Urinary retention

Last updated
Urinary retention
Other namesIschuria, bladder failure, bladder obstruction
Harnverhalt.jpg
Urinary retention with greatly enlarged bladder as seen by CT scan.
Specialty Emergency medicine, urology
Symptoms Sudden onset: Inability to urinate, low abdominal pain [1]
Long term: Frequent urination, loss of bladder control, urinary tract infection [1]
TypesAcute, chronic [1]
CausesBlockage of the urethra, nerve problems, certain medications, weak bladder muscles [1]
Diagnostic method Amount of urine in the bladder post urination [1]
Treatment Catheter, urethral dilation, urethral stents, surgery [1]
Medication Alpha blockers such as terazosin, 5α-reductase inhibitors such as finasteride [1]
Frequency6 per 1,000 per year (males > 40 years old) [1]

Urinary retention is an inability to completely empty the bladder. [1] Onset can be sudden or gradual. [1] When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. [1] When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. [1] Those with long-term problems are at risk of urinary tract infections. [1]

Contents

Causes include blockage of the urethra, nerve problems, certain medications, and weak bladder muscles. [1] Blockage can be caused by benign prostatic hyperplasia (BPH), urethral strictures, bladder stones, a cystocele, constipation, or tumors. [1] Nerve problems can occur from diabetes, trauma, spinal cord problems, stroke, or heavy metal poisoning. [1] Medications that can cause problems include anticholinergics, antihistamines, tricyclic antidepressants, cyclobenzaprine, diazepam, nonsteroidal anti-inflammatory drugs (NSAID), amphetamines, and opioids. [1] [2] Diagnosis is typically based on measuring the amount of urine in the bladder after urinating. [1]

Treatment is typically with a catheter either through the urethra or lower abdomen. [1] [3] Other treatments may include medication to decrease the size of the prostate, urethral dilation, a urethral stent, or surgery. [1] Males are more often affected than females. [1] In males over the age of 40 about 6 per 1,000 are affected a year. [1] Among males over 80 this increases 30%. [1]

Signs and symptoms

Onset can be sudden or gradual. [1] When the onset is sudden, symptoms include an inability to urinate and lower abdominal pain. [1] When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. [1] Those with long-term problems are at risk of urinary tract infections. [1]

Complications

The urinary bag of a person with post obstructive diuresis

Acute urinary retention is a medical emergency and requires prompt treatment. The pain can be excruciating when urine is not able to flow out. Moreover, one can develop severe sweating, chest pain, anxiety and high blood pressure. Other patients may develop a shock-like condition and may require admission to a hospital. Serious complications of untreated urinary retention include bladder damage and chronic kidney failure. [4] Urinary retention is a disorder treated in a hospital, and the quicker one seeks treatment, the fewer the complications.[ citation needed ]

In the longer term, obstruction of the urinary tract may cause:[ citation needed ]

Causes

Bladder

Prostate

Penile urethra

Postoperative

Risk factors include

Chronic

Chronic urinary retention that is due to bladder blockage which can either be as a result of muscle damage or neurological damage. [7] If the retention is due to neurological damage, there is a disconnect between the brain to muscle communication, which can make it impossible to completely empty the bladder. [7] If the retention is due to muscle damage, it is likely that the muscles are not able to contract enough to completely empty the bladder. [7]

The most common cause of chronic urinary retention is BPH. [1]

Other

Diagnosis

As seen on axial CT Urinaryobstruction.png
As seen on axial CT
Ultrasonography showing a trabeculated wall, seen as small irregularities mainly at left (superior part). This is strongly associated with urinary retention. Ultrasound of trabeculated urinary bladder.jpg
Ultrasonography showing a trabeculated wall, seen as small irregularities mainly at left (superior part). This is strongly associated with urinary retention.

Analysis of urine flow may aid in establishing the type of micturition (urination) abnormality. Common findings, determined by ultrasound of the bladder, include a slow rate of flow, intermittent flow, and a large amount of urine retained in the bladder after urination. A normal test result should be 20-25 mL/s peak flow rate. A post-void residual urine greater than 50 ml is a significant amount of urine and increases the potential for recurring urinary tract infections.[ citation needed ] In adults older than 60 years, 50-100 ml of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. [7] In chronic retention, ultrasound of the bladder may show massive increase in bladder capacity (normal capacity is 400-600 ml).[ citation needed ]

Non-neurogenic chronic urinary retention does not have a standardized definition; however, urine volumes >300mL can be used as an informal indicator. [7] Diagnosis of urinary retention is conducted over a period of 6 months, with 2 separate measurements of urine volume 6 months apart. Measurements should have a PVR (post-void residual) volume of >300mL. [7]

