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Urinary retention is an inability to completely empty the bladder.[1] Onset can be gradual or sudden.[1] When of rapid 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]

Urinary retention
Synonyms Ischuria, bladder failure
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]
Types Acute, chronic[1]
Causes Blockage 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]
Frequency 6 per 1,000 per year (males > 40 years old)[1]

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, decongestants, cyclobenzaprine, diazepam, NSAIDs, amphetamines, and opioids.[1] 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 penis or lower abdomen.[1][2] 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]

Contents

Signs and symptomsEdit

Urinary retention is characterised by poor urinary stream with intermittent flow, straining, a sense of incomplete voiding, and hesitancy (a delay between trying to urinate and the flow actually beginning). As the bladder remains full, it may lead to incontinence, nocturia (need to urinate at night), and high frequency. Acute retention, causing complete anuria, is a medical emergency, as the bladder can stretch to an enormous size, and possibly tear if not dealt with quickly. If the bladder distends enough, it becomes painful. In such a case, there may be suprapubic constant, dull, pain. The increase in bladder pressure can also prevent urine from entering the ureters or even cause urine to pass back up the ureters and get into the kidneys, causing hydronephrosis, and possibly pyonephrosis, kidney failure, and sepsis. A person should go straight to an emergency department or A&E service as soon as possible if unable to urinate with a painfully full bladder.

CausesEdit

In the bladder:

In the prostate:

Penile urethra:

  • Congenital urethral valves
  • Phimosis or pinhole meatus
  • Circumcision
  • Obstruction in the urethra, for example a stricture (usually caused either by injury or STD), a metastasis or a precipitated pseudogout crystal in the urine
  • STD lesions (gonorrhoea causes numerous strictures, leading to a "rosary bead" appearance, whereas chlamydia usually causes a single stricture)

Chronic:

Other

ChronicEdit

Chronic urinary retention that is due to bladder blockage which can either be as a result of muscle damage or neurological damage.[3] 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.[3] 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.[3]

The most common cause of chronic urinary retention is BPH.[1] BPH is a result of the ongoing process of testosterone being converted to dihydrotestosterone which stimulates prostate growth.[4] Over a person's lifetime, the prostate experiences constant growth due to the conversion of testosterone to dihydrotestosterone.[4] This can cause the prostate to push on the urethra and block it, which can lead to urinary retention.[4]

DiagnosisEdit

 
As seen on axial CT

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. 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.[3] In chronic retention, ultrasound of the bladder may show massive increase in bladder capacity (normal capacity is 400-600 ml).

Non-neurogenic chronic urinary retention does not have a standardized definition; however, urine volumes >300mL can be used as an informal indicator.[3] 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.[3]

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 (trans-rectal ultra-sound 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.

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.

ComplicationsEdit

The urinary bag of a person with post obstructive diuresis

Urinary retention often occurs without warning. It is basically the inability to pass urine. In some people, the disorder starts gradually but in others it may appear suddenly. 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.[5] Urinary retention is a disorder treated in a hospital, and the quicker one seeks treatment, the fewer the complications.

In the longer term, obstruction of the urinary tract may cause:

Postoperative urinary retention risk factorsEdit

Postoperative urinary retention risk factors: age, medications, anesthetics, benign prostatic hyperplasia/lower urinary tract symptoms, and surgery related factors, including operating room time, intravenous fluids, and procedure type.[6][7][8][9][10][11][12]

Age:

Older patients can suffer from degeneration of neural pathways involved with bladder function and it can be responsible for the increased risk of postoperative urinary retention.[6][7]The risk of postoperative urinary retention increases up to 2.11 fold for patients older than 60 years.[6][7]

Sex:

Another risk factor is sex. It has been shown that sex increases risks for urinary retention not related to surgery given.[7] For men, benign prostatic hyperplasia increases risk, due to the fact that it’s a risk factor for lower urinary tract dysfunction and retention.[8] This association has not been as strongly elucidated for postoperative urinary retention.[7][8][9]

