Urinary retention in women Urinary retention in women is often transient and of no known cause. J Basson, MB ChB; C L E van der Walt, MB ChB, DOM (Singapore), MMed (Urol), FC Urol SA; C F Heyns, MB ChB, MMed (Urol), PhD, FCSSA (Urol) Department of Urology, Stellenbosch University and Tygerberg Hospital, Tygerberg, Cape Town, South Africa Corresponding author: C F Heyns ([email protected]) Urinary retention in women is uncommon, instrumentation, or fibrosis with chronic in a functional obstruction, the so-called with a much lower incidence than in men. inflammation.[7] Fowler’s syndrome.[9,10] It may be acute (with suprapubic pain) or chronic (typically painless). Urinary Urinary retention is often the presenting Cauda equina syndrome is caused by lumbar retention in females is frequently transient, symptom of urethral cancer.8 Other disc protrusion, and 1 - 15% of patients with no apparent cause, which makes symptoms include haematuria, pelvic present with abnormal bladder function the management of these patients more pain, obstructive and irritative urinary secondary to impingement of sacral nerve challenging.[1-3] symptoms, weight loss and malaise. On roots.6 Protrusion is most common in the examination a hard mass is often felt in the L4 - 5 and L5 - S1 disc spaces. Patients are Aetiology urethra or anterior vaginal wall. Diagnosis is usually between 35 and 45 years of age. In the past, most studies focused on confirmed by biopsy. Urinary retention and straining are the most ‘psychogenic’ or ‘hysterical’ causes, but the common urological symptoms, together with list of possible causes is quite extensive, Surgery for stress urinary incontinence may lower back pain, bilateral sciatica, saddle and all should be taken into consideration cause retention in 2.5 - 24% of cases.[7] Tension- anaesthesia, lower limb weakness and bowel when treating these patients. The aetiology free vaginal tape (TVT) sling procedures often dysfunction.[6] EMG demonstrates bladder of urinary retention in women can cause ‘hypercontinence’. and sphincter denervation, and the diagnosis be broadly classified into mechanical/ is usually made by computed tomography anatomical, functional/neurological, and Functional/neurological causes (CT), magnetic resonance imaging (MRI) miscellaneous causes.[4-7] Functional/neurological causes of urinary or myelography.[6] Cauda equina syndrome retention in women include cerebral and should be diagnosed early and treated Mechanical/anatomical causes spinal cord diseases which can be congenital, promptly, since failure to do so may result in Mechanical/anatomical causes include neoplastic, degenerative, inflammatory, permanent neurological damage. urethral stenosis, foreign objects, bladder vascular or traumatic, e.g. spinal cord injury stones, constipation, urethral cancer, uterine (suprasacral), multiple sclerosis, Parkinson’s Miscellaneous/other causes fibroids, bladder-neck obstruction, pelvic disease, cauda equina syndrome and These include eosinophilic cystitis, herpes organ prolapse, cervical cancer and anti- Fowler’s syndrome (Table 2). simplex virus (HSV) infection, epidural incontinence surgery (Table 1). anaesthesia, anti-cholinergic or sympath- Fowler et al. described a syndrome in young omimetic agents, urinary tract infection Urethral stenosis is a common cause of women, usually <30 years old, who typically (UTI), and postpartum, postoperative and retention in postmenopausal women, in presented with painless urinary retention psychogenic causes (Table 3). whom hormonal insufficiency leads to associated with residual urine volumes of urogenital atrophy. Other causes of urethral >1 000 ml.[9,10] Electromyography (EMG) Postpartum urinary retention has a prevalence stenosis include scarring after surgery or revealed abnormal bursts of activity of of 0.45 - 14.1%.[5] The pathophysiology is the striated urethral sphincter, resulting poorly understood and various mechanisms Table 1. Mechanical/anatomical have been proposed. Hormones and causes of urinary retention in women Table 2. Functional/neurological causes of urinary retention in Urethral stenosis Table 3. Miscellaneous/other women Foreign bodies (e.g. ring pessaries) causes of urinary retention in women Constipation Fowler’s syndrome Multiple sclerosis Bladder stones Eosinophilic cystitis Cerebral palsy Urethral cancer Postpartum Spinal cord injury Uterine fibroids Herpes simplex virus infection Cerebrovascular accident Epidural anaesthesia Clot retention Detrusor-sphincter dyssynergia Pelvic organ prolapse Cauda equina syndrome Anticholinergic therapy Bladder neck obstruction Parkinson’s disease Psychogenic Anti-incontinence surgery Spina bifida occulta Urinary tract infection Pelvic masses Diabetes mellitus Postoperative 182 CME May 2013 Vol. 31 No. 5 Urinary retention in women contractile responses of the bladder, together pelvic organ prolapse should be performed. of the urethra. If these interventions are with injured bladder innervation, may play a Palpation of the urethra may reveal a urethral unsuccessful, transection or removal of the role.