• Neurologic conditions
• Psychological conditions
Genetics
N/A
PATHOPHYSIOLOGY (2)
• Kinking or stricture of the urethra depending on procedure performed or anatomy
• Cases of neurologic complications include detrusor acontractility versus detrusor sphincter dyssynergia
• Diabetes mellitus, causing low detrusor tone
ASSOCIATED CONDITIONS
• Chronic constipation
• Multiple sclerosis (MS)
• Pelvic organ prolapse (POP)
• Spinal cord injury
• Stress urinary incontinence
GENERAL PREVENTION
• Avoidance of anti-incontinence surgery or optimization of patient selection and/or surgical technique
• Quick detection of neurologic conditions
DIAGNOSIS
HISTORY
• Complaints of frequency, decreased force of stream, urgency or urge incontinence, or UTI are indicative of bladder outlet obstruction (BOO)
• Feeling of vaginal bulge
• History of stroke, diabetes, MS, Parkinson’s disease, “back problems,” neurologic conditions, depression
• Chronic narcotic medication use
• Chronic constipation
• Use of psychotropic medication
PHYSICAL EXAM
• Examine abdomen to evaluate any prior surgeries
• Bladder distension
• Pelvic examination:
– Urethral hypermobility, cystocele, pelvic organ prolapse, diverticulum, vaginal/pelvic mass, rectal prolapse, or rectocele
• Motor/sensory tone to rule out neurologic disorder
• Stress urinary incontinence (or overflow incontinence)
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis
• Urine culture
• Complete metabolic panel
Imaging
• Ultrasound:
– Measure post-void residual urine
– Look for hydronephrosis
• MRI of brain/spinal cord in young females with new onset voiding symptoms (MS, occult spinal dysraphism)
Diagnostic Procedures/Surgery
• Videourodynamics show high pressure, low flow state with closed bladder neck in primary BOO, “spinning top”
– Flow rate less than 12 mL/s with maximum detrusor pressure of 20 cm H2O
– Uroflow—”saw tooth” pattern. Does not distinguish between BOO and decreased detrusor function
– EMG of sphincter to assess for sphincter/detrusor coordination
• Cystoscopy to assess for stones, eroded material, diverticulum, extrinsic mass, stricture, or kinking
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Iatrogenic (26%)—most commonly following anti-incontinence surgery.
– 2–8% of women require reintervention.
– Retropubic suspension can cause urethral “kinking”
– Tension-free vaginal tape has lowest rage of retention
– Retention is frequently self-limited and will resolve within 6–12 wk following anti-incontinence surgery
Manage with catheterization or clean intermittent catheterization
• Anatomic:
– Urethral stricture (13%)
– Ectopic ureterocele
– Urethral diverticulum (3%)
– Urethral malignancy
– Bladder neck obstruction
– Pelvic organ prolapse (24%)
• Dysfunctional Voiding (5%)
– Pseudomyotonia—severe spasticity of sphincter without nerve stimulation (rare)
– Fowler syndrome—young women without neurologic disease. Highly responsive to neuromodulation.
Higher incidence of depression and polycystic ovarian syndrome
• Neurologic
– Detrusor sphincter dyssynergia (5%)
• Pharmacologic
– Anticholinergic, opioid, and other narcotic medications
Antihistamines
Anticholinergics: Atropine, belladonna, benztropine, mesylate, cyclic antidepressants, phenothiazines, ipratropium bromide
Antispasmodics
Tricyclic antidepressants
α-Agonists: Cold preparations, ephedrine derivatives, amphetamines
Narcotics
Detrusor muscle relaxants: Tolterodine, trospium, oxybutynin, solifenacin, hyoscyamine
NSAIDS
• Psychogenic
• Myogenic (eg, detrusor acontractility)
TREATMENT
GENERAL MEASURES (3)
• Treatment based on underlying cause
• Stop medications predisposing to retention
• Evaluation and management of chronic constipation/bowel dysfunction
• Foley catheterization vs. clean intermittent catheterization (preferred) to manage acute retention
MEDICATION
First Line
• Alpha-adrenergic blockade can be useful in patients with dysfunctional voiding
– Tamsulosin: 0.4 mg daily
– Doxazosin: 1–4 mg daily
– Terazosin: 1–5 mg daily
– Prazosin: 1–5 mg daily
Second Line
• Baclofen for patients with neurologic causes of dysfunctional voiding
– 5 mg TID, increase 15 mg/d q3 days, max. 80 mg/d divided TID/QID
SURGERY/OTHER PROCEDURES
• For iatrogenic causes, intervention should be postponed for a period of 12 wk to allow for stabilization of symptoms
– Urethrolysis is the gold standard, circumferentially free the urethra
Recurrence or development of stress incontinence high as 30%
– Bladder neck incision/resection has mixed result in primary bladder neck obstruction, caution not to cut too deep and develop fistulas
– Refractory strictures can undergo reconstruction with vaginal flap
ADDITIONAL TREATMENT
Radiation Therapy
NA
Additional Therapies
• Urethral dilation for urethral strictures. Caution because this can lead to fibrosis and is falling out of favor.