Medications:

The following medications are associated with increased risks of postoperative urinary retention: anticholinergics and medications with anticholinergic properties, alpha-adrenergic agonists, opiates (The incidence of opioid precipitated retention in the postoperative setting has been found to be as high as 25%.[10]), nonsteroidal antiinflammatories (NSAIDs) (up to 2 fold.[11]), calcium-channel blockers and beta-adrenergic agonists.[12]

Anesthesia:

General anesthetics can cause bladder atony by acting as smooth muscle relaxants.[7][8] In addition to that, it can directly interfere with autonomic regulation of detrusor tone and predispose patients to bladder overdistention and subsequent retention.[7][8] On the other hand, spinal anesthesia results in a blockade of the micturition reflex.[7][8] Overall, spinal anesthesia shows a higher risk of postoperative urinary retention compared to general anesthesia.[7][8]

Benign prostatic hyperplasia:

Men with benign prostatic hyperplasia are at an increased risk of acute urinary retention.[6] This finding is supported by a meta-analysis of 570 articles. It was established that lower urinary tract symptoms were significantly associated with an increased risk of urinary retention (OR 2.83).[6]

Surgery related:

Operative times longer than 2 hours increased the risk of postoperative urinary retention 3-fold.[7]17 Longer surgery times increase patients’ risks of urinary retention. A rule of thumb suggests that for operative cases lasting longer than 3 hours, a Foley catheter should be inserted preoperatively.[12] Overall, there is a theory that longer operative times, increased amounts of IV fluids, and higher doses of anesthetics and opiates likely all together increase risks of postoperative urinary retention.[12]

TreatmentEdit

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). Older patients with ongoing problems may require continued intermittent self catheterization.[13] 5-alpha-reductase inhibitor increase the chance of normal urination following catheter removal.[14] In case, if catheter can't be negotiated, suprapubic puncture can be done with lumbar puncture needle.

MedicationEdit

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.

CatheterEdit

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.

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[15] technique in one simple demonstration, and that reduces the rate of infection from long-term Foley catheters. Self catheterization requires doing the procedure every 3 or 4 hours 4-6 times a day.

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.

SurgeryEdit

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.[16] 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.[17]

Sitting voiding positionEdit

A meta-analysis on the influence of voiding position on urodynamics in healthy males and males with LUTS showed that in the sitting position, the residual urine in the bladder was significantly reduced. The other parameters, namely the maximum urinary flow and the voiding time were increased and decreased respectively. For healthy males, no influence was found on these parameters, meaning that they can urinate in either position.[18]

EpidemiologyEdit

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 (blood pressure pills, anti histamines, antiparkinson medications), after spinal anaesthesia or stroke.

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 numbers of individuals with acute prostatitis is unknown, because many do not seek treatment. In the USA, 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.[19]

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 catherization usually resolves the problem.[20]

