Male Urinary Retention: Acute and Chronic

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Continuing Education Activity

Urinary retention is the inability to void urine voluntarily. The condition is common worldwide and can occur acutely or chronically. Acute urinary retention in men most commonly occurs secondary to benign prostatic hyperplasia. Acute urinary retention in women is rare but still occurs, and the anatomical differences preclude treatment and best course management. Urinary retention, characterized by the incomplete emptying of the bladder, manifests as acute or chronic conditions. Treatment involves tailored approaches, considering multifactorial causes and individual patient factors. This activity concerns male urinary retention, including acute and chronic cases.

Clinicians participating in this activity will review the epidemiology, pathophysiology, etiology, history, physical evaluation, laboratory, and other testing procedures to evaluate and diagnose the condition. Treatment options, patient instructions, follow-up care, potential complications, associated comorbidities, and key points in healthcare team management are discussed. An interprofessional primary care team and specialists, particularly urologists, are best equipped to handle male urinary retention.

Objectives:

  • Identify the signs and symptoms indicative of male urinary retention, distinguishing between acute and chronic presentations.

  • Assess patients with chronic urinary retention, evaluating bladder function, post-void residual volume, and associated comorbidities.

  • Select optimal treatment modalities based on patient characteristics, preferences, and responses to previous interventions.

  • Implement strategies within an interprofessional team to enhance outcomes for men with urinary retention.

Introduction

Urinary retention is the inability to void urine voluntarily, leaving the bladder incompletely empty. Acute urinary retention is the sudden inability to void, usually associated with bloating, severe urgency, general distress, lower abdominal distension, and suprapubic pain. The condition is the most common worldwide urologic emergency, occurring predominantly in men. Acute urinary retention is most commonly secondary to benign prostatic hyperplasia (BPH). Acute urinary retention in women is rare, as men are 13 times more likely to develop this problem. (See StatPearls' companion reference, "Female Urinary Retention," for more information.)[1] Chronic urinary retention frequently presents without acute symptoms. The International Continence Society defines chronic urinary retention as a nonpainful bladder that remains palpable after voiding.[2][3] 

Given the multifactorial etiologies, the evaluation and treatment plan for patients with urinary retention may involve concurrent treatment of comorbidities. Determining procedural, pharmacological, or nonpharmacological treatment is up to the treating clinicians and is based on an accurate history and physical exam.

Etiology

Causes of acute urinary retention are numerous and generally categorized as obstructive, infectious, inflammatory, pharmacologic, neurologic, or other.

Acute Urinary Retention

Obstructive causes

The most common cause of urinary retention is mechanical outflow obstruction, usually caused by physical narrowing of the urethral lumen from strictures or BPH. An increase in the muscle tone at the bladder neck, such as from α-agonist drug use or sphincteric dysfunction, may result in detrusor sphincter dyssynergia.[4][5]

Other obstructive causes include constipation, prostatic cancer, intravesical median lobe enlargement, bladder cancer, urethral strictures, urethral foreign bodies, bladder stones, urolithiasis, phimosis, paraphimosis, and urethral trauma.[6][7]

Infections

This category includes prostatitis and urinary tract infections causing urethritis and urethral edema. The effect is more pronounced in patients with pre-existing BPH.[8] Acute prostatitis will cause prostatic swelling and narrow the urinary passage. Urethral mucosal edema from trauma or infection may also obstruct urinary flow.[2][9] Infections from genital herpes or varicella-zoster may affect the sacral nerves and result in neuropathy with subsequent urinary retention.[10][11]

Neurologic causes

Any disruption of the normal neurological pathways involved in micturition can result in urinary difficulties or retention. Neurological causes of urinary retention typically involve a central nervous system disorder (such as a stroke, multiple sclerosis, spinal cord injury, or Parkinson disease) or some alteration in the sensory/motor innervation of the detrusor muscle or the urinary sphincter mechanism.[7] Back pain and other neurological deficits usually accompany such disorders.[6] 

Patients with existing or known neurological disorders may develop urinary retention with less obvious symptoms due to alterations in sensory perception. A high index of suspicion should be maintained for voiding difficulties like urinary retention in such individuals. Patients with a prior diagnosis of BPH are at higher risk.[12][13] Normal, voluntary urination requires the complex integration and coordination of high cortical neurologic functions with pelvic sympathetic, parasympathetic, and somatic nerves.[14] These actions facilitate normal voiding.

