Urinary Retention in Women

Background

• Urinary retention is a severe acute or chronic impairment of voiding that is characterized by an inability to achieve bladder emptying by voluntary micturition, leading to either complete retention or elevated postvoid residual.
• Urinary retention is a consequence of ≥ 1 or more of the following:
  • reduced bladder contractility
  • poorly sustained detrusor contraction
  • lack of adequate anatomical outlet
  • deficient outlet relaxation
  • impaired neurologic coordination of the voiding process
• Acute urinary retention usually presents as an emergency with painful bladder distention and a postvoid residual volume approximately > 250-300 mL.
• Chronic urinary retention usually presents as painless bladder distention with an elevated postvoid residual volume and leads to overflow dribbling and a risk of impaired upper urinary tract function.
  • Fowler syndrome is an associated condition affecting young women with a minimal history of lower urinary tract symptoms or problems which is characterized by painless urinary retention with high bladder volumes often following an unrelated precipitating event, such as minor surgery.
• Postpartum urinary retention (PUR) is a common consequence of bladder dysfunction after vaginal delivery.
  • Overt PUR is the inability to void spontaneously within 6 hours of vaginal delivery or removal of a urinary catheter after a cesarean section.
  • Covert PUR is characterized by the ability to void spontaneously but with a postvoid residual bladder volume ≥ 150 mL.
• Procedures with the associated risk of urinary retention include:
  • pelvic organ prolapse repair
  • urinary incontinence surgery
  • hysterectomy
  • chemodenervation of the bladder with onabotulinumtoxinA for overactive bladder induced urinary incontinence
  • epidural during labor and delivery
• Use of medications such as opiates, antipsychotics, and tricyclic antidepressants increase the risk of urinary retention.

Evaluation

• Urinary retention is best diagnosed using subjective symptoms collected through a comprehensive history, physical examination, urinalysis, and urodynamic testing including the objective measurement of postvoid residual urine volume and pressure-flow studies.
• Consider performing a postoperative voiding trial as it may help rule out patients at risk of postsurgical urinary retention.
• Differentiate between primary anatomical or functional cause of urinary retention.
• Assess serum electrolytes and creatinine and urinalysis in selected patients based on the patient history.
• Perform a bladder ultrasound on all patients to assess the postvoid residual urine volume when a concern for urinary retention is present.
• Consider obtaining a pressure-flow study to assess the lower urinary tract function and anatomy to differentiate between detrusor underactivity or acontractility and bladder outlet obstruction.
• Additional imaging may be necessary in patients with a suspicion of conditions such as obstruction, renal dysfunction, or malignancy.

Management

• Goals of treatment for urinary retention include symptom reduction, prevention of urinary tract infections, and avoidance of upper tract deterioration.
• Patients with acute urinary retention should be treated with urethral or suprapubic catheterization for immediate decompression and monitored for postobstructive diuresis, acute kidney injury, and electrolyte abnormalities with the tracking of urinary volume, serum electrolytes, and creatinine 2-3 times daily.
• Chronic urinary retention may be treated with:
  • conservative management, including: timed and prompted voiding, pelvic floor rehabilitation, dietary interventions, withdrawal of causative medications, and manual reduction or use of a pessary for anatomic obstructions
  • bladder catheterization:
    • intermittent urethral catheterization to women who can be taught to self-catheterize or who have a carer who can perform the technique
    • indwelling urethral catheterization to women unable to manage intermittent self-catheterization
  • Pharmacotherapy:
    • Consider alpha adrenergic receptor blockers, such as tamsulosin and prazosin, which have been reported to improve voiding dysfunction.
    • Consider cholinergic drugs, such as bethanechol and distigmine bromide, which may improve detrusor contractility and enhance bladder emptying.
  • Sacral neuromodulation or posterior tibial nerve stimulation should be considered for urinary retention due to detrusor underactivity or idiopathic chronic nonobstructive urinary retention.
  • Reserve surgical management for patients unresponsive to conservative methods and unable or unwilling to perform clean intermittent catheterization.
    • Common procedures include transurethral incision of bladder neck, urinary diversion, and urethral dilation.
• For patients with postpartum urinary retention, offer intermittent catheterization as initial treatment within 24 hours, and indwelling catheterization within 24-72 hours.
• For patients with urinary retention following urinary incontinence surgery, such as a midurethral sling procedure, which is not resolving with early management and intermittent postoperative catheterization, consider a sling takedown or urethrolysis if it is causing a mechanical obstruction.