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urinary retention

Etiology: (causes not exclusive) 1) benign prostatic hypertrophy (BPH) 2) postrenal azotemia 3) overflow incontinence 4) fecal impaction, especially in the elderly 5) postoperative complication [9] - may be contribution of opioid receptor agonist 6) pharmaceutical agents a) parasympatholytics (oral, inhaled or parenteral) - oxybutynin, fesoterodine b) sedating antihistamines (loratadine & fexofenadine are exceptions) c) sympathomimetics prevent bladder neck relaxation - pseudoephedrine ... d) many cold remedies contain parasympatholytics, sedating antihistamines or sympathomimetics e) opioid receptor agonists [3] f) calcium channel blockers g) alpha-adrenergic agonists [3] 7) natural remedies (pharmaceutical herbs) a) herbs containing sympathomimetics - ephedra, ma huang, country mallow, heartleaf, bitter orange Clinical manifestations: - bladder fullness, palpable bladder - sensation of incomplete bladder emptying - urinary frequency - urinary hesitancy Laboratory: - basic metabolic panel - serum creatinine [5] - serum potassium: hyperkalemia may occur due to RTA-4 [3] - prostate-specific antigen in serum (men) Special laboratory: - post-void residual (PVR) - PVR > 200 mL is clearly abnormal - PVR > 300 mL in symptomatic patients should prompt catheterization - PVR > 500 mL in asymptomatic patients should prompt catheterization [13] - bladder scanning preferable to urinary catheter - intermittent straight catheter preferable to indwelling urinary catheter - if intermittent straight catheterization is required more than every 4 hours, or urine output is > 500 mL every 4 hours, transition to indwelling urinary catheter [13] - urodynamic studies can be helpful Radiology: - CT of pelvis for suspected mass, but not routine [5] Complications: - delirium (cystocerebral syndrome) - high 1 year mortality [2] a) 13% without comorbity (18% if NOT due to BPH) b) 29% with comorbidity (41% if NOT due to BPH) Management: - stop offending medication(s) (step 1, see etiology) - insert foley catheter as needed - see post-void residual (PVR) for management of PVR > or < 200 mL - if due to benign prostatic hypertrophy, start tamsulosin [5,8] - remove catheter in 3 days [3] - if benign prostatic hypertrophy complicated by recurrent urinary tract infections, refer to urology for surgical options - see postrenal azotemia - suprapubic application of warm wet gauze may stimulate voiding, but lacks from proof of efficacy in controlled trials [9]

Related

overflow incontinence

Specific

bladder outlet obstruction

General

postrenal azotemia; obstructive uropathy sign/symptom

References

  1. Prescriber's Letter 11(1):1 2004
  2. Armitage JN et al, Mortality in men admitted to hospital with acute urinary retention: Database analysis. BMJ 2007, Nov 8 PMID: 17991937 http://dx.doi.org/10.1136/bmj.39377.617269.55
  3. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  4. Marshall JR, Haber J, Josephson EB. An evidence-based approach to emergency department management of acute urinary retention. Emerg Med Pract. 2014 Jan;16(1):1-20; quiz 21. Review. PMID: 24804332
  5. NEJM Knowledge+ Question of the Week. July 17, 2018 https://knowledgeplus.nejm.org/question-of-week/1216
  6. Choong S, Emberton M. Acute urinary retention. BJU Int 2000 Feb 15; 85:186 PMID: 10671867 Free full text
  7. Curtis LA, Dolan TS, Cespedes RD. Acute urinary retention and urinary incontinence. Emerg Med Clin North Am 2001 Sep 14; 19:591. PMID: 11554277
  8. Lucas MG, Stephenson TP, Nargund V. Tamsulosin in the management of patients in acute urinary retention from benign prostatic hyperplasia. BJU Int 2005 Feb; 95:354. PMID: 15679793 Free full text
  9. Medical Knowledge Self Assessment Program (MKSAP) 18, American College of Physicians, Philadelphia 2018 - Bjerregaard LS, Hornum U, Troldborg C et al Postoperative Urinary Catheterization Thresholds of 500 versus 800 ml after Fast-track Total Hip and Knee Arthroplasty: A Randomized, Open-label, Controlled Trial. Anesthesiology. 2016 Jun;124(6):1256-64. PMID: 27054365
  10. Stephenson A, Seitz D, Bell CM et al. Inhaled anticholinergic drug therapy and the risk of acute urinary retention in chronic obstructive pulmonary disease: a population-based study. Arch Intern Med. 2011;171(10):914-920 PMID: 21606096 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/227387
  11. Billet M, Windsor TA. Urinary retention. Emerg Med Clin North Am. 2019;37(4):649-660 PMID: 31563200 https://journals.sagepub.com/doi/10.5301/RU.2013.11688
  12. NEJM Knowledge+ Nephrology/Urology
  13. Chrouser K et al. Urinary retention evaluation and catheterization algorithm for adult inpatients. JAMA Netw Open 2024 Jul 16; 7:e2422281. PMID: 39012634 PMCID: PMC11252892 Free PMC article. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2821168