Bladder storage

As the bladder fills, detrusor stretch receptors are stimulated. Their signal travels through spinal nerves S2 to S4 and the hypogastric nerve to the brain's sensory cortex and pontine storage center. When an individual's threshold bladder volume is reached, this is perceived as an urge to void, and the micturition process may begin. Until then, the hypogastric nerve provides sympathetic tone, which inhibits bladder contractions, contracts the internal sphincter, and promotes bladder storage. The "guarding reflex" is activated, which increases external sphincteric compression through pudendal (somatic) nerve activation. The "guarding reflex" also increases sympathetic (hypogastric) stimulation to relax the detrusor muscle and tighten the internal sphincter.

Voiding

The central nervous system's periaqueductal grey area and pontine micturition center are activated. Signals are sent to the sacral micturition center and hypogastric nerve. Hypogastric (sympathetic) nerve activity is suppressed, which relaxes the internal sphincter and pelvic floor muscles while suppressing the "guarding reflex." Parasympathetic signals are sent to the detrusor from the sacral micturition center (S2 to S4) through the pelvic nerves, which cause the bladder muscle to contract. At the same time, somatic signals through the pudendal nerve relax the external sphincter. Urinary retention associated with autonomic dysreflexia, cauda equina syndrome, detrusor-sphincter dyssynergia, spinal cord injury, and spinal shock is discussed later.

Detrusor muscle dysfunction

Inadequate detrusor muscle tone and contractility can cause acute urinary retention. The retention may result from deliberate or accidental bladder overdistension, such as during prolonged general or epidural analgesia without an indwelling catheter. Patients with BPH or symptoms of obstructive uropathy at baseline are at risk.

Medications

Up to 10% of all cases of male urinary retention are potentially attributable to the direct use of various medications and their adverse effects. Medications that cause urinary retention primarily exert neuromuscular effects, with anticholinergics and α-adrenergic agonists most closely associated with the disorder.

Drugs associated with urinary retention include:

  • Amphetamines
  • Anesthetic agents (various)
  • Antiarrhythmics (quinidine, procainamide, disopyramide)
  • Anticholinergics (atropine, scopolamine, glycopyrrolate, mepenzolate, oxybutynin, flavoxate, hyoscyamine, belladonna, propantheline, dicyclomine)
  • Antidepressants (imipramine, nortriptyline, amitriptyline, doxepin, amoxapine, maprotiline)
  • Antihistamines (diphenhydramine, chlorpheniramine, brompheniramine, cyproheptadine, hydroxyzine)
  • Antihypertensives (hydralazine, nifedipine)
  • Antiparkinsonian agents (trihexyphenidyl, benztropine, amantadine, levodopa, bromocriptine)
  • Antipsychotics (haloperidol, thiothixene, thioridazine, chlorpromazine, fluphenazine, prochlorperazine)
  • Carbamazepine
  • Dopamine
  • Hormonal agents (progesterone, estrogen, testosterone)
  • Indomethacin
  • Muscle relaxants (diazepam, baclofen, cyclobenzaprine)
  • Opioids
  • Sympathomimetics α-adrenergic agents (ephedrine sulfate, phenylephrine, phenylpropanolamine, pseudoephedrine)
  • Sympathomimetic β-adrenergic agents (isoproterenol, metaproterenol, terbutaline)
  • Vincristine [15]

Other causes

Other etiologies such as pelvic, urethral, or bladder trauma and various surgical procedures can cause urinary retention by altering the anatomy of the urinary tract, causing direct injury to these organs, or through delayed recovery from the effects of anesthesia.

The above etiologies and pathophysiologies must be considered when evaluating acute urinary retention.[16][12][13][17]

Chronic Urinary Retention

The American Urological Association (AUA) defines chronic urinary retention as a persistent post-void residual urine volume >300 mL over at least 6 months that has been measured at least twice.[18] Due to the retention, patients may feel incomplete emptying, frequency, overflow incontinence, weak or intermittent stream, hesitancy, or symptoms of renal failure. The condition may also be asymptomatic. 