• Clean intermittent catheterization may be best choice for patients with acontractile bladder
• Constipation management
– Colace 100 mg 1 tab by mouth BID
– Magnesium citrate 250 mL PO
Complementary & Alternative Therapies
Concurrent evaluation and management by gastroenterology
ONGOING CARE
PROGNOSIS
• Depends on the etiology
– Iatrogenic retention following slings has a good success rate with urethrolysis up to 92%
– α-Blockade shows 50% improvement in PVR, symptoms, and flow rate
COMPLICATIONS
• Urethrolysis can lead to development of stress incontinence
• Bladder neck incision can lead to incontinence, vesicovaginal fistula, or need for repeat procedures
• Urethral dilation can cause recurrent stricture and fibrosis
FOLLOW-UP
Patient Monitoring
• Repeat urodynamic studies are recommended if problem persists
• Videourodynamics should be done if concern for bladder neck obstruction
• Neurologic evaluation if new diagnosis of MS, Parkinson’s disease
Patient Resources
National Kidney and urologic diseases information clearinghouse. http://kidney.niddk.nih.gov/kudiseases/pubs/UrinaryRetention/
REFERENCES
1. Abrams P. The standardisation of terminology in lower urinary tract function: Report from the standardisation sub-committee of the International Continence Society. Urology. 2003;61(1):37.
2. Buchko BL, Robinson LE. An evidence-based approach to decrease early post-operative urinary retention following urogynecologic surgery. Urol Nurs. 2012;32(5):260–264.
3. Kuznetsov D, Kobashi K. Bladder outlet obstruction in females. AUA Update Series. 2005;7(24):53–60.
ADDITIONAL READING
• Adelowo AO, Hacker MR, Merport Modest A, et al. Do symptoms of voiding dysfunction predict urinary retention? Female Pelvic Med Reconstr Surg. 2012;8(6):344–347.
• Kim JW, Moon du G, Shin JH, et al. Predictors of voiding dysfunction after mid-urethral sling surgery for stress urinary incontinence. Int Neurolurol J. 2012;16(1):30–36.
• Yande S, Joshi M. Bladder outlet obstruction in women. J Midlife Health. 2011;2(1):11–17.
See Also (Topic, Algorithm, Media)
• Bladder Outlet Obstruction (BOO)
• Multiple Sclerosis, Urologic Considerations
• Pelvic Organ Prolapse (Cystocele and Enterocoele)
• Urinary Retention after Stress Urinary Incontinence Surgery in Females
• Urinary Retention, Adult Male
• Urinary Retention, Adult Male Algorithm 
• Urinary Retention, Pediatric
• Urinary Retention, Postoperative
CODES
ICD9
• 598.9 Urethral stricture, unspecified
• 788.20 Retention of urine, unspecified
• 788.29 Other specified retention of urine
ICD10
• N35.9 Urethral stricture, unspecified
• R33.8 Other retention of urine
• R33.9 Retention of urine, unspecified
CLINICAL/SURGICAL PEARLS
• There are multiple causes of urinary retention in females; urodynamics can help distinguish causes.
• In young females with new onset voiding complaints must rule out diabetes or neurologic diagnosis such as MS.
• Pelvic organ prolapse is a major cause of retention.