The causes of Urinary bladder retention can be understood by broadly understanding it into two simplest terms- Urinary tract blockage and Neurological causes. We will elaborate and simplify the causes of urinary retention under these two words as follows:
What is Urinary Retention?
Urinary retention is the inability to urinate, thereby the bladder doesn’t empty. It could be acute or chronic retention of urine. Acute Urinary Retention is a medical emergency and needs to be treated with a foley catheter most often.
The following are broad causes of Urinary Retention in males:
|Obstructive||Benign prostatic hyperplasia; meatal stenosis; paraphimosis; penile constricting bands; phimosis; prostate cancer|
|Infectious and inflammatory||Balanitis; prostatic abscess; prostatitis|
|Other||Penile trauma, fracture, or laceration|
Urinary Tract Blockage
Rewind a bit, what are the components of the Urinary tract?
Now, if the Urinary bladder can be compressed by many adjacent structures, so the following causes urinary retention in males:
- Benign prostate hyperplasia (most common in men in the age group of 50-60 years)
- Nephrolithiasis or renal stones or kidney stones
- Urethral Stricture (narrowing)
- Weak bladder muscle
- Prostate carcinoma
- Bladder diverticula
- Infections causing swelling of adjacent structures- Prostatitis, Cystitis
The bladder sends a signal to the brain, telling it to empty the urinary bladder. What if the brain doesn’t get these signals or is unable to manipulate them? The bladder will keep filling and the brain will not understand if it’s full or not, resulting in Urinary retention, right?
The following are neurological causes of Urinary Retention:
|Autonomic or peripheral nerve||Autonomic neuropathy; diabetes mellitus; Guillain-Barré syndrome; herpes zoster virus; Lyme disease; pernicious anemia; poliomyelitis; radical pelvic surgery; sacral agenesis; spinal cord trauma; tabes dorsalis|
|Brain||Cerebrovascular disease; concussion; multiple sclerosis; neoplasm or tumor; normal pressure hydrocephalus; Parkinson’s disease; Shy-Drager syndrome|
|Spinal cord||Dysraphic lesions; intervertebral disk disease; meningomyelocele; multiple sclerosis; spina bifida occulta; spinal cord hematoma or abscess; spinal cord trauma; spinal stenosis; spinovascular disease; transverse myelitis; tumors or masses of conus medullaris or cauda equine|
Although history taking is the first step to approaching the patient with urinary retention, a physical examination should be done carefully to predict the correct diagnosis.
The following are the points of History, Physical Examination, and Possible Etiology in male patients with urinary retention:
|History||Physical examination||Possible etiology|
|Previous history of urinary retention||Enlarged, firm, non-tender, nonnodular prostate on digital rectal examination; prostate examination may be normal||Benign prostatic hyperplasia|
|Fever; dysuria; back, perineal, and rectal pain||Tender, warm, boggy prostate; possible penile discharge||Acute prostatitis|
|Weight loss; constitutional signs and symptoms||Enlarged nodular prostate; prostate examination may be normal||Prostate cancer|
|Pain; swelling of foreskin or penis||Edema of the penis with non-retractable foreskin; externally applied penile device||Phimosis, paraphimosis, or edema caused by an externally placed constricting device|
Lab tests involve Urinalysis, Serum BUN and creatinine, RBS (random blood sugar>125) for diabetes mellitus, and prostate-specific antigen for ruling out prostate cancer.
Imaging studies include USG (ultrasound) of the pelvis, KUB (Kidney Urinary Bladder) CT Scan of the Abdomen and pelvis, and Brain & Spine with MRI. Blood tests may be evaluated as well. Following are tests done for diagnosing Urinary Retention in males:
|Test type||Diagnostic test||Rationale|
|Laboratory||Urinalysis||Evaluate for infection, hematuria, proteinuria, glucosuria|
|Serum blood urea nitrogen, creatinine, electrolytes||Evaluate for renal failure from lower urinary tract obstruction|
|Serum blood glucose||Evaluate for undiagnosed or uncontrolled diabetes mellitus in neurogenic bladder|
|Prostate-specific antigen||Elevated in prostate cancer; may be elevated in benign prostatic hyperplasia, prostatitis, and the setting of acute urinary retention|
|Imaging studies||Renal and bladder ultrasonography||Measure post-void residual urine; evaluate for bladder and urethral stones, hydronephrosis, and upper urinary tract disease|
|Pelvic ultrasonography; CT of abdomen and pelvis||Evaluate for suspected pelvic, abdominal, or retroperitoneal mass or malignancy causing extrinsic bladder neck compression|
|MRI or CT of the brain||Evaluate for intracranial lesions, including tumors, strokes, and multiple sclerosis (MRI preferred in multiple sclerosis)|
|MRI of spine||Evaluate for lumbosacral disk herniation, cauda equina syndrome, spinal tumors, spinal cord compression, multiple sclerosis|
|Other||Cystoscopy, retrograde cystourethrography||Evaluate for suspected bladder tumors and bladder or urethral stones or strictures|
|Urodynamic studies (e.g., uroflowmetry, cystometry, electromyography, urethral pressure profile, video urodynamics, pressure flow studies of micturition)||Evaluate bladder function (detrusor muscle and sphincter) in patients with neurogenic bladder to help guide management|
Initial management involves catheterization with Foley’s catheter. However, if urethral catheterization is unsuccessful or contraindicated, Supra-Pubic catheterization is the choice. The aim is to decompress the bladder before more damage occurs. Thus, emptying the bladder with urine bags is the first line of treatment for Acute Urinary Retention.
The next step is to establish the diagnosis with the proper lab tests and imaging. Correct history and physical examination also help in establishing the diagnosis of retention of urine.
Additionally, symptomatic treatment may be given to control the exaggerated symptoms in the patient and provide relief from the severe pain of stretching the bladder.
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