Chronic urinary retention develops slowly over months to years and may be diagnosed when patients develop unexplained renal failure or when imaging for unrelated reasons demonstrates a severely distended bladder or bilateral hydronephrosis. Rarely, the retention will cause only vague lower abdominal distension with no other overt signs or symptoms despite massive bladder volumes.[19][20]

The etiology of chronic urinary retention is mostly neurogenic and is often associated with detrusor muscle damage or dysfunction. An overall 8% prevalence of neuropathy is a cause of bladder dysfunction and chronic retention. Detrusor dysfunction will occur in patients with muscular weakness from chronic bladder overdistention, resulting in decreased bladder emptying.[21]

Diabetes is a frequent underlying cause of neurogenic bladder, leading to chronic urinary retention from diabetic neuropathy. Diabetes causes myogenic and neurogenic alterations in bladder function and the voiding reflex due to prolonged hyperglycemia and oxidative stress toxicity.[22][23][24][25] Peripheral neuropathy may also cause bladder dysfunction. 

Spinal injuries caused by infarction and demyelination disorders typically present as acute urinary retention but may lead to a chronic form as they are often irreversible.[26] A patient may have incomplete bladder emptying from prostatic swelling during an infection or from a urethral stricture.

A patient's presentation for urinary retention may be delayed. When identified and corrected, the bladder muscle may lose significant tonicity; this can occur acutely during spinal anesthesia and postoperatively after prolonged general anesthesia without a Foley catheter.[27][28][29] Many cases of chronic urinary retention result from a permanent bladder injury or detrusor muscular dysfunction caused by an episode of acute retention, especially if treatment is delayed.[15][30]

Epidemiology

Acute urinary retention is most common in men aged 60 to 80. Over a 5-year time period, 10% of men older than 70 years and close to one-third in their 80s will develop acute urinary retention.[12][31] The primary male etiology is BPH, which causes prostatic enlargement and mechanical outlet obstruction.

Risk factors for BPH include:

  • Black race
  • Diabetes mellitus
  • High ethanol consumption
  • Increasing age
  • Lack of exercise and a sedentary lifestyle
  • Obesity

Neurogenic causes of urinary retention tend to occur in younger individuals. The mortality rate for men with spontaneous urinary retention at 1 year increases from 4.1% in patients aged 45 to 54 to 33% in those aged 85 and older.[6][28] Patients with neurological disorders develop urinary retention more often than the general population. Of patients admitted for rehabilitation therapy, 27% have urinary retention, and 20% have no symptoms.[19] This is why a urological assessment, including a post-void residual measurement, is recommended for all patients on admission to rehabilitation centers.

History and Physical

Patients with acute urinary retention typically present with lower abdominal pain and an inability to urinate for some time. However, symptoms of urinary retention may vary. The urinary stream may be weak or absent. Urinary leakage and voiding in small amounts could indicate overflow incontinence, which frequently occurs with chronic retention. A long history of gradually worsening lower urinary tract symptoms may occur suddenly. Lower abdominal distension or a feeling of bloating is also common.

Chronic urinary retention also has a variety of symptoms. Some patients may be asymptomatic, but most will have some urinary symptoms as follows:

  • The inability to empty the bladder after urination
  • A feeling of incomplete bladder emptying
  • Frequent urination in small amounts
  • Hesitancy or difficulty in starting the flow of urine from the bladder
  • A consistently slow or weak urinary stream
  • The urgent need to urinate, but with little success
  • The feeling of the need to void again shortly after urinating (double voiding)

A specific urological history is essential, such as the presence of hematuria, dysuria, fever, low back pain, neurologic symptoms of tremors, or unexplained weakness. The clinician should inquire about any prior history of prostatic diseases such as cancer, trauma, surgeries, kidney stones, prostate infections, sexually transmitted infections, and radiation treatment or exposure. A thorough urogenital review of systems is required.

The medication list should be thoroughly reviewed as several medications can cause or contribute to urinary retention (usually anticholinergics). An inquiry into past surgical procedures and anesthesia may also prove informative.[32] A urological symptom score, such as the AUA symptom score, can be helpful. This quick, validated scoring system is designed to stratify the urological symptoms and track response to therapy.

