Urinary retention
Synonyms and keywords: Ischuria; urine retention

# Overview
- Urinary retention  is a lack of ability to urinate. It is a common complication of benign prostatic hypertrophy (also known as benign prostatic hyperplasia or BPH), although anticholinergics may also play a role, and requires a catheter. Various medications (e.g. some antidepressants) and recreational use of amphetamines and opiates are notorious for this.

# 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.

# Classification
- Based on the duration of symptoms, it may be classified as either acute (500-800ml), acute on chronic (>800ml), or chronic (4L).
- Based on the mode of disease, it can be classified as traumatic or non-traumatic.

# Pathophysiology
The main pathophysiology behind urine retention is:
- Increased urethral resistance secondary to bladder outlet obstruction. The resistance to the flow of urine can occur because of mechanical obstruction such as BPH(most common in men), stricture or  fecal impaction.
- Impaired bladder contractility, (less common cause) a decrease in tone of bladder muscles (smooth or striated).
- Loss of normal bladder sensory or motor innervations to the detrusor muscle is caused by a multiple pathologies of nervous system, for example, spinal cord lesion (traumatic or neurological), diabetic neuropathy,  cauda equina syndrome, cerebrovascular accident, myelitis, spinal stroke.
- Postoperative AUR occurs during a prolonged procedure with the patient non catheterised and in men who have had mild symptoms of BPH preoperatively. It is also exacerbated by the use of opiates, with anticholinergic administration and the generalised increase in alpha-adrenergic activity that is present naturally after surgery, causing increased sphincter tone and constricting neck of bladder. Overdistension of the bladder is seen after a general anaesthetic or a large fluid challenge during procedures.

# Causes

## Life Threatening Causes
- Acute renal failure
- Acute respiratory distress syndrome
- Amitriptyline toxicity
- Amoxapine toxicity
- Black widow spider envenomation
- Bladder cancer
- Bladder papilloma
- Brown snake poisoning
- Cardiomyopathy
- Cathinone poisoning
- Chemical poisoning
- Clomipramine toxicity
- Dehydration
- End-stage renal disease
- Gastrointestinal bleeding
- Heat exhaustion
- Hemorrhagic shock
- Jimsonweed poisoning
- Mycobacterium tuberculosis
- Pelvic malignancies
- Prostate cancer
- Pulmonary venous hypertension
- Rhabdomyosarcoma
- Urethral cancer

## Common Causes
- Benign prostatic hypertrophy
- Prostate cancer
- Pelvic malignancies
- Congenital urethral valve abnormalities
- Detrusor muscle dyssynergia
- Circumcision
- Damage to the bladder
- Aclidinium bromide
- Benztropine
- Chlorpromazine
- Clobazam
- Cetirizine hydrochloride
- Clemastine
- Cytarabine
- Dexchlorpheniramine
- Ezogabine
- Hydrocodone bitartrate,
- Acetaminophen
- Nabilone
- Nalmefene
- Perphenazine
- Pomalidomide
- Thiothixene
- Thioridazine hydrochloride
- Obstruction in the urethra
- Paruresis

