Diagnosis

Urinary retention

Etiology

Cause [cae][uid][muu]

• Obstructive retention:

  • Men: BPH (53% of all causes), prostate cancer, prostatitis, urolithiasis, constipation, bladder neck stricture, urethral stricture, phimosis, paraphimosis, circumcision, meatal stenosis

  • Women: cystocele, rectocele, gynecologic malignancy/pelvic mass, uterine fibroid, ovarian cyst, cervical cancer, Fowler's syndrome, sling procedures, failure of pelvic floor relaxation, poorly fitted pessary, vaginal lichen planus

  • Both: Bladder calculi, bladder neck stenosis, bladder neoplasm, bladder radiation, fecal impaction, constipation, gastrointestinal or retroperitoneal malignancy/mass, urethral strictures/diverticula, urethral cancer, foreign bodies, stones

• Infectious and inflammatory:

  • Men: Balanitis, prostattic abscess, prostatitis, posthitis

  • Women: Acute vulvovaginitis, Behçet's syndrome, vaginal lichen planus, vaginal pemphigus

  • Both: Urinary tract infection, aneurysm, schistosomiasis, Gullian-Barrè syndrome, herpes simplex virus (genital herpes), Lyme disease, periurethral abscess, transverse myelitis, tubercular cystitis, urethritis, varicella-zoster virus

• Non-obstructive retention:

  • Trauma: childbirth, penis fracture, pelvic trauma, iatrogenic nerve injury (surgery)

  • Neurologic: stroke, CNS-patology (multiple sclerosis, brain tumor, hydrocephalus, Parkinson disease, cerebral palsy), meningomyelocele, detrusor sphincter dyssynergia, neurogenic bladder, diabetes mellitus, Gullian-Barrè syndrome, cauda equina syndrome, heavy metal poisoning, Parkinson disease

  • Drug side effects: Post-operative due to anesthesia, NSAIDs, anticholinergic, antiarrhytmics, antidepressants, antihistamines, antihypertensives, antiparkinsonian, antipsychotics, hormonal agents, muscle relaxants, α-adrenergic, β-adrenergic, amphetamine, carbamazepinem opioids, vincristine

Pathophysiology [muu]

1. Voluntary urination requires close coordination between muscles of the pelvic floor, bladder, and urethra

2. Any disruption along the pathway can cause urinary retention

   • Mechanical obstruction: urinary channel narrowing, extrinsic compression, increased sphincter muscle tone

   • Neurological impairment: inadequate urinary driving force such as incomplete relaxation of the urinary sphincter, inefficient detrusor muscle contraction

3. Clinical manifestation:

   • The inability to empty the bladder after urination

   • Frequent urination in small amounts

   • Hesitancy or difficulty in starting the flow of urine

   • Slow or weak urinary stream

   • The urgent need to urinate, but with little success

   • The feeling of the need to void again shortly after urinating

Complications [uid]

• Electrolyte imbalance

• UTI

• Pyelonephritis

• Urosepsis

• Hydroureter and hydronephrosis

• Renal failure

• Bladder rupture

Epidemiology

Incidence per 100.000 [qtf][zbs][yos]

Approach

• Blood test: PSA, blood glucose, creatinine, BUN, electrolytes

• Urine stix

• Urine culture

• Digital rectal examination

• Bladder scan

• Ultrasound abdomen

• Cystoscopy

• Urodynamic studies

• CT abdomen

• MRI

Treatment

1. Bladder decompression: [cae][uid]

   • Urethral catheter (permanent or clean intermittent self-catheterization)

   • Suprapubic catheter

   • Cystoscopy

2. Medical treatment (prophylaxis): start after catheter placement

   • α1-Blocker (tamsulosin)

   • 5α-Reductase Inhibitor

3. If postvoid residual urine volume > 300 mL or lower urinary tract symptoms --> referral to urologic department for diagnostics and treatment

   • BPH --> transurethral resection of the prostate (TURP)

   • Urethral stricture --> dilation

   • Gynecologic treatment: pessary or surgery

   • Sacral neuromodulation or tibial nerve stimulation

Differential diagnoses

Ascites, Bladder cancer, Constipation, Gastrointestinal obstruction, Hypovolemia, Periurethral abscess, Phimosis, Prostate cancer, Renal failure, Stroke, Urolithiasis