Determining the serum prostate-specific antigen (PSA) may help diagnose or rule out prostate cancer, though this is also raised in BPH and prostatitis. A TRUS biopsy of the prostate (transrectal ultrasound guided) can distinguish between these prostate conditions. Serum urea and creatinine determinations may be necessary to rule out backflow kidney damage. Cystoscopy may be needed to explore the urinary passage and rule out blockages.[ citation needed ]

In acute cases of urinary retention where associated symptoms in the lumbar spine are present such as pain, numbness (saddle anesthesia), parasthesias, decreased anal sphincter tone, or altered deep tendon reflexes, an MRI of the lumbar spine should be considered to further assess cauda equina syndrome.[ citation needed ]

Treatment

In acute urinary retention, urinary catheterization, placement of a prostatic stent, or suprapubic cystostomy relieves the retention. In the longer term, treatment depends on the cause. BPH may respond to alpha blocker and 5-alpha-reductase inhibitor therapy, or surgically with prostatectomy or transurethral resection of the prostate (TURP).[ citation needed ]

Use of alpha-blockers can provide relief of urinary retention following de-catheterization for both men and women. [9] [10] In case, if catheter can't be negotiated, suprapubic puncture can be done with lumbar puncture needle.

Medication

Some people with BPH are treated with medications. These include tamsulosin to relax smooth muscles in the bladder neck, and finasteride and dutasteride to decrease prostate enlargement. The drugs only work for mild cases of BPH but also have mild side effects. Some of the medications decrease libido and may cause dizziness, fatigue and lightheadedness.[ citation needed ]

Catheter

Acute urinary retention is treated by placement of a urinary catheter (small thin flexible tube) into the bladder. This can be either an intermittent catheter or a Foley catheter that is placed with a small inflatable bulb that holds the catheter in place.[ citation needed ]

Intermittent catheterization can be done by a health care professional or by the person themselves (clean intermittent self catheterization). Intermittent catheterization performed at the hospital is a sterile technique. Patients can be taught to use a self catheterization technique in one simple demonstration, [11] and that reduces the rate of infection from long-term Foley catheters. Self catheterization requires doing the procedure periodically during the day, the frequency depending on fluid intake and bladder capacity. If fluid intake/outflow is around 1.5 litres per day, this would typically be performed roughly three times per day, i.e. roughly every six to eight hours during the day, more frequently when fluid intake is higher and/or bladder capacity lower.

For acute urinary retention, treatment requires urgent placement of a urinary catheter. A permanent urinary catheter may cause discomfort and pain that can last several days.

Older people with ongoing problems may require continued intermittent self catheterization (CISC). CISC has a lower infection risk compared to catheterization techniques that stay within the body. [11]

Challenges with CISC include compliance issues as some people may not be able to place the catheter themselves. [12]

Surgery

The chronic form of urinary retention may require some type of surgical procedure. While both procedures are relatively safe, complications can occur.

In most patients with benign prostate hyperplasia (BPH), a procedure known as transurethral resection of the prostate (TURP) may be performed to relieve bladder obstruction. [13] Surgical complications from TURP include a bladder infection, bleeding from the prostate, scar formation, inability to hold urine, and inability to have an erection. The majority of these complications are short lived, and most individuals recover fully within 6–12 months. [14]

Sitting voiding position

A meta-analysis on the influence of voiding position on urodynamics in males with lower urinary tract symptoms showed that in the sitting position, the residual urine in the bladder was significantly reduced, the maximum urinary flow was increased, and the voiding time was decreased. For healthy males, no influence was found on these parameters, meaning that they can urinate in either position. [15]

Epidemiology

Urinary retention is a common disorder in elderly males. The most common cause of urinary retention is BPH. This disorder starts around age 50 and symptoms may appear after 10–15 years. BPH is a progressive disorder and narrows the neck of the bladder leading to urinary retention. By the age of 70, almost 10 percent of males have some degree of BPH and 33% have it by the eighth decade of life. While BPH rarely causes sudden urinary retention, the condition can become acute in the presence of certain medications including antihypertensives, antihistamines, and antiparkinson medications, and after spinal anaesthesia or stroke.[ citation needed ]

