Urinary retention

Onset can be sudden or gradual. 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: • Bladder stones • Atrophy of the detrusor muscle (atonic bladder is an extreme form) • Hydronephrosis (congestion of the kidneys) • Hypertrophy of the detrusor muscle (the muscle that squeezes the bladder to empty it during urination) • Diverticula (formation of pouches) in the bladder wall (which can lead to stones and infection) == Causes ==

Bladder • Infection • Detrusor sphincter dyssynergia • Neurogenic bladder (commonly spinal cord damage, pelvic splanchnic nerve damage, cauda equina syndrome, pontine micturition or storage center lesions, demyelinating diseases, multiple system atrophy, genital herpes, or meningitis-retention syndrome) • Iatrogenic (caused by medical treatment/procedure) scarring of the bladder neck (commonly from removal of indwelling catheters or cystoscopy operations) • Damage to the bladder Prostate • Benign prostatic hyperplasia (BPH) • Prostate cancer and other pelvic malignancies • Prostatitis 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 • Pseudodyssynergia • STD lesions (gonorrhoea causes numerous strictures, leading to a "rosary bead" appearance, whereas chlamydia usually causes a single stricture) • Emasculation Postoperative Risk factors include • Age: Older people may have degeneration of neural pathways involved with bladder function and it can lead to an increased risk of postoperative urinary retention. The risk of postoperative urinary retention increases up to 2.11 fold for people older than 60 years. and stimulants, such as methylphenidate, amphetamine and MDMA. • Use of NSAIDs, or drugs with anticholinergic properties. • Stones or metastases, which can theoretically appear anywhere along the urinary tract, but vary in frequency depending on anatomy. • Muscarinic antagonists such as atropine and scopolamine. • Malfunctioning artificial urinary sphincter. == Diagnosis ==

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. 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. 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. 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. 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. == 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). Use of alpha-blockers can provide relief of urinary retention following de-catheterization for both men and women. In case, if catheter can't be negotiated, suprapubic puncture can be done with lumbar puncture needle. Medication α1-receptor antagonists and 5α-reductase inhibitors Urinary retention, including drug-induced cases, may be an early sign of benign prostatic hyperplasia (BPH). Treatment typically includes α1-receptor antagonists such as tamsulosin, which relaxes smooth muscle in the bladder neck, and 5α-reductase inhibitors like finasteride and dutasteride, which reduce prostate enlargement. Clinical trials have demonstrated that combining these medications improves urinary symptoms and lowers the likelihood of retention recurrence. Striated muscle relaxants Baclofen, a gamma-aminobutyric acid (GABA) agonist, acts on GABAergic interneurons in the sacral intermediolateral cell column, facilitating the relaxation of the striated urinary sphincter during voiding. Some evidence suggests it may be beneficial for women with bladder outlet obstruction and pediatric patients. Opioid antagonists Naloxone, has been tested for urinary retention following epidural or intrathecal anesthesia. While effective, it also reverses analgesia, making it unsuitable for postoperative cases. Nalbuphine, a mixed agonist/antagonist opioid modulator, has shown promise in a reported case of postoperative urinary retention, preserving analgesia while relieving retention. Further studies are needed to confirm its efficacy. Studies show that TENS can be applied at different locations, such as transvaginally, over the symphysis pubis and ischial tuberosity to stimulate the pudendal nerve, or at the second sacral foramina and lower abdomen. Challenges with CISC include compliance issues as some people may not be able to place the catheter themselves. 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. 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. 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. == 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. 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. 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. == References ==