Urinary retention: Clinical sciences

Urinary retention refers to a condition characterized by the inability to voluntarily empty the urinary bladder. It can be acute or chronic, ranging from partial to complete urinary retention. Based on the underlying cause, urinary retention can occur due to spinal cord compression or injury; or as a result of medication side effects; urethral obstruction; or urinary tract infection.

Now, if your patient presents with urinary retention, your first step is to obtain a focused history and physical examination. Alright, let’s start with individuals that present with acute urinary retention. These patients typically report sudden inability to voluntarily void in combination with a sudden lower abdominal pain. On your physical exam, you will typically notice suprapubic tenderness and palpable bladder. These findings are highly suggestive of acute urinary retention.

Now, let’s go back and take a look at patients with chronic urinary retention. These individuals typically report a gradual inability to voluntarily void and lower abdominal discomfort or pain. Some patients might report symptoms of urinary tract infection, such as fever and dysuria, while others might report use of medications associated with urinary retention. Finally, history might reveal benign prostate hyperplasia or diabetes mellitus. On the physical exam, again, you will notice suprapubic tenderness and palpable bladder. These history and physical exam findings are highly suggestive of chronic urinary retention!

Now, here’s a clinical pearl to keep in mind! In biologically female individuals, assess for potential pelvic masses or organ prolapse, which can also result in urinary retention! Additionally, in all patients, you can order an ultrasound to check whether or not the bladder is full, and you can also assess for hydronephrosis.

Now, once you diagnose urinary retention, you should always consider bladder decompression using a urethral or suprapubic catheter. This way you will eliminate accumulated urine from the bladder and relieve painful sensations. Keep in mind that bladder decompression is typically reserved for individuals with acute urinary retention, but, on rare occasions, you could decompress the bladder in individuals with chronic urinary retention as well. Next, assess your patient for neurological red flags, such as bilateral weakness of lower extremities and decreased rectal tone, which could indicate a spinal cord compression, like Cauda Equina Syndrome.

Let’s say your patient presents with neurological red flags. In this case, you should definitely be worried about spinal cord involvement, such as compression from herniated discs, spinal fractures, or tumors; as well as injury from trauma. Your next step is to order imaging, more specifically an MRI of the spine! If the MRI reveals a spinal lesion, mass, or injury, you can diagnose urinary retention due to spinal cord compression or injury, and immediately consult your surgery team.

Now, here’s a clinical pearl to keep in mind! Other conditions, such as diabetes mellitus and multiple sclerosis, can cause urinary retention due to neurogenic bladder. However, these patients may not experience the neurological red flags of decreased anal sphincter tone or bilateral lower extremity weakness.

Ok, now let’s go back and take a look at patients with no neurological red flags. In this case, first, you should ask your patient about medications associated with urinary retention, such as anticholinergics, antipsychotics, antihistamines, antidepressants, and opioids.