In young males, the most common cause of urinary retention is infection of the prostate (acute prostatitis ). The infection is acquired during sexual intercourse and presents with low back pain, penile discharge, low grade fever and an inability to pass urine. The exact number of individuals with acute prostatitis is unknown, because many do not seek treatment. In the US, at least 1–3 percent of males under the age of 40 develop urinary difficulty as a result of acute prostatitis. Most physicians and other health care professionals are aware of these disorders. Worldwide, both BPH and acute prostatitis have been found in males of all races and ethnic backgrounds. Cancers of the urinary tract can cause urinary obstruction but the process is more gradual. Cancer of the bladder, prostate or ureters can gradually obstruct urine output. Cancers often present with blood in the urine, weight loss, lower back pain or gradual distension in the flanks. [16]

Urinary retention in females is uncommon, occurring 1 in 100,000 every year, with a female-to-male incidence rate of 1:13. It is usually transient. The causes of UR in women can be multi-factorial, and can be postoperative and postpartum. Prompt urethral catheterization usually resolves the problem. [17]

Related Research Articles

<span class="mw-page-title-main">Urinary tract infection</span> Infection that affects part of the urinary tract

A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyelonephritis). Symptoms from a lower urinary tract infection include suprapubic pain, painful urination (dysuria), frequency and urgency of urination despite having an empty bladder. Symptoms of a kidney infection, on the other hand, are more systemic and include fever or flank pain usually in addition to the symptoms of a lower UTI. Rarely, the urine may appear bloody. Symptoms may be vague or non-specific at the extremities of age.

<span class="mw-page-title-main">Bladder</span> Organ in vertebrates that collects and stores urine from the kidneys before disposal

The bladder is a hollow organ in humans and other vertebrates that stores urine from the kidneys. In placental mammals, urine enters the bladder via the ureters and exits via the urethra during urination. In humans, the bladder is a distensible organ that sits on the pelvic floor. The typical adult human bladder will hold between 300 and 500 ml before the urge to empty occurs, but can hold considerably more.

<span class="mw-page-title-main">Prostate</span> Gland of the male reproductive system

The prostate is an accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found in all male mammals. It differs between species anatomically, chemically, and physiologically. Anatomically, the prostate is found below the bladder, with the urethra passing through it. It is described in gross anatomy as consisting of lobes and in microanatomy by zone. It is surrounded by an elastic, fibromuscular capsule and contains glandular tissue, as well as connective tissue.

<span class="mw-page-title-main">Benign prostatic hyperplasia</span> Noncancerous increase in size of the prostate gland

Benign prostatic hyperplasia (BPH), also called prostate enlargement, is a noncancerous increase in size of the prostate gland. Symptoms may include frequent urination, trouble starting to urinate, weak stream, inability to urinate, or loss of bladder control. Complications can include urinary tract infections, bladder stones, and chronic kidney problems.

<span class="mw-page-title-main">Urinary incontinence</span> Uncontrolled leakage of urine

Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geriatric health care. The term enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis. UI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse. People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.

<span class="mw-page-title-main">Urinary catheterization</span> Insertion of a catheter through the urethra to drain urine

In urinary catheterization, a latex, polyurethane, or silicone tube known as a urinary catheter is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection. It may also be used to inject liquids used for treatment or diagnosis of bladder conditions. A clinician, often a nurse, usually performs the procedure, but self-catheterization is also possible. A catheter may be in place for long periods of time or removed after each use.

<span class="mw-page-title-main">Hematuria</span> Presence of blood in urine

Hematuria or haematuria is defined as the presence of blood or red blood cells in the urine. "Gross hematuria" occurs when urine appears red, brown, or tea-colored due to the presence of blood. Hematuria may also be subtle and only detectable with a microscope or laboratory test. Blood that enters and mixes with the urine can come from any location within the urinary system, including the kidney, ureter, urinary bladder, urethra, and in men, the prostate. Common causes of hematuria include urinary tract infection (UTI), kidney stones, viral illness, trauma, bladder cancer, and exercise. These causes are grouped into glomerular and non-glomerular causes, depending on the involvement of the glomerulus of the kidney. But not all red urine is hematuria. Other substances such as certain medications and foods can cause urine to appear red. Menstruation in women may also cause the appearance of hematuria and may result in a positive urine dipstick test for hematuria. A urine dipstick test may also give an incorrect positive result for hematuria if there are other substances in the urine such as myoglobin, a protein excreted into urine during rhabdomyolysis. A positive urine dipstick test should be confirmed with microscopy, where hematuria is defined by three or more red blood cells per high power field. When hematuria is detected, a thorough history and physical examination with appropriate further evaluation can help determine the underlying cause.

Dysuria refers to painful or uncomfortable urination.

