Amar J. Raval, MD
Akhil Das, MD, 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).
EPIDEMIOLOGY
Incidence
Incidence increases with age in males (∼10% in men aged 70 yr)
Prevalence
Exact prevalence is difficult to estimate
RISK FACTORS
• General: Diabetes, herpes zoster, drugs, psychogenic, neurologic disease, bladder calculus, recent surgery (especially with epidural or spinal anesthesia), groin surgery such as hernia repair, prostate brachytherapy, stroke, pelvic trauma
• Elderly men: BPH, prostate cancer, history of retention, urologic procedures or instrumentation, medications, prostatitis, urothelial carcinoma (rare cause)
• Recent inguinal/pelvic surgery (ie, hernia)
• Medications:
– Antihistamines
– Anticholinergics: Atropine, belladonna, benztropine, mesylate, phenothiazines, ipratropium bromide
– Antispasmodics
– Tricyclic antidepressants
– α-Agonists: Cold preparations, ephedrine derivatives, amphetamines
– Narcotics
– Detrusor muscle relaxants: Tolterodine, trospium, oxybutynin, solifenacin, hyoscyamine
– NSAIDS
Genetics
• Increased risk of moderate-to-severe symptoms in men with positive family history
– Some BPH thought to be inherited in pattern consistent with autosomal dominant pattern
PATHOPHYSIOLOGY
• Most commonly occurs in patients with preexisting bladder outlet obstruction or with a known history of neurologic voiding dysfunction.
• Infection, bleeding, or over distension is the usual precipitating event.
• Drainage of bladder results in prompt symptomatic relief.
• Although acute retention is usually thought of as painful, in certain circumstances pain may not be a presenting feature.
– When due to prolapsed intervertebral disc, post partum, or after regional anaesthesia such as an epidural anesthetic.
– The retention volume should be significantly greater than the expected normal bladder capacity.
– In patients after surgery, due to bandaging of the lower abdomen or abdominal wall pain, it may be difficult to detect a painful, palpable, or percussible bladder (1).
ASSOCIATED CONDITIONS
• Diabetes
• Disease of prostate
– BPH
– Prostate cancer
– Prostatitis
• Neurologic conditions
– Neurogenic bladder
– Multiple sclerosis
– Cerebrovascular accident
– Parkinson disease
– Spinal cord injury
– Demyelinating disorders
• UTI
• Recent hernia or other surgery
DIAGNOSIS
HISTORY
• Acute retention: Sudden onset of the inability to void more than small volumes of urine
– Associated with an uncomfortable sensation and a distended bladder
• Chronic retention: Longstanding inability to completely void, with occasionally large PVRs, but not usually associated with discomfort.
– Common symptoms include frequency, urgency, overflow incontinence, and weak urinary stream
• Retention may suggest infection or BPH:
– Symptoms of bladder outlet obstruction: Weak stream, hesitancy, incomplete voiding, dribbling.
– Symptoms of irritative voiding: Frequency, urgency, dysuria, nocturia
• Previous urinary retention
• Urologic procedure/instrumentation resulting in scarring, stricture, or clot retention.
• STDs
• Strictures
• Medication use
• Recent gross hematuria, resulting in clot retention.
• Pain: Bone pain and weight loss suggest prostate cancer.
• Spinal cord injury or pelvic trauma.
• Recent surgery, especially in those with spinal or epidural anesthesia.
• Diabetes mellitus
PHYSICAL EXAM
• Palpable abdominal mass
– Assess for severe urgency and/or pain on suprapubic palpation
• DRE
– Symmetrically enlarged prostate suggests BPH
– Nodularity suggests cancer
– Boggy, tender prostate suggests prostatitis
• Complete neurologic exam if suspicion for a neurologic etiology exists
– Anal (S2) and levator muscle tone (S3–S4)
– Check sensation over the penis (S2), perianal area (S2–S3), outside of the foot (S2), sole (S2–S3), and large toe (S3)
– Suspect spina bifida or meningomyelocele when extremity findings do not parallel perineum findings, ie, absent sensation and tone in feet but partial tone or sensation in perineum
• Examine genitalia for rashes or lesions, ie, herpes zoster flare
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Chemistry: BUN and creatinine may be abnormal in retention especially if hydronephrosis is present
– Increased post obstructive diuresis risk with post renal obstructive renal failure
• Urinalysis and culture
– Leukocyte esterase or nitrite positivity with pyuria suggests infection
– Hematuria suggestive of infection, tumor, or calculi
• PSA usually not checked acutely due to false positive with prostatitis, recent prostate surgery, etc.
