Dana A. Weiss, MD
Douglas A. Canning, MD, FACS
BASICS
DESCRIPTION
• Urinary retention is the inability to properly empty the urinary bladder. Can be acute or chronic partial or complete.
– Acute
Uncommon in children
Acute onset of inability to void for over 12 h
Associated with uncomfortable often painful sensation and distended bladder.
– Chronic
Inability to void over long period of time
Usually asymptomatic
EPIDEMIOLOGY
Incidence
Not reported
Prevalence
2:1 boys:girls
RISK FACTORS
• Acute onset
– Surgery, narcotic use, immobility, urinary tract infection (bacterial or viral), local inflammation (balanitis, meatal stenosis, labial adhesions, cellulitis), constipation, incarcerated inguinal hernia, acute neurologic inflammatory processes, invasive mass, drug related
• Chronic
– Dysfunctional voiding, Hinman syndrome (non-neurogenic neurogenic bladder), lazy bladder syndrome, spina bifida, reduced mental status, benign obstructing mass, locally invasive mass, posterior urethral valves, prune belly syndrome
Genetics
Genes related to underlying etiology
PATHOPHYSIOLOGY
• Obstruction
– External compression, intrinsic obstruction by valve, stone, stricture, etc.
• Neurogenic bladder
• Inflammation/infection
– Effect on brain/meninges (encephalitis, meningitis), spinal cord (transverse myelitis), nerve roots (radiculitis), peripheral nerves (neuritis)
• Constipation (1)
– Distended rectum displaces bladder and trigone anteriorly, impairing bladder outflow. Impairment of urethrovesical and sacral reflexes from rectal distension.
• Drug related
– Disruption of autonomic balance between bladder and proximal urethra
ASSOCIATED CONDITIONS
• Dysfunctional elimination syndrome
• Neurologic inflammatory disorders: Transverse myelitis, Guillain–Barré syndrome, encephalitis
• Neurologic neoplasms: neuroblastoma, ependymoma, Ewing sarcoma
• Benign neurologic abnormalities: Tethered cord
• Inflammatory conditions
• Obstructive processes
– Posterior urethral valves, prune belly syndrome, urethral strictures, foreign body, or stones
GENERAL PREVENTION
Early education of proper voiding habits (drinking water, voiding 6–8 times per day, avoiding constipation).
DIAGNOSIS
HISTORY
• Recent events, including surgery
• Subtle neurologic changes
• History of constipation
• History of hematuria, dysuria
• Recent medications
PHYSICAL EXAM
• Palpable mass (bladder)
• External genitalia exam
– Meatal stenosis, phimosis, balanoposthitis; labial adhesions, prolapsed urethra
• Spine and lower back
– Sacral dimple, sacral tuft
• Motor and sensory exam
• Digital Rectal exam
– Tone
– Mass
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis
• Urine culture
• Electrolytes
– Creatinine, potassium, magnesium
Imaging
• Renal bladder ultrasound (RBUS), pelvic ultrasound
• MRI spine (if no other etiology identified)
• Voiding cystourethrogram (VCUG) if concern for PUV, stricture (wait until urine culture negative prior to study)
• Retrograde urethrogram
Diagnostic Procedures/Surgery
• Urodynamic evaluation
• Cystoscopy
Pathologic Findings
Based on etiology
DIFFERENTIAL DIAGNOSIS
• Obstruction
– Tumor
– Benign mass (fibroepithelial polyp)
– Urethral valves (posterior or anterior)
– Urethral stone
– Prolapsing ureterocele
– Urethral stricture
– Paraurethral cyst
– Hydrometrocolpos
• Inflammation
– Cystitis (bacterial or viral) (2)
– Bacterial
Gram positive
Gram negative
– Viral
Herpes simplex virus (HSV)
Varicella Zoster virus (VZV)
Cytomegalovirus (CMV)
Epstein Barr Virus (EBV)
– Eosinophilic cystitis
– Prostatic abscess
• Neurogenic dysfunction
– Neuropathic bladder
Myelomeningocele
Sacrococcygeal teratoma
Prune belly syndrome
Tethered spinal cord
– Detrusor sphincter dyssynergia
• Other
– Constipation
– Adverse drug effect
– Trauma
– Electrolyte abnormalities (hypermagnesemia) (1)
TREATMENT
GENERAL MEASURES
• Empty bladder with catheter
• Initiate clean intermittent catheterization until resolution.