<span class="mw-page-title-main">Tamsulosin</span> Medication

Tamsulosin, sold under the brand name Flomax among others, is a medication used to treat symptomatic benign prostatic hyperplasia (BPH) and chronic prostatitis and to help with the passage of kidney stones. The evidence for benefit with a kidney stone is better when the stone is larger. Tamsulosin is taken by mouth.

Prostatic congestion is a medical condition of the prostate gland that happens when the prostate becomes swollen by excess fluid and can be caused by prostatosis. The condition often results in a person with prostatic congestion feeling the urge to urinate frequently. Prostatic congestion has been associated with prostate disease, which can progress due to age. Oftentimes, the prostate will grow in size which can lead to further problems, such as prostatitis, enlarged prostate, or prostate cancer.

In urology, voiding cystourethrography (VCUG) is a frequently performed technique for visualizing a person's urethra and urinary bladder while the person urinates (voids). It is used in the diagnosis of vesicoureteral reflux, among other disorders. The technique consists of catheterizing the person in order to fill the bladder with a radiocontrast agent, typically diatrizoic acid. Under fluoroscopy the radiologist watches the contrast enter the bladder and looks at the anatomy of the patient. If the contrast moves into the ureters and back into the kidneys, the radiologist makes the diagnosis of vesicoureteral reflux, and gives the degree of severity a score. The exam ends when the person voids while the radiologist is watching under fluoroscopy. Consumption of fluid promotes excretion of contrast media after the procedure. It is important to watch the contrast during voiding, because this is when the bladder has the most pressure, and it is most likely this is when reflux will occur. Despite this detailed description of the procedure, at least as of 2016 the technique had not been standardized across practices.

<span class="mw-page-title-main">Neurogenic bladder dysfunction</span> Bladder disorder due to disease or injury of the nervous system

Neurogenic bladder dysfunction, often called by the shortened term neurogenic bladder, refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination. There are multiple types of neurogenic bladder depending on the underlying cause and the symptoms. Symptoms include overactive bladder, urinary urgency, frequency, incontinence or difficulty passing urine. A range of diseases or conditions can cause neurogenic bladder including spinal cord injury, multiple sclerosis, stroke, brain injury, spina bifida, peripheral nerve damage, Parkinson's disease, multiple system atrophy or other neurodegenerative diseases. Neurogenic bladder can be diagnosed through a history and physical as well as imaging and more specialized testing. In addition to symptomatic treatment, treatment depends on the nature of the underlying disease and can be managed with behavioral changes, medications, surgeries, or other procedures. The symptoms of neurogenic bladder, especially incontinence, can severely degrade a person's quality of life.

<span class="mw-page-title-main">Prostatic stent</span>

A prostatic stent is a stent used to keep open the male urethra and allow the passing of urine in cases of prostatic obstruction and lower urinary tract symptoms (LUTS). Prostatic obstruction is a common condition with a variety of causes. Benign prostatic hyperplasia (BPH) is the most common cause, but obstruction may also occur acutely after treatment for BPH such as transurethral needle ablation of the prostate (TUNA), transurethral resection of the prostate (TURP), transurethral microwave thermotherapy (TUMT), prostate cancer or after radiation therapy.

Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. The term is more commonly applied to men – over 40% of older men are affected – but lower urinary tract symptoms also affect women. The condition is also termed prostatism in men, but LUTS is preferred.

Urologic diseases or conditions include urinary tract infections, kidney stones, bladder control problems, and prostate problems, among others. Some urologic conditions do not affect a person for that long and some are lifetime conditions. Kidney diseases are normally investigated and treated by nephrologists, while the specialty of urology deals with problems in the other organs. Gynecologists may deal with problems of incontinence in women.

Feline idiopathic cystitis (FIC) or feline interstitial cystitis or cystitis in cats, is one of the most frequently observed forms of feline lower urinary tract disease (FLUTD). Feline cystitis means "inflammation of the bladder in cats". The term idiopathic means unknown cause; however, certain behaviours have been known to aggravate the illness once it has been initiated. It can affect both males and females of any breed of cat. It is more commonly found in female cats; however, when males do exhibit cystitis, it is usually more dangerous.

<span class="mw-page-title-main">Urodynamic testing</span> Assessment of bladder and urethra performance

Urodynamic testing or urodynamics is a study that assesses how the bladder and urethra are performing their job of storing and releasing urine. Urodynamic tests can help explain symptoms such as:

<span class="mw-page-title-main">Overflow incontinence</span> Medical condition

Overflow incontinence is a concept of urinary incontinence, characterized by the involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to urinate. This condition occurs in people who have a blockage of the bladder outlet, or when the muscle that expels urine from the bladder is too weak to empty the bladder normally. Overflow incontinence may also be a side effect of certain medications.

