Urinary Retention in Adults: Diagnosis and Initial Management BRIAN a. SELIUS, DO, and rAJESH SUBEDI, MD, Northeastern Ohio Universities College of Medicine, St. Elizabeth Health Center, Youngstown, Ohio Urinary retention is the inability to voluntarily void urine. This condition can be acute or chronic. Causes of urinary retention are numerous and can be classified as obstructive, infectious and inflammatory, pharmacologic, neuro- logic, or other. The most common cause of urinary retention is benign prostatic hyperplasia. Other common causes include prostatitis, cystitis, urethritis, and vulvovaginitis; receiving medications in the anticholinergic and alpha- adrenergic agonist classes; and cortical, spinal, or peripheral nerve lesions. Obstructive causes in women often involve the pelvic organs. A thorough history, physical examination, and selected diagnostic testing should determine the cause of urinary retention in most cases. Initial management includes bladder catheterization with prompt and com- plete decompression. Men with acute urinary retention from benign prostatic hyperplasia have an increased chance of returning to normal voiding if alpha blockers are started at the time of catheter insertion. Suprapubic catheteriza- tion may be superior to urethral catheterization for short-term management and silver alloy-impregnated urethral catheters have been shown to reduce urinary tract infection. Patients with chronic urinary retention from neurogenic bladder should be able to manage their condition with clean, intermittent self-catheterization; low-friction catheters have shown benefit in these patients. Definitive management of urinary retention will depend on the etiology and may include surgical and medical treatments. (Am Fam Physician. 2008;77(5):643-650. Copyright © 2008 American Academy of Family Physicians.) rinary retention is the inabil- physician to make an accurate diagnosis ity to voluntarily urinate. Acute and begin initial management. urinary retention is the sudden and often painful inability to Causes of Urinary Retention U void despite having a full bladder.1 Chronic Although classification systems vary, causes urinary retention is painless retention asso- of urinary retention can be categorized ciated with an increased volume of residual as obstructive, infectious and inflamma- urine.2 Patients with urinary retention tory, pharmacologic, neurologic, or other can present with complete lack of voiding, (Table 11,5-7). incomplete bladder emptying, or overflow incontinence. Complications include infec- OBSTRUCTIVE tion and renal failure. Obstruction of the lower urinary tract at or Family physicians often encounter distal to the bladder neck can cause urinary patients with urinary retention. In two retention. The obstruction may be intrinsic large cohort studies of U.S. men 40 to (e.g., prostatic enlargement, bladder stones, 83 years of age, the overall incidence was urethral stricture) or extrinsic (e.g., when a 4.5 to 6.8 per 1,000 men per year. The uterine or gastrointestinal mass compresses incidence dramatically increases with age the bladder neck causing outlet obstruc- so that a man in his 70s has a 10 percent tion). The most common obstructive cause chance and a man in his 80s has a more than is benign prostatic hyperplasia (BPH).1,5 In 30 percent chance of having an episode of a study of 310 men over a two-year period, acute urinary retention.3,4 The incidence in urinary retention was caused by BPh in 53 women is not well documented. Although percent of patients. Other obstructive causes the differential diagnosis of urinary reten- accounted for another 23 percent.7 tion is extensive, a thorough history, care- Each year in the United States, there are ful physical examination, and selected approximately 2 million office visits and diagnostic testing should enable the family more than 250,000 surgical procedures Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2008 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References In men with benign prostatic hyperplasia, initiation of treatment with alpha blockers at the time of catheter B 36, 37 insertion improves the success rate of trial of voiding without catheter. Men with urinary retention from benign prostatic hyperplasia should undergo at least one trial of voiding C 31 without catheter before surgical intervention is considered. Prevention of acute urinary retention in men with benign prostatic hyperplasia may be achieved by long- B 38-40 term treatment with 5-alpha reductase inhibitors. Silver alloy-impregnated urethral catheters reduce the incidence of urinary tract infections in hospitalized A 41 patients requiring catheterization for up to 14 days. Suprapubic catheters improve patient comfort and decrease bacteriuria and recatheterization in patients A 42 requiring catheterization for up to 14 days. Low-friction, hydrophilic-coated catheters increased patient satisfaction and decreased urinary tract infection A 47, 48 and hematuria in patients with neurogenic bladder who practice clean, intermittent self-catheterization. