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Urinary Retention


Causes of urinary retention

  • Acute retention
    • Prostate pathology – benign or malignant
      • Commonest cause in men is benign prostatic hypertrophy (BPH)
    • Infection including STI
    • Phimosis, circumcision
    • Congenital urethral valves
    • Clot retention from bleeding source
    • Urethral strictures
    • Constipation
    • Post-operative
    • Neurological
      • Cauda equine syndrome, any spinal injury above level of bladder innervation
    • Medications
      • Anticholinergic, opiate, antihistamines, cold/flu remedies medication
    • Alcohol
  • Chronic retention
    • Prostate pathology (as above)
    • Pelvic mass
      • Benign or malignant
    • Diabetes
    • Neurological
      • MS or other chronic upper motor neurone pathology


History taking in urinary retention

  • Presenting complaint
    • Acute retention
      • Rapid onset suprapubic pain (if painless and acute suspect CNS pathology)
      • Inability to pass urine
      • Possible bleeding
      • Symptoms in keeping with aetiology
        • e.g. recent dysuria, recent spinal trauma
    • Chronic
      • May be as above but more likely:
      • May be asymptomatic
      • Low flow micturition
      • Nocturnal incontinence
      • Palpable painless bladder
      • Clinical signs of chronic renal failure
  • History of presenting compliant
    • UTI symptoms
    • Timing and speed of symptoms
    • Pain site and severity
    • Desire to void
    • Sensation of incomplete voiding
    • Previous episodes of retention
    • Recent surgery
    • Bowels opening
  • Past medical history
    • Diabetes
    • Known prostate disease
    • Urinary tract tumour/any cancer
    • Neurological disease e.g. disc prolapse, MS etc
    • Known anatomical distortion
    • PMHx will also help determine fitness for future surgery
  • Medications
    • Anticholinergics e.g. oxybutynin
    • TCAs
    • Opiates
    • Antihistamines
    • Cold remedies
    • Anticoagulants if bleeding
  • Allergies
  • Social history
    • Smoking
    • Risk factors for malignancy


Focused examination in urinary retention

  • ABCDE approach to ensure patient safe
  • Abdominal examination
    • Is the bladder either visible or percussible
      • A percussible bladder has at least 150mls in it
    • Is the bladder palpable?
      • A palpable bladder has over 200mls in it
    • Any other abdominal masses palpable?
    • PR exam
      • Prostate size and prostate texture (smooth = BPH, craggy = tumour)?
      • Anal tone?
      • Faecal impaction?
  • Focused neurological examination
    • Looking for potential spinal lesion, MS (a rare primary presenting complaint in MS), other neurological condition that can be associated with dysautonomia e.g. Parkinson’s


Initial investigation of urinary retention

  • Urine dip and MSU
  • U&Es, FBC and clotting (G&S if frank haematuria)
  • Blood glucose
  • Consider PSA if suspicious prostate
  • Post-catheter
    • Measure residual volume of bladder
    • Measure urinary volume removed in first 10-15 minutes to determine true acute retention versus “acute on chronic” retention
    • Residual volumes of greater than one litre make patients more likely to fail a trial without catheter (TWOC) and increase the chances of have recurrent retention


Further investigation of urinary retention

  • Renal tract USS if very high residual or abnormal renal function on bloods
  • CT if space occupying lesion suspected
  • Cystoscopy if urethral/prostate disease suspected
  • Urodynamic studies if bladder dysfunction suspected


Initial management of acute urinary retention

  • Acute retention
    • Catheterise patient
      • Aseptic technique
      • Consider stat dose of gentamicin (80mg IM if no renal failure) if high risk for UTI
    • Post-catheterisation patients may be admitted if:
      • Clot retention
      • Complicated renal colic
      • Frank haematuria
      • Social reasons or lots of co-morbidities
      • Greater than two litres of residual urine
    • Post-catheterisation patients may be sent home if they have none of the issues above
    • On discharge
      • Urgent follow-up if suspected malignancy, mild haematuria, very abnormal U&Es
      • Non-urgent (usually 2-4 weeks) if uncomplicated UTI, mild prostate pathology.
      • Academic debate regarding how long to leave catheter in: some advocate immediate removal once drained, others leave in for up to 2 weeks before attempting trial without catheter (TWOC)
      • In men, give Tamsulosin (400mcgs PO) as a stat dose prior to TWOC. Consider starting long term alpha blockers after discussion with urology.
      • Suprapubic catheterisation should be discussed with urology if catheterisation fails.
    • Treat the cause
      • As above, tamsulosin for BPH
      • Antibiotics for UTI
        • Trimethoprim or nitrofurantoin as per local trust policy
      • Treatment of constipation
        • Movicol 3 sachets twice per day, increased dietary fibre
      • More complex causes will need discussion with relevant team
  • Chronic retention
    • Less urgency
    • Catheterise if renal dysfunction or hydronephrosis: be wary of over diuresis requiring intravascular support and monitor electrolytes
    • Management is very specific to cause but tend to avoid TWOC until definitive treatment is available due to poor outcome of TWOC in chronic retention.



  • Kalejaiye, Odunayo, and Mark J. Speakman. “Management of acute and chronic retention in men.” European urology supplements 8.6 (2009): 523-529.
  • Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am Fam Physician 2008; 77: 643-650.
  • McNeill, S. A., et al. “Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study.” Urology 65.1 (2005): 83-89.)



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