The management of female urinary retention

Sara Ramsey & Michael PalmerDept of Urology, Gartnavel General Hospital, Glasgow, UK

Abstract. Female acute urinary retention (AUR) is relatively uncommon and often poorly managed. Thereare several common precipitants though much of the literature refers to female AUR as a psychogeniccondition. The underlying abnormality is often detrusor failure, not outlet obstruction. Investigationsshould focus on identifying serious or reversible causes and should include a detailed history and physicalexamination, urine dipstick, culture and pelvic ultrasound. Patients should be catheterised and reversiblecauses should be treated. Women who fail to void after catheter removal should be taught ISC. Alpha-blockers are no better than placebo in the treatment of female AUR. There is no role for urethral dilatation.Patients with apparently idiopathic retention should be referred to a urologist with an interest in bladderdysfunction for consideration of urodynamics.

Key words: Acute urinary retention, Fowler’s syndrome, Review, Women

Introduction

Female acute urinary retention (AUR) is relativelyuncommon compared to AUR in men. It is esti-mated that 3 cases per 100,000 occur per year [1].Its relatively low incidence and little publishedevidence base leads to inconsistent and often sub-optimal management of female AUR. This articlereviews the common causes and evidence base forinvestigation and management of female AUR.

Aetiology

Acute urinary retention is defined as the inabilityto void urine, with a retained volume of urine of200 mls or greater. The common causes of acuteurinary retention (AUR) in women can be classi-fied into sub-groups as shown in Table 1. Thereare more than 100 published case reports describ-ing rare and isolated causes of urinary retention.

Numerous publications describe idiopathicfemale urinary retention as psychogenic or hys-terical, including relatively recent articles. Fortypercent of the women surveyed in 2002 followingacute urinary retention were given the impression

that their condition was psychological [2]. Uro-dynamic evidence suggests that the underlyingdisorder is usually detrusor failure rather thanoutflow obstruction [3, 4] except in the rare Fow-ler’s syndrome, where there is failure of relaxationof the urethral sphincter [11].

Investigation

Investigations should be tailored to identifyingpotential serious or reversible causes. The authorssuggest that detailed history should include drughistory, bowel habit, sensory/motor deficit, lowerurinary tract symptoms, and previous surgery,particularly gynaecological or urological. Thisshould be accompanied by a detailed examinationincluding neurological and pelvic examination.

We also suggest a urine dipstick and CSU toexclude infection, and a pelvic USS to identify anyoccult mass effect, particularly from gynaecologi-cal or urological malignancy. As women have lowpressure bladders, their upper tracts are relativelyimmune in even large volume retention and thereis no evidence to support routine upper tractimaging [4].

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Flexible cystoscopy is quick, safe and well tol-erated by patients [5] to visualise the urethra andbladder. It should be used to exclude anatomicalabnormalities and intravesical pathology but thereis no published evidence regarding its role in uri-nary retention in women.

Management

The management of urinary retention in bothgenders involves relieving the retention by cathe-terisation and treating any remediable cause. Anyneurological abnormality on examination shouldlead to prompt imaging by MRI and appropriatereferral if abnormal.

Catheterisation

Post-operative retention should be treated by an in–out catheter, and by an indwelling catheter if afurther retention develops [6]. If a precipitatingfactor such as infection or constipation is identifiedthis should be rectified and a trial of voiding per-formed thereafter. There is no literature regardingthe optimum timing for this.

Some patients will not void successfully fol-lowing catheter removal. Increased risk of failureis associated with urinary symptoms prior toretention and apparently idiopathic causes [1].These women should be given the option oflearning clean intermittent self-catheterisation(CISC). CISC avoids the potential morbidity of anindwelling catheter and is preferable to most maleand female patients [7, 8]. CISC also allows thepatient to monitor their residual volumes asdetrusor activity may return over time. Evidence inthe literature is rather anecdotal, but Smith andMorrant [8] report 10 women returning to normalvoiding following CISC alone.

Pharmacological management

Alpha-blockers such as tamsulosin have beenshown to lower the resting urethral pressure inhealthy women [9]. However, a trial of alpha-blocker versus placebo showed no significantdifference in success at trial of voiding in women[10]. As the underlying cause is often detrusorunderactivity, and in the rare Fowler’s syndrome[11] the urethral sphincter is abnormal there islittle rationale for targeted urethral treatment.

Specialist investigations

In apparently idiopathic causes referral to aurologist with an interest in bladder dysfunctionis advised. Urodynamics may demonstratedetrusor failure but 40% of normal women showtest-related detrusor inhibition [4]. The decisionto perform urodynamics will be based on indi-vidual practice as there are no standard criteriaregarding female retention.

In young women, particularly those with poly-cystic ovarian syndrome, urethral pressure profilesshould be performed to identify women withFowler’s syndrome [11]. This is retention caused byfailure of relaxation of the urethral sphincter whichresponds to sacral neuromodulation.

Surgery

A significant number of women have had unsuc-cessful urethral dilatations in an attempt to restorevoiding function [4]. There is no evidence or logic

Table 1. The common causes of female AUR

Anatomical Organ prolapse

e.g., cystocoele

Mass effect

Gynaecological tumour

Urological tumour

Constipation

Bladder neck stenosis

Drugs Opiates

Antimuscarinics

Antipsychotics

a adrenergic agonists

Operative Pain

Anaesthetic related

e.g., epidural anaesthesia

Incontinence surgery

Neurological Cord trauma

Degenerative neurological disease

e.g., Multiple sclerosis

Cauda equine syndrome

Fowler’s syndrome

Infective Urinary tract infection

Genital herpes

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to support urethral dilatation on an anatomicallynormal urethra to treat female urinary retention.

Bladder neck obstruction is an exceptionallyrare event in women [12] and should be diagnosedby video urodynamics. Surgery carries a risk ofincontinence and should not be performed withouturodynamic evidence.

Conclusions

Female AUR is rare and often not well man-aged. Investigations should focus on identifyingany reversible precipitants. Patients who fail tovoid after catheter removal should be given theoption of performing CISC and referred to aurologist. There is no role for alpha-blockers, orurethral dilatation and patients with apparentlyidiopathic retention should not be labelled hys-terical. There is a lack of prospective trials ofinvestigations and management and multi-centretrials may be necessary to improve evidence-based practice.

Acknowledgement

The research post is funded by the Fischer FamilyFoundation, a charitable trust.

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Address for correspondence: Sara Ramsey MBChB MRCS

(Gla), Research Fellow, Dept of Urology, Gartnavel General

Hospital, 1053 Great Western Rd, Glasgow, G12 0YN, UK

Phone: 0044 141 211 0128

E-mail: sara_l_ramsey@ntlworld.com

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