Imaging
• Bedside bladder scan
– Post void residual (PVR) can be obtained and useful for diagnosis of acute and chronic urinary retention
• Renal/bladder US
– Can be obtained if diagnosis uncertain
– Can delineate hydronephrosis and/or bladder wall thickening
• CT of abdomen/pelvis
– Can delineate bladder calculi, prostate size, hydronephrosis, bladder wall thickening, obstructing masses, and foreign bodies
• Retrograde urethrogram
– Obtained if history of pelvic trauma with new onset urinary retention to rule out urethral injury
Diagnostic Procedures/Surgery
• Foley catheter placement for bladder drainage is diagnostic and curative
• Cystoscopy for definitive diagnosis or acutely to place catheter
• Urodynamic studies
– Uroflowmetry, cystometrogram, electromyography, urethral pressure profile, pressure flow studies
DIFFERENTIAL DIAGNOSIS
• Generally either bladder outlet obstruction or bladder dysfunction:
– Anatomic:
Penis: Phimosis, paraphimosis, meatal stenosis, foreign-body constriction
Urethra: Tumor, foreign body, calculus, urethritis, stricture, clot retention, hematoma
Prostate: BPH, prostate cancer, bladder neck contracture, prostatitis, prostatic infarction
– Trauma
Urethral disruption
– Neurologic
Motor paralytic: Spinal shock, spinal cord syndromes, ie, spina bifida, meningomyelocele
Sensory paralytic: Tabes dorsalis, diabetes, multiple sclerosis, and pernicious anemia
Syringomyelia, myasthenia gravis
Herpes zoster, poliovirus
Herniated disks
– Drugs: see “Risk Factors”
TREATMENT
GENERAL MEASURES
• Acute retention: Catheterization for decompression
– In men with BPH, consider immediate α-blocker therapy to improve likelihood of successful catheter removal
– Some consider suprapubic tube (SPT) superior in the management of short-term retention
• Chronic retention: Clean intermittent catheterization preferred over long-term indwelling catheter
• Definitive management may involve medications, surgical intervention, or chronic catheterization strategies
• Urodynamic studies may be required to establish diagnosis
• Treatment should be directed toward cause, with goal of preventing future episodes
• Antibiotics as indicated for infection
• Decrease or stop medications that can contribute to voiding dysfunction
MEDICATION
First Line
• Most medications are used for BPH; may also help with transient postoperative retention (2).
• α-Adrenergic blockers: Relax prostatic/bladder neck smooth muscle tone, most useful for acute retention
– Alfuzosin 10 mg/d
– Doxazosin start 1 mg/d to max. 8 mg
– Silodosin 8 mg/d
– Tamsulosin start 0.4 mg to max. 0.8 mg
– Terazosin start 1 mg/d to max. 20 mg
• Side-effects: syncope, orthostasis, retrograde ejaculation, asthenia, and nasal congestion
• 5α-reductase inhibitors: Reduce prostatic volume, longer-term effects
– Finasteride or dutasteride
– Side-effects: Decreased libido and sexual dysfunction
– Reduce PSA by ∼50% and correction should be used when evaluating risk for cancer
• Combination therapy (α-adrenergic blocker + 5α-reductase inhibitor)
• Tadafil 2.5–5 mg/d FDA approved to treat both lower urinary tract symptoms (LUTS) and erectile dysfunction (ED)
Second Line
• Bethanechol (10–50 mg PO tid–qid)
– Direct cholinergic stimulant; increases detrusor tone
– Indicated for the treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention and for neurogenic atony of the urinary bladder with retention
– Side effects: Diarrhea, nausea, bronchospasm, hypotension, tachycardia, seizure
SURGERY/OTHER PROCEDURES
• If catheter placement fails, bedside or intraoperative cystoscopy can be performed:
– Cystoscopy is usually diagnostic and can delineate urethral stricture, a false passage, bladder neck contracture, and obstructing prostatic tissue.
– Once bladder is entered under direct vision, a wire can be placed and dilations sequentially performed. The wire can then be used to allow passage of a Council tip catheter.
• If cystoscopy is unsuccessful, consider SPT placement
– Open SPT preferable in patients with history of multiple abdominal surgeries
– If no prior surgery, place SPT via percutaneous approach
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• >30% of patients with an episode of urinary retention will recur if untreated
• Prevention of recurrence underscores management decisions
COMPLICATIONS
• Bladder rupture in acute urinary retention; usually associated with trauma.
• Relief of chronic prolonged obstruction may result in post-obstructive diuresis or major hemorrhage secondary to bladder mucosal disruption or tearing of bladder vessels, hematuria may require evacuation of clots.
• Significant hypotension may occur secondary to vaso-vagal response.
• Longstanding, untreated urinary retention can lead to reflux nephropathy and permanent voiding dysfunction.
FOLLOW-UP
Patient Monitoring
• Monitoring of electrolyte imbalance and fluid resuscitation for post obstructive diuresis (>200 mL/h).
• Patient with signs of infection or impaired renal function should be admitted and observed.
Patient Resources
National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). http://kidney.niddk.nih.gov/kudiseases/pubs/UrinaryRetention/
REFERENCES
1. Curtis LA, Dolan TS, Cespedes RD, et al. Acute urinary retention and urinary incontinence. Emerg Med Clin N Am. 2001;19(3):591–620.
2. Edwards JL. Diagnosis and management of benign prostatic hyperplasia. Am Fam Physician. 2008;77(10):1403–1410.
ADDITIONAL READING
• Groves HK, Chang D, Palazzi K, et al. The incidence of acute urinary retention secondary to BPH is increasing among California men. Prostate Cancer Prostatic Dis. 2013;16(3):260–265.
• Kaplan SA, Wein AJ, Staskin DR, et al. Urinary retention and post-void residual urine in men: Separating truth from tradition. J Urol. 2008;180(1):47–54.
See Also (Topic, Algorithm, Media)
• Bladder Neck Contracture
• Bladder Outlet Obstruction
• Foley Catheter Problems
• Lower Urinary Tract Symptoms
• Post Obstructive Diuresis
• Prostate Cancer, General
• Prostatitis
• Suprapubic Pain
• Urethra, Stricture
• Urinary Retention, Adult Female
• Urinary Retention, Male Algorithm 
• Urinary Retention, Pediatric
• Urinary Retention, Postoperative
CODES
ICD9
• 596.0 Bladder neck obstruction
• 600.91 Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS)
• 788.20 Retention of urine, unspecified
ICD10
• N32.0 Bladder-neck obstruction
• N40.1 Enlarged prostate with lower urinary tract symptoms
• R33.9 Retention of urine, unspecified
CLINICAL/SURGICAL PEARLS
In chronic retention clean intermittent catheterization (CIC) is preferred over long-term indwelling catheter.