• Complete workup based upon findings on history and physical exam
• For chronic retention, after complete workup to rule out pathologic cause, begin behavioral modification (increase water intake, increasing voiding attempts to every 3 h, treat constipation)
MEDICATION
First Line
• Polyethylene Glycol 3350 for constipation/dysfunctional elimination syndrome
– 0.5–1.5 g/kg daily, max. dose 17 g/d.
Use only in children older than 6 mo
Second Line
• α-Blockers (3,4)
– Smooth muscle relaxation and decreased bladder outlet resistance:
Doxazosin <6 yr 0.5 mg daily
Doxazosin >6 yr 1 mg daily
• Steroids for inflammatory processes (2)
– Very seldom used. Stress dose steroids.
SURGERY/OTHER PROCEDURES
• In acute setting, place urethral catheter
• If unable to place catheter, place suprapubic cystostomy tube.
• For posterior urethral valves, perform cystoscopy, transurethral incision of valves.
• For urethral stones, cystoscopy and laser lithotripsy or basket extraction (may require antegrade and retrograde approach).
• For obstructing fibroepithelial polyp, transurethral resection possible, vs. open cystotomy and excision.
• For obstructing prolapsing ureterocele, incision of ureterocele may leave obstructing tissue. May require excision of ureterocele and bladder neck reconstruction.
• Urethral stricture—based on length
• For significant detrusor sphincter dyssynergia, may benefit from botulinum toxin injection into urethral sphincter vs. urethral dilation
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Behavioral modification
– Timed voiding
– Increased water intake
– Pelvic floor relaxation
Complementary & Alternative Therapies
Biofeedback program for dysfunctional elimination syndrome
ONGOING CARE
PROGNOSIS
Based upon etiology.
COMPLICATIONS
• Bladder rupture in acute urinary retention; usually associated with trauma
• Postobstructive diuresis after relief of acute retention
• Urinary tract infection from stasis of chronic retention
• Chronic retention with high detrusor pressure can lead to renal impairment
• Missed diagnosis of malignant cause of urinary retention
FOLLOW-UP
Patient Monitoring
• Monitor for post-obstructive diuresis after drainage. May require fluid replacement in neonates
• Follow uroflow and post-void residual after treatment
Patient Resources
National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). http://kidney.niddk.nih.gov/kudiseases/pubs/UrinaryRetention/
REFERENCES
1. Gatti JM, Perez-Brayfield M, Kirsch AJ, et al. Acute urinary retention in children. J Urol. 2001;165:918–921.
2. Chu SD, Singer JS. Acute urinary retention secondary to Epstein-Barr Virus infection in a pediatric patient: A case report and review of causes of acute urinary retention. Urology. 2013;81(5):1064–1066.
3. Thom M, Campigotto M, Vemulakonda V, et al. Management of lower urinary tract dysfunction: A stepwise approach. J Ped Urol. 2012;8:20–24.
4. Austin PF, Homsy YL, Masel JL, et al. α-Adrenergic blockade in children with neuropathic and non-neuropathic voiding dysfunction. J Urol. 1999;162:1064–1067.
ADDITIONAL READING
N/A
See Also (Topic, Algorithm, Media)
• Posterior Urethral Valves
• Prune Belly Syndrome
• Sacral agenesis, urologic considerations
• Ureterocele
• Urinary Retention, Adult Female
• Urinary Retention, Adult Male
• Urinary Retention, Adult Male Algorithm 
• Urinary Tract Infection, Complicated Pediatric
CODES
ICD9
• 596.0 Bladder neck obstruction
• 599.0 Urinary tract infection, site not specified
• 788.20 Retention of urine, unspecified
ICD10
• N32.0 Bladder-neck obstruction
• N39.0 Urinary tract infection, site not specified
• R33.9 Retention of urine, unspecified
CLINICAL/SURGICAL PEARLS
• Urinary retention in a newborn must be closely evaluated with RBUS and VCUG to rule out posterior urethral valves, ureterocele, and urethral atresia.
• Young boys presenting with acute urinary retention should undergo DRE to rule out prostatic or bladder rhabdomyosarcoma.