<span class="mw-page-title-main">Prostatic artery embolization</span> Non-surgical technique for the treatment of benign prostatic hyperplasia

Prostatic artery embolization is a non-surgical technique for treatment of benign prostatic hyperplasia (BPH).

References

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  2. 1 2 de Jong AC, Maaskant JM, Groen LA, van Woensel JB (January 2021). "Monitoring of micturition and bladder volumes can replace routine indwelling urinary catheters in children receiving intravenous opioids: a prospective cohort study". European Journal of Pediatrics. 180 (1): 47–56. doi:10.1007/s00431-020-03703-7. PMC   7782390 . PMID   32529397.
  3. ↑ Sliwinski A, D'Arcy FT, Sultana R, Lawrentschuk N (April 2016). "Acute urinary retention and the difficult catheterization: current emergency management". European Journal of Emergency Medicine. 23 (2): 80–88. doi:10.1097/MEJ.0000000000000334. PMID   26479738. S2CID   26988888.
  4. ↑ "General information on urinary retention". Retention Urinary. Archived from the original on 20 February 2010.
  5. ↑ Khasriya R, Barcella W, De Iorio M, Swamy S, Gill K, Kupelian A, Malone-Lee J (July 2018). "Lower urinary tract symptoms that predict microscopic pyuria". International Urogynecology Journal. 29 (7): 1019–1028. doi:10.1007/s00192-017-3472-7. PMC   6004270 . PMID   28971220.
  6. 1 2 3 4 5 6 7 8 9 10 Kowalik U, Plante MK (June 2016). "Urinary Retention in Surgical Patients". The Surgical Clinics of North America. 96 (3): 453–467. doi:10.1016/j.suc.2016.02.004. PMID   27261788.
  7. 1 2 3 4 5 6 Stoffel JT (September 2017). "Non-neurogenic Chronic Urinary Retention: What Are We Treating?". Current Urology Reports. 18 (9): 74. doi:10.1007/s11934-017-0719-2. PMID   28730405. S2CID   12989132.
  8. ↑ Graham SE, Keane TE, Glenn JF (2010). Glenn's Urologic Surgery. Lippincott Williams & Wilkins. p. 306. ISBN   9780781791410.
  9. ↑ Fisher E, Subramonian K, Omar MI (June 2014). "The role of alpha blockers prior to removal of urethral catheter for acute urinary retention in men". The Cochrane Database of Systematic Reviews (6): CD006744. doi: 10.1002/14651858.CD006744.pub3 . PMC   11214126 . PMID   24913721.
  10. ↑ Mevcha A, Drake MJ (April 2010). "Etiology and management of urinary retention in women". Indian Journal of Urology. 26 (2): 230–235. doi: 10.4103/0970-1591.65396 . PMC   2938548 . PMID   20877602.
  11. 1 2 Sherman ND. "Clean Intermittent Self-Catheterization". The New York Times. Archived from the original on 6 February 2016.
  12. ↑ Seth JH, Haslam C, Panicker JN (2014). "Ensuring patient adherence to clean intermittent self-catheterization". Patient Preference and Adherence. 8: 191–198. doi: 10.2147/PPA.S49060 . PMC   3928402 . PMID   24611001.
  13. ↑ Ellsworth PI (10 February 2010). Stöppler MC (ed.). "Inability to urinate". eMedicine Health. Archived from the original on 5 March 2010.
  14. ↑ "Urinary retention overview". National Kidney and Urologic Diseases Information Clearinghouse. Archived from the original on 29 January 2010. Retrieved 10 February 2010.
  15. ↑ de Jong Y, Pinckaers JH, ten Brinck RM, Lycklama à Nijeholt AA, Dekkers OM (2014). "Urinating standing versus sitting: position is of influence in men with prostate enlargement. A systematic review and meta-analysis". PLOS ONE. 9 (7): e101320. Bibcode:2014PLoSO...9j1320D. doi: 10.1371/journal.pone.0101320 . PMC   4106761 . PMID   25051345.
  16. ↑ "Urologic Emergencies". Urology Channel Portal. 10 February 2010. Archived from the original on 10 March 2010.
  17. ↑ Özveren B, Keskin S (2016). "Presentation and prognosis of female acute urinary retention: Analysis of an unusual clinical condition in outpatients". Urology Annals. 8 (4): 444–448. doi: 10.4103/0974-7796.192111 . PMC   5100150 . PMID   28057989.
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