## Causes by Organ System

## Causes in Alphabetical Order
- Accelerated hypertension
- Aclidinium bromide
- Acquired angioedema
- Acrylamide
- Acute intermittent porphyria
- Acute prostatis
- Acute renal failure
- Acute respiratory distress syndrome
- Ajuga nipponensis makino
- Alcohol
- Aller-chlor
- Al-r
- Amantadine
- Amitriptyline toxicity
- Ammonical ulceration of the foreskin
- Amoxapine toxicity
- Anaesthesia complications
- Anemic
- Antepartum eclampsia
- Anthraquinone
- Antipsychotic agents
- Anuria
- Aortic arches defect
- Apo-clonidine
- Arsine
- Atropine
- Autonomic neuropathy
- Autumn crocus
- Azotemia
- Benign prostatic hypertrophy
- Benztropine
- Black widow spider envenomation
- Bladder cancer
- Bladder conditions
- Bladder diverticulum
- Bladder neck stenosis
- Bladder obstruction
- Bladder papilloma
- Boric acid
- Botulism
- Bright's disease
- Bromaline elixir
- Bromanate elixir
- Bromatapp
- Brown snake poisoning
- Bucladin-s softab
- Buprenex
- Bywaters' syndrome
- C1esterase deficiency
- Cardiomyopathy
- Cast syndrome
- Catapresan-100
- Catastrophic antiphospholipid syndrome
- Cathinone poisoning
- Cauda equina syndrome
- Cetirizine hydrochloride
- Chemical poisoning
- Chlo-amine
- Chlorate salts
- Chloromethane
- Chlorpheniramine
- Chlor-pro
- Chlorpromazine
- Chlor-trimeton
- Chlor-tripolon
- Cholera
- Chromosome 19p duplication syndrome
- Chronic fatigue syndrome
- Chronic granulomatous disease
- Chronic kidney disease
- Cinnarizine
- Circumcision
- Clemastine
- Clobazam
- Clomipramine toxicity
- Clonidine
- Congenital giant megaureter
- Cyclizine
- Cystocele
- Cytarabine
- Cytosar-u
- Damage to the bladder
- Degenerative disc disease
- Dehydration
- Desipramine
- Detrol
- Detrusor muscle dyssynergia
- Dexchlorpheniramine
- Diabetic neuropathy
- Diamorphine
- Diarrhea
- Diphenhydramine
- Dixarit
- Dobriner syndrome
- Donepezil
- Dothiepin
- Doxepin toxicity
- D-plus hemolytic uremic syndrome
- Duodenal atresia
- Durogesic
- Eclampsia
- Edronax
- End-stage renal disease
- Enlarged prostate
- Eosinophilic cystitis
- Epidural anesthetic
- Ethylene glycol
- Eugenol oil poisoning
- Exposure to cold
- Ezogabine
- Familial visceral myopathy
- Fantonest
- Fentanyl injection
- Fesoterodine
- Fowler-christmas-chapple syndrome
- Gastrointestinal bleeding
- Genatap elixir
- General anesthetic
- Glomerulonephritis
- Glyphosate
- Golden chain tree poisoning
- Goodpasture syndrome
- Haematocolpos
- Hair bleach
- Hair dye
- Heat exhaustion
- Hellp syndrome
- Hemolytic uremic syndrome
- Hemorrhagic shock
- Hepatorenal syndrome
- Hereditary angioedema
- Herpes genitalis
- Herpes zoster
- Hydrocodone bitartrate
- Hydronephrosis
- Hydroxyzine
- Hyperemesis gravidarum
- Hypertension of pregnancy
- Hysteria
- Imipramine toxicity
- Impacted calculus in urethra
- Intrapartum eclampsia
- Jimsonweed poisoning
- Kidney stones
- Kloromin
- Lassa fever
- Leptomeningitis
- Levomepromazine
- Lichen sclerosis
- Malignant hypertension
- Marezine
- Mate
- Mayapple poisoning
- Mckusick-kaufman syndrome
- Megacystitis
- Megaduodenum
- Metastatic prostate cancer
- Mouth wash
- Multiple system atrophy
- Munk disease
- Muscarinic antagonists
- Mycobacterium tuberculosis
- Myelitis
- Myphetapp
- Nabilone
- Naked brimcap poisoning
- Nalmefene
- Naropin with fentanyl
- Neisseria gonorrhoea
- Nephritis
- Nephrotic syndrome
- Neurogenic bladder
- Nortriptyline
- Novo-clonidine
- Nu-clonidine
- Obstruction in the urethra
- Ohss
- Ormazine
- Orotic aciduria
- Orotidylic decarboxylase deficiency
- Oxalosis
- Paruresis
- Pdeunculated bladder tumor
- Pelvic malignancies
- Perazine
- Perirectal abscess
- Perphenazine
- Pethidine
- Phenelzine
- Phenetron
- Phyllodes tumor
- Pipothiazine
- Pizotifen
- Plant poisoning
- Poliomyelitis
- Polyarteritis nodosa
- Polycystic ovaries urethral sphincter dysfunction
- Pomalidomide
- Posterior urethral valve
- Posterior valve
- Postoperative spindle cell nodule
- Postpartum eclampsia
- Post-vaccinial encephalitis
- Pregnancy
- Prochlorperazine
- Prolapse of invertebral disc
- Prostate cancer
- Prostate conditions
- Prostate enlargement
- Prostate hyperplasia
- Prostatic abscess
- Prostatic enlargement
- Prostatic stromal proliferations of uncertain malignant potential
- Protriptyline toxicity
- Prune belly syndrome
- Pudendal nerve entrapment
- Pulmonary branches stenosis
- Pulmonary venous hypertension
- Radiotherapy
- Reboxetine
- Rectal operations
- Renon-delille syndrome
- Retigabine
- Retroperitoneal fibrosis
- Rhabdomyosarcoma
- Sea snake poisoning
- Senna
- Septic abortion
- Shock
- Solanum tuberosum
- Solder
- Spirochetes disease
- Sublimaze
- Surgery complication
- Tamine
- Telachlor
- Teldrin
- Temegesic
- Terodiline
- Tetanus
- Thioridazine hydrochloride
- Thiothixene
- Thorazine
- Tolterodine
- Toxic mushrooms
- Transthyretin amyloidosis
- Transverse myelitis
- Trimipramine toxicity
- 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
- Uterine prolapse
- Variegate porphyria
- Vibazine
- Vibrio infection
- Waterhouse-friederichsen syndrome
- Weil syndrome
- Yellow fever