American Urological Association Symptom Score

The patient's history presenting with symptoms of acute urinary retention should focus on lower urinary tract symptoms using questions such as, "Over the past month,..."

  • How frequently have you had the sensation of not being able to empty your bladder after voiding? 
  • How frequently have you had to urinate again less than 2 hours after finishing urination?
  • How frequently have you found you stopped and started several times when you were voiding?
  • How often have you found it difficult to postpone urination?
  • How often have you had a weak stream?
  • How often have you had to push or strain to begin urination?
  • How many times did you get up to urinate from the time you go to bed until you get up in the morning? 

The AUA symptom score (and the similar International Prostate Symptom Score [IPPS]) have been validated, and the above questions were used.[33][34]

Points are given based on responses as follows:

0 = Not at all 

1 = Less than 1 time in 5 

2 = Less than half the time

3 = About half the time

4 = More than half the time

5 = Almost always or all the time

This scoring system helps identify mild symptoms (0 to 9), moderate symptoms (10 to 19), and severe symptoms (20 to 35) related to the prostate as a cause.[24][25][35][36] In general, a symptom score of 10 or more indicates treatment for BPH should be started, changed, or increased.

The physical examination should focus on the lower quadrants of the abdomen, pelvis, and genitals. Palpation can determine a distended bladder. The digital rectal exam may identify an enlarged prostate, a fecal impaction (with possible impingement on the bladder neck or prostatic urethra), or poor sphincter tone (suggesting a possible spinal cord problem). A neurologic examination of strength, sensation, reflexes, and muscle tone should be performed to identify possible neuropathy. A thorough patient history and physical exam will often make the diagnosis and identify the etiology.[8][37][38]

Evaluation

A bladder ultrasound helps diagnose acute urinary retention, but immediate Foley catheterization is reasonable and recommended in obvious cases as both diagnostic and therapeutic. Bedside bladder ultrasounds are useful but may be inaccurate because of body habitus, tissue edema, prior surgery, ascites, or scarring. A formal bladder ultrasound, noncontrast CT, straight catheterization, or Foley placement may be needed in such cases. A CT of the abdomen and pelvis may be the preferred approach if another pathology is suspected.

A normal bladder will empty almost completely, typically to <100 mL. A post-void residual of 100 to 200 mL indicates some problem with bladder emptying but is reasonably acceptable in most patients. Residual urine volumes >200 mL are considered pathological and abnormal, while post-void residuals >400 mL typically indicate retention. (Normal bladder maximum capacity is about 500 mL.)

The urine volume obtained immediately after catheter placement from complete bladder drainage should be recorded. If the volume exceeds 400 mL, this is generally considered consistent with retention, and a Foley catheter should generally remain in place. For bladder volumes of 200 to 400 mL, the clinical scenario guides the decision to leave a Foley catheter in place. (Patients with residual volumes of <200 mL probably do not have acute urinary retention and should undergo further evaluation.)[39][40][41][42]

The urine volume retained and/or drained immediately after catheterization helps predict bladder recovery. The larger the residual urine volume and the longer the patient has had retention, the poorer the recovery of bladder muscle tone. (The minimum intravesical pressure necessary for bladder emptying is a detrusor muscle capable of generating at least 30 to 35 cm of water pressure.) 

The estimated recovery potential for bladder muscle based on residual urine volume is as follows:

  • Bladder (detrusor) recovery is very good for retained bladder volumes <1000 mL, especially if short-term.
  • Recovery is usually fair to good for post-void residual volumes of 1000 to 1500 mL. 
  • From 1500 to 2000 mL, bladder muscle recovery is fair. 
  • Above 2000 mL, detrusor muscle recovery is problematic. 

The longer the retention duration and the greater the post-void residual volume, the longer the Foley should be left before a voiding trial to maximize detrusor muscle rehabilitation and recovery. In severe cases, 1 month is suggested. The largest residual urine volume in the medical literature is 11 L, found in an 80-year-old man with a spinal cord lesion. His symptoms were increasing abdominal distension and lower leg edema. In cases of severe bladder overdistension, usually 2000 mL or more, the bladder muscle fibers are stretched apart and replaced with non-muscular fibrous tissue. The result is an atonic, decompensated bladder that has lost its contractile capability.[20] Treatment in such cases is typically a permanent Foley catheter, intermittent self-catheterization protocol, or a suprapubic tube. 