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 579 or http:// www.aafp.org/afpsort.xml. performed for patients with BPH.4 BPH causes bladder urine. Fecal impaction and gastrointestinal or retroperi- neck obstruction through two mechanisms: prostate toneal masses large enough to cause extrinsic bladder enlargement and constriction of the prostatic urethra neck compression can result in urinary retention. Uri- from excessive alpha-adrenergic tone in the stromal nary retention from bladder tumors is usually caused by portion of the gland.8 blood clots from intravesicular bleeding and often pres- Other obstructive causes of urinary retention in ents with painless hematuria.9 men include prostate cancer, phimosis, paraphimosis, and external-constricting devices applied to the penis. INFECTIOUS AND INFLAMMATORY Obstructive causes in women often involve pelvic organ The most common cause of infectious acute urinary prolapse such as cystocele or rectocele. Urinary retention retention is acute prostatitis. Acute prostatitis is usually can also result from external compression of the blad- caused by gram-negative organisms, such as Escherichia der neck from uterine prolapse and benign or malignant coli and Proteus species, and results in swelling of the pelvic masses. In men and women, urethral strictures, acutely inflamed gland.1,10 Urethritis from a urinary stones, and foreign bodies can directly block the flow of tract infection (UTI) or sexually transmitted infection Table 1. Selected Causes of Urinary Retention Cause Men Women Both Obstructive Benign prostatic hyperplasia; Organ prolapse (cystocele, rectocele, Aneurysmal dilation; bladder calculi; meatal stenosis; uterine prolapse); pelvic mass bladder neoplasm; fecal impaction; paraphimosis; penile (gynecologic malignancy, uterine gastrointestinal or retroperitoneal constricting bands; fibroid, ovarian cyst); retroverted malignancy/mass; urethral strictures, phimosis; prostate cancer impacted gravid uterus foreign bodies, stones, edema Infectious and Balanitis; prostatic abscess; Acute vulvovaginitis; vaginal lichen Bilharziasis; cystitis; echinococcosis; inflammatory prostatitis planus; vaginal lichen sclerosis; Guillain-Barré syndrome; herpes simplex vaginal pemphigus virus; Lyme disease; periurethral abscess; transverses myelitis; tubercular cystitis; urethritis; varicella-zoster virus Other Penile trauma, fracture, or Postpartum complication; urethral Disruption of posterior urethra and bladder laceration sphincter dysfunction (Fowler’s neck in pelvic trauma; postoperative syndrome) complication; psychogenic NOTE: For pharmacologic and neurologic causes of urinary retention, see Tables 2 and 3, respectively. Information from references 1 and 5 through 7. 644 American Family Physician www.aafp.org/afp Volume 77, Number 5 ◆ March 1, 2008 Urinary Retention can cause urethral edema with resultant urinary reten- mediated detrusor muscle contraction.13 Table 25 lists tion, and genital herpes may cause urinary retention medications associated with urinary retention. from local inflammation and sacral nerve involvement (Elsberg syndrome).11 In women, painful vulvovaginal NEUROLOGIC lesions and vulvovaginitis can cause urethral edema, as Normal functioning of the bladder and lower urinary well as painful urination, which also results in urinary tract depends on a complex interaction between the retention. brain, autonomic nervous system, and somatic nerves supplying the bladder and urethra. Interruption along PHARMACOLOGIC these pathways can result in urinary retention of neu- Medications with anticholinergic properties, such as rologic etiology (Table 36). Neurogenic or neuropathic tricyclic antidepressants, cause urinary retention by bladder is defined as any defective functioning of the decreasing bladder detrusor muscle contraction.12 Sym- bladder caused by impaired innervation.14 pathomimetic drugs (e.g., oral decongestants) cause uri- Urinary retention from neurologic