# 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
Common risk factors related to the development of urinary retention include:
- Age > 50 years
- Long surgical procedure
- Administering large amount of intraoperative fluids
- Regional anesthesia
- Underlying bladder disease
- Previous pelvic surgery
- Neurological dysfunctioning
Some risk factors related to post partum course:
- Epidural analgesia
- Episiotomy
- Length of second stage of labor
- Instrument delivery
- Labor augmentation

# 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:
- Bladder stones
- Loss of detrusor muscle tone (atonic bladder is an extreme form)
- Hydronephrosis (congestion of the kidneys)
- Hypertrophy of detrusor muscle
- Diverticula in the bladder wall (leads to stones and infection)
- Urinary track infection/UTI
- pyelonephritis
- Bladder rupture
- Post obstructive diuresis (POD), a rare but potentially lethal complication associated with the treatment of urinary obstructions. Even in severe cases this condition can become pathologic, resulting in dehydration, electrolyte imbalances, and sometimes death if not adequately treated. Therefore all patients after acute obstruction should be monitored for 24 hours for any unusual symptoms.
- Acute retention, UTIs and complications of renal failure are uncommon in men with chronic PVRs. Conservative management for this group of patients is reasonable but outpatient management is understudy for future.
- Some complications associated with urinary catheters: Urethral trauma, Urinary tract infection, Retained balloon fragments, Bladder stone formation, Bladder fistula and Bladder perforation
Prognosis is generally good if condition is treated timely and with proper counseling about different complications, patients with retention who denied surgical treatment can be safely followed for at least 5 years without renal deterioration.

# Diagnosis

## Diagnostic Study of Choice
The diagnosis of urinary retention is made through history including information about current prescription medications and use of over-the-counter medications and herbal supplements, physical exam, and lab test (to find the specific cause). Urinary retention is difficult to diagnose due to concomitant comorbidities and potential cognitive impairments. There are no specific diagnostic criteria for urinary retention. Lab test include
- post-void residual urine (Chronic urinary retention be defined as PVR volume > 300 mL measured on two separate occasions and persisting for at least six months)
- Urodynamics
- cystoscopy
- Bladder ultrasound
- Urine analysis
- Digital rectal exam for Benign prostatic hyperplasia
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.

## History and Symptoms
- Urinary retention is difficult to diagnose due to concomitant comorbidities and potential cognitive impairments.
- 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.
- Common symptoms of the disease include unable to void, lower abdominal pain, back pain, and acute distress if the bladder is full.
- 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 hydronephrosis leading to scarring and may end in 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.
- 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
- serum urea
- electrolytes
- creatinine
- urine analysis
- urine microscopy and culture
- blood sugar
- Prostate Specific Antigen

## 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
- Urethrocystoscopy
- Urodynamic studies

# Treatment

## Medical Therapy
- In acute urinary retention, urinary catheterization or suprapubic cystostomy instantly relieves the retention. Urethral catheterization is particularly useful in patients where the cause of urinary retention is temporary, such as infection or medication. It is contraindicated in patients with recent urologic surgery such as radical prostatectomy or urethral reconstruction. If there is difficulty for indwelling a catheter, the patient should be sent to the urologist immediately.
- In the longer term, treatment depends on the cause. Benign prostatic hypertrophy may respond to alpha blocker and 5-alpha-reductase inhibitor therapy, or surgically with prostatectomy or transurethral resection of the prostate (TURP).
- Suprapubic catheterization is superior to urethral catheterization for short-term management.
- Silver alloy-impregnated urethral catheters have been shown to reduce the risk of urinary tract infection.
- Chronic urinary retention from the neurogenic bladder can be managed with clean, intermittent self-catheterization.
Urinary retention is considered an absolute contraindication to the use of the following medications:
- Darifenacin
- Fesoterodine
- Oxybutynin
- Solifenacin
- Tolterodine

## 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.

## Prevention
- There are no established measures for the prevention of urinary retention.
- Effective strategies to decrease the risk of urinary retention include:
- Pelvic floor strengthening exercises
- General genital/pelvic hygiene
- Good diet
- Good bathroom habits/routine
- Taking medication as directed by the physician.
- There is no vaccine available for the prevention of this disease.

# Related Chapters
- Constipation
- Urinary incontinence