Urinary retention

Urinary retention is a common and potentially serious condition encountered in the emergency department (ED), characterized by the inability to empty the bladder completely. As a junior doctor, understanding the causes, assessment, and management of urinary retention is crucial for providing effective patient care.

Understanding Urinary Retention

Urinary retention can be acute or chronic:

• Acute Urinary Retention: Sudden inability to urinate, often painful and requiring immediate intervention.

• Chronic Urinary Retention: Gradual development with incomplete bladder emptying, which may be less painful but can lead to complications like urinary tract infections (UTIs).

Common Causes of Urinary Retention

Obstructive Causes

• Benign Prostatic Hyperplasia (BPH): Enlargement of the prostate gland in men, leading to obstruction of urine flow.

• Urethral Stricture: Narrowing of the urethra due to scar tissue.

• Bladder Stones: Can obstruct the urethra or bladder outlet.

• Tumors: Bladder or pelvic tumors compressing the urinary tract.

Infectious and Inflammatory Causes

• Prostatitis: Inflammation or infection of the prostate gland.

• Cystitis: Inflammation of the bladder, often due to infection.

Neurological Causes

• Spinal Cord Injury: Disruption of nerve signals controlling bladder function.

• Multiple Sclerosis: Can affect nerve pathways involved in urination.

• Diabetic Neuropathy: Nerve damage from diabetes affecting bladder control.

Medications

• Drugs with anticholinergic properties (e.g., antihistamines, antidepressants) can impair bladder contraction.

• Opioids can reduce bladder tone and lead to retention.

Initial Assessment and Management

History Taking

A thorough history is essential to guide further evaluation:

• Onset and duration of symptoms

• Associated symptoms such as pain, frequency, urgency, or hematuria

• History of urinary tract infections or previous episodes of retention

• Medication use that may contribute to retention

• Past medical history including neurological disorders or surgeries

Physical Examination

The physical examination should focus on identifying signs that may indicate specific causes:

• Abdominal examination: Palpate for a distended bladder.

• Genital examination: Check for signs of infection or obstruction.

• Neurological examination: Assess for sensory deficits or signs of spinal cord involvement.

Diagnostic Workup

Depending on clinical suspicion from history and examination, the following tests may be considered:

• Bladder Ultrasound: To assess post-void residual volume and confirm retention.

• Urinalysis: To check for infection or hematuria.

• Blood Tests: Including renal function tests if kidney impairment is suspected.

Management Strategies

Management of urinary retention in the ED focuses on relieving the obstruction and addressing underlying causes:

1. Immediate Relief:

   • Catheterization (urethral or suprapubic) to decompress the bladder and relieve acute retention.

2. Address Underlying Causes:

   • Alpha-blockers (e.g., tamsulosin) for BPH-related obstruction.

   • Antibiotics for infections like prostatitis or cystitis.

   • Adjust medications contributing to retention if possible.

3. Monitoring and Follow-up:

   • Monitor urine output post-catheterization for diuresis or hematuria.

   • Referral to urology for further evaluation if structural abnormalities are suspected.

Challenges and Considerations

Urinary retention can lead to complications such as UTIs, bladder damage, or renal impairment if not addressed promptly. It is important to identify reversible causes and provide appropriate follow-up care. In cases where neurological causes are suspected, collaboration with neurology may be necessary.

By taking a systematic approach to the assessment and management of urinary retention in the emergency setting, you can effectively address this condition while ensuring appropriate follow-up care.