[5] cancer. A thorough neurological examination sling may be necessary. is essential and should include assessment of HSV type 2 is a common sexually trans- perianal tone and perineal sensation. In women with cauda equina syndrome, mitted infection, causing painful vesicles prompt surgical intervention (laminectomy) on the labia and/or vulva. Urinary retention UTI can be excluded or confi rmed by restores normal bladder function in at least may be secondary to pain or the sacral urinalysis and culture. If indicated, a 25% of patients. radiculopathy caused by HSV infection. [6] full blood count, urea, electrolytes and creatinine can be done. Women with postpartum urinary retention are usually treated with CISC, and the Urinary retention in Cystoscopy is done aft er transient causes majority of patients will have no long-term females is frequently are eliminated and can diagnose urethral impairment of bladder function. stenosis, urethral cancer, eosinophilic transient, with no cystitis and bladder stones. Biopsies are In neurological cases continuous indwelling apparent cause, which performed if clinically indicated. Cystoscopy catheterisation may be necessary. If CISC is is also indicated in women with previous not feasible, suprapubic catheterisation or makes the management [7] anti-incontinence surgery to evaluate the urinary diversion may be warranted. of these patients more urethra and bladder. challenging. Cauda equina syndrome Further investigations include X-rays of the lumbar spine, abdomino-pelvic ultrasound is caused by lumbar Clinical assessment and/or CT imaging. Urodynamic studies disc protrusion, and 1 - Most patients present with obstructive and EMG may be indicated in some patients. 15% of patients present as well as irritative lower urinary tract MRI of the brain and spine is indicated in symptoms (LUTS), including weak stream, any patient with neurological symptoms or with abnormal bladder hesitancy, abdominal straining, infrequent signs, and if no other cause of the retention function secondary to [6] voiding, dysuria, frequency and nocturia.4 is found. impingement of sacral In some patients urinary retention may be the fi rst symptom or sign. Treatment nerve roots. Drainage of the bladder by transurethral Th e history should include characterisation of catheterisation resolves the acute emergency. Women with urinary retention caused the patient’s voiding symptoms, i.e. the onset In some cases a suprapubic catheter may by HSV infection are usually treated by and duration, aggravating and ameliorating be necessary. In most idiopathic cases, factors, associated symptoms such as fever, including UTI, the urinary retention abdominal or fl ank pain, history of trauma is transient, and will need no further or surgery, and the presence of cutaneous treatment. For UTI, appropriate antibiotic lesions (rash, vesicles). Th e history should treatment will resolve the retention. also include questioning about bowel habits, visual and/or gait abnormalities, muscle Constipation causing urinary retention is weakness and/or sensory disturbances of the treated with laxatives, increased fl uid intake, lower extremities.[6] diet modifi cation and changes in bowel habits. Th e previous medical history is important, as well as previous surgical procedures, Anatomical causes of urinary retention especially spinal, pelvic, anorectal and anti- are best treated surgically to remove the incontinence surgery.6 Prescription and obstructive lesion and restore the normal non-prescription medication should be outlet. listed, as these include common causes for transient urinary retention (anticholinergics, Treatment of urethral stenosis consists of antipsychotics and sympathomimetics).[7] hormonal replacement (systemic or topical) in postmenopausal women and urethral Physical examination should focus on dilatation in some cases. inspection for cutaneous lesions, trauma, prior surgery and signs of spinal dysraphism.[6] Women with urinary retention aft er anti- Th e abdomen should be palpated for any incontinence surgery are usually treated masses. Bimanual pelvic examination as with clean intermittent self-catheterisation well as speculum examination to exclude (CISC) for up to 6 weeks, or dilatation 183 CME May 2013 Vol. 31 No. 5 Urinary retention in women capsules transurethral or suprapubic catheterisation, References together with acyclovir or valacyclovir. 1. Carley ME, Carley JM, Vasdev GV, et al. 6. Smith CP, Kraus