ReferencesEdit

  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x "Urinary Retention". National Institute of Diabetes and Digestive and Kidney Diseases. Aug 2014. Archived from the original on 4 October 2017. Retrieved 24 October 2017. 
  2. ^ 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 : official journal of the European Society for Emergency Medicine. 23 (2): 80–8. doi:10.1097/MEJ.0000000000000334. PMID 26479738. 
  3. ^ a b c d e f 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. 
  4. ^ a b c Herati, AS; Kohn, TP; Butler, PR; Lipshultz, LI (June 2017). "Effects of Testosterone on Benign and Malignant Conditions of the Prostate". Current sexual health reports. 9 (2): 65–73. doi:10.1007/s11930-017-0104-7. PMID 29056882. 
  5. ^ General information on urinary retention Archived 2010-02-20 at the Wayback Machine. 2010-02-10
  6. ^ a b c d e Mason, Sam E.; Scott, Alasdair J.; Mayer, Erik; Purkayastha, Sanjay. "Patient-related risk factors for urinary retention following ambulatory general surgery: a systematic review and meta-analysis". The American Journal of Surgery. 211 (6): 1126–1134. doi:10.1016/j.amjsurg.2015.04.021. 
  7. ^ a b c d e f g h i j Lamonerie, L.; Marret, E.; Deleuze, A.; Lembert, N.; Dupont, M.; Bonnet, F. (2004-04-01). "Prevalence of postoperative bladder distension and urinary retention detected by ultrasound measurement". BJA: British Journal of Anaesthesia. 92 (4): 544–546. doi:10.1093/bja/aeh099. ISSN 0007-0912. 
  8. ^ a b c d e f g Hansen, B. S.; Søreide, E.; Warland, A. M.; Nilsen, O. B. (May 2011). "Risk factors of post-operative urinary retention in hospitalised patients". Acta Anaesthesiologica Scandinavica. 55 (5): 545–548. doi:10.1111/j.1399-6576.2011.02416.x. ISSN 1399-6576. PMID 21418152. 
  9. ^ a b Dal Mago, Adilson José; Helayel, Pablo Escovedo; Bianchini, Eduardo; Kozuki, Henrique; de Oliveira Filho, Getúlio Rodrigues (July 2010). "Prevalence and predictive factors of urinary retention assessed by ultrasound in the immediate post-anesthetic period". Revista Brasileira De Anestesiologia. 60 (4): 383–390. doi:10.1016/S0034-7094(10)70047-7. ISSN 1806-907X. PMID 20659610. 
  10. ^ a b Verhamme, Katia M. C.; Sturkenboom, Miriam C. J. M.; Stricker, Bruno H. Ch; Bosch, Ruud (2008). "Drug-induced urinary retention: incidence, management and prevention". Drug Safety. 31 (5): 373–388. ISSN 0114-5916. PMID 18422378. 
  11. ^ a b Verhamme, Katia M. C.; Dieleman, Jeanne P.; Van Wijk, Marc A. M.; van der Lei, Johan; Bosch, Joseph L. H. R.; Stricker, Bruno H. C.; Sturkenboom, Miriam C. J. M. (2005-07-11). "Nonsteroidal anti-inflammatory drugs and increased risk of acute urinary retention". Archives of Internal Medicine. 165 (13): 1547–1551. doi:10.1001/archinte.165.13.1547. ISSN 0003-9926. PMID 16009872. 
  12. ^ a b c d Kowalik, Urszula; Plante, Mark K. (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. ISSN 1558-3171. PMID 27261788. 
  13. ^ "Clean Intermittent Self-Catheterization". Archived from the original on 2017-07-16. 
  14. ^ Zeif HJ, Subramonian K (2009). "Alpha blockers prior to removal of a catheter for acute urinary retention in adult men". Cochrane Database Syst Rev (4): CD006744. doi:10.1002/14651858.CD006744.pub2. PMID 19821385. 
  15. ^ Sherman, Neil D. (August 17, 2006). "Clean Intermittent Self-Catheterization". A.D.A.M., Inc. Archived from the original on July 16, 2017. 
  16. ^ eMedicine Health. "Inability to urinate" Archived 2010-03-05 at the Wayback Machine. 2010-02-10.
  17. ^ National kidney and urologic diseases information clearinghouse. "Urinary retention overview" Archived 2010-01-29 at the Wayback Machine. 2010-02-10.
  18. ^ Phillips, Robert S.; de Jong, Ype; Pinckaers, Johannes Henricus Francisca Maria; ten Brinck, Robin Marco; Lycklama à Nijeholt, Augustinus Aizo Beent; Dekkers, Olaf Matthijs (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. doi:10.1371/journal.pone.0101320. PMC 4106761 . PMID 25051345. 
  19. ^ Urologic Emergencies Archived 2010-03-10 at the Wayback Machine. Urology Channel portal. 2010-02-10
  20. ^ 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. PMID 28057989. 

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