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*Long surgical procedure
*Long surgical procedure
*Large amount of Intraoperative fluids
*Large amount of Intraoperative fluids
*Reginal [[anesthesia]]
*Regional [[anesthesia]]
*Underlying bladder disease
*Underlying bladder disease
*Previous pelvic surgery
*Previous pelvic surgery

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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]
  • Mode of disease, Traumatic or non-traumatic.

Pathophysiology

The main pathophysiology behind urine retention is:[1]

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

Some risk factors related to surgery:

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

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:

Diagnosis

Diagnostic Study of Choice

The diagnosis of urinary retention is made through history, physical exam, and lab test (to find the specific cause). 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 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.
  • 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 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.
  • Common physical examination findings of the disease include unable to void, lower abdominal pain, back pain, and acute distress if the bladder is full.
  • 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


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.[6]

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. ↑ Serlin DC, Heidelbaugh JJ, Stoffel JT (2018). "Urinary Retention in Adults: Evaluation and Initial Management". Am Fam Physician. 98 (8): 496–503. PMID 30277739.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ Selius BA, Subedi R (2008). "Urinary retention in adults: diagnosis and initial management". Am Fam Physician. 77 (5): 643–50. PMID 18350762.
  6. ↑ 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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