Psychogenic Urinary Retention in Children: a Case Report

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provided by Elsevier - Publisher Connector Pediatr Neonatol 2010;51(5):300−302

CASE REPORT

Psychogenic Urinary Retention in Children: A Case Report

Kong-Sang Wan1,2*, Nai-Hsuan Liu3, Chih-Kuang Liu4,5, I-Zen Hwang6

1Department of Pediatrics, Taipei City Hospital, Renai Branch, Taipei, Taiwan 2College of Medicine, National Yang-Ming University, Taipei, Taiwan 3Department of Family Medicine, Taipei City Hospital, Renai Branch, Taipei Taiwan 4Department of Urology, Taipei City Hospital, Zhonxing Branch, Taipei, Taiwan 5College of Medicine, Fu Jen Catholic University, Taipei, Taiwan 6Department of Psychiatry, Taipei City Hospital, Renai Branch, Taipei, Taiwan

Received: May 25, 2009 Psychogenic urinary retention occurs relatively infrequently in children and is less Revised: Nov 12, 2009 common than in adults. The influence of psychogenic factors on voiding generally Accepted: Dec 4, 2009 results in an irritative syndrome, but rarely in urinary retention. A definitive diagnosis is established by excluding other pathological conditions. Evaluation includes KEY WORDS: urine culture, renal echography, spine magnetic resonance imaging, voiding cysto- children; urethrography, intravenous pyelography, and uroflowmetry. Here, we report on a psychogenic urinary 6-year-old girl with a 1-month history of voiding difficulty. Urology studies, including urine culture, revealed Escherichia coli, which was not present in preadmission retention; urine cultures. Renal ultrasound and radiological images showed no gross abnormali- urinary tract infection ties or vesicoureteral reflux, but uroflowmetry showed a low flow rate with residual urine. The results of imaging studies and pediatric psychiatric consultation led to a diagnosis of psychogenic urinary retention combined with urinary tract infection. Urinary rehabilitation included intermittent catheterization, bladder training, and supportive psychotherapy, after which the patient recovered and was discharged.

1. Introduction not provide significant additional diagnostic value, and noninvasive diagnostic methods (i.e., clinical Psychogenic urinary retention should be suspected examination, ultrasound, and uroflowmetry) should in patients with acute urinary retention (AUR) with be used initially.4 Treatment usually consists of a no organic explanation. It is well known in adults, combination of intermittent catheterization, blad- but has rarely been described in children.1 AUR in der training, and supportive psychotherapy.5 children can be associated with constipation and infrequent voiding.2,3 Urine retention is defined as the lack of volitional bladder emptying for more than 2. Case Report 12 hours, with a urine volume greater than that expected for age [(age in years + 2) × 30 mL] or a A 6-year-old girl presented suffering from voiding palpably distended bladder. Urodynamic studies do difficulties. She had required her father to compress

*Corresponding author. Department of Pediatrics, Taipei City Hospital, Renai Branch, 10 Renai Road, Section 4, Da An District, Taipei 106, Taiwan. E-mail: [email protected]

©2010 Taiwan Pediatric Association Psychogenic urinary retention in children 301 her abdomen to help her urinate every morning for retention of urine because of urethral irritation or about 1 month before admission. A distended urinary dysuria.6,7 Causes of voiding dysfunction that in- bladder had frequently been identified on physical duce AUR include psychological causes such as de- examination, and urinary catheterization was per- pression and hysteria, numerous inhibitory factors formed several times in private clinics to relieve of educational origin, and sexual abuse.3,8 bladder distention. The patient had urge syndrome, Psychogenic urinary retention in childhood can but no diurnal or nocturnal enuresis. There were appear during the period when complete control no signs of fever, abdominal pain, or flank pain, but of micturition is being developed. Late recognition constipation was present. She denied any history of of this condition worsens its prognosis, because high urinary tract infection (UTI) or medication intake. pressure and infection in the urinary tract can lead The patient appeared relaxed, alert and well- to end-stage renal failure.9,10 Voiding dysfunction oriented. A physical examination was unremarkable, thus typically presents after toilet training, and may except for a palpably distended urinary bladder. originate from behavioral issues that arise around The results of laboratory tests, including complete this time of child development. blood count, urinalysis, liver function tests, renal The clinical symptoms may vary from mild in- function tests, and blood electrolyte measurements continence to severe disorders, with endpoints of were all within normal limits. More than 105/mL irreversible bladder dysfunction with vesicoureteral colonies of Escherichia coli were detected in the reflux, UTI, and nephropathy.11 Although functional urine culture, and intravenous cefazolin was there- voiding disorder and UTI are common in childhood, fore administered, based on the results of antimicro- they are not usually accompanied by upper urinary bial sensitivity testing. Renal echography showed tract deterioration.12 Children with urge inconti- negative findings for both kidneys. Other imaging nence have a significantly higher rate of previous studies, including spine magnetic resonance imag- UTI than children with voiding postponement. They ing, voiding cystourethrography, and intravenous are characterized by a variety of behavioral symp- pyelography showed no reflux, stones, or masses toms, such as withdrawal, aggression, delinquent in the genitourinary system. behavior, and attention problems. In contrast, chil- Because of persistent difficulties in urination, dren with voiding postponement have a more ab- consultations were made with a urologist and psy- normal uroflow curve rate and a wide variety of chiatrist. A low flow rate with 59 mL residual urine clinically relevant behavioral symptoms, usually was detected on uroflowmetry. A diagnostic psy- with attention and delinquency problems.13 chiatric interview using the Wechsler Preschool and Functional urinary incontinence in children may Primary Scale of Intelligence assessment indicated be caused by disturbances during the filling phase a borderline IQ, a lower than average speaking or the voiding phase, or a combination of both. Girls ability, and mild mental retardation. No emotional present with symptoms of detrusor overactivity more problems were identified, but the patient had defi- often than boys, although other symptoms, such as cient social stimulation. These evaluations confirmed UTI or constipation, sometimes prevail.14 Moreover, psychogenic urinary retention with UTI. girls with recurrent UTI have host-mediated pre- The patient completed a 7-day course of antibi- disposing behavioral and functional abnormalities, otic treatment for UTI. Urinary rehabilitation and including infrequent voiding, poor fluid intake, func- supportive psychotherapy were also given. She was tional stool retention, and voiding dysfunction. discharged after 2 weeks of hospitalization. There However, UTI is not necessarily related to poor gen- was no recurrence of symptoms on follow-up after ital hygiene or toilet habits.15 Diagnosis is based on 6 months. medical and voiding histories, physical examination, bladder diaries, and uroflowmetry. In conclusion, psychogenic voiding dysfunction 3. Discussion is an important differential diagnosis when evalu- ating patients with asymptomatic bacteriuria and Acute urinary retention is an uncommon diagnosis in urinary retention. The influence of psychogenic fac- childhood. It is associated with a variety of causes, tors on voiding generally results in irritation syn- including neurologic disorders, severe psychogenic drome, and only rarely in urinary retention. Voiding voiding dysfunction, UTI, constipation, adverse ef- dysfunction is typically present after toilet training fects of medications, local inflammation, and lo- and may originate from behavioral issues. Urodyna- cally invading neoplasms. It can also be idiopathic.1 mic studies are usually reserved for patients with Urinary retention is described as the inability to dysfunctional voiding with UTI.14−16 Management void volitionally, despite adequate urine volume in usually involves a combination of intermittent cath- the bladder. It is a common complaint in adults. In eterization, bladder training, psychotherapy, and contrast, children are more likely to have voluntary anticholinergic treatment.5,16 302 K.S. Wan et al

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