Further evaluation of urinary retention should consist of the following:

  • Obtain a urine sample for a urinalysis and possible culture, if appropriate. (If possible, use a specimen from voided urine or a newly placed Foley catheter.)                                                                                          
  • A bladder scan should be performed but must not delay Foley catheterization in obvious, acute cases.                                   
  • Immediate placement of a Foley catheter if the diagnosis is apparent                                                                  
  • In appropriate patients, this can be converted to intermittent self-catheterization.                                                
  • Start or increase α-blocker BPH therapy.                                                                                                       
  • Arrange for a follow-up voiding trial in 72 hours, if appropriate.                                                                                    
  • In chronic retention, pre- and post-void urine volumes are helpful.                                                                    
  • Chemistries: sodium, potassium, bicarbonate, chloride, blood urea nitrogen, and creatinine                                     
  • A complete blood count                                                                                                                                   
  • A renal ultrasound should be performed for large post-void residual volumes (>1500 mL), newly discovered renal failure, or azotemia.                                                                                                                  
  • Bilateral hydronephrosis is highly suggestive of chronic urinary retention.                                                           
  • If neurologic signs or symptoms are present on examination with suspicion of stroke, CT of the head is recommended.           
  • If spinal cord processes are suspected, perform an MRI.[2][8][6][35][43][44]

Treatment / Management

Initial therapy for acute urinary retention is the immediate placement of a 16-French 5 cc to 10 cc balloon Foley catheter to decompress the bladder, bypass obstructive uropathy, and relieve severe patient discomfort. If the bladder is inaccessible transurethrally, a suprapubic tube may be required emergently. Urethral catheterization is particularly useful in patients where the cause of urinary retention is likely to be temporary, such as infection, post-anesthesia, or secondary to medication. Urethral catheterization is contraindicated in patients with recent urologic surgery, such as radical prostatectomy or urethral reconstruction. These patients should undergo suprapubic catheterization and drainage. 

Studies on the rate of bladder decompression have shown that rapid, complete drainage is best, even for very large bladder volumes, although this was not previously recommended. Clamping the catheter and partial or intermittent bladder drainage does not reduce the complications of hematuria, vasovagal hypotension, or post-obstructive diuresis. Catheter clamping and partial bladder drainage will only produce patient discomfort and increase the risk of a urinary tract infection.[26][32][37][45]

Clean Intermittent Self-Catheterization

For patients with <1000 mL of post-void residual urine, clean intermittent self-catheterization is a reasonable alternative to Foley catheterization. (Patients with >1000 mL probably better tolerate the Foley initially to allow for bladder muscle rehabilitation and recovery.) Fewer complications are apparent with clean intermittent self-catheterization, which correlates with an increased rate of spontaneous voiding and reduced urinary tract infections. Clean intermittent self-catheterization is often more acceptable to the patient if the nursing staff focuses on good instruction in catheter placement. Further outpatient support services may help. Patients are usually quite receptive to education.[18] 

The catheter size should be large enough to drain the bladder quickly yet small enough to be comfortable. For most patients, this is a 14- or 16-French size. Catheter materials include latex (soft but has thick walls, a smaller lumen, and potential allergy), silicone (moderate stiffness, thin walls), and vinyl (stiff). Hydrophilic coatings are available and may allow more comfortable catheterization.

The frequency of catheterization depends on urine production and bladder capacity. Drainage of more than 500 mL at a time suggests a more frequent catheterizing schedule should be instituted. Three or 4 times a day is suggested for most patients. Keeping the drained volumes below 500 mL helps minimize intravesical pressure, prevent reflux, avoid bladder overdistension, and reduce the incidence of urinary tract infections. Prophylactic antibiotics are not routinely recommended for patients on clean intermittent self-catheterization. 

Clean intermittent self-catheterization is the indicated and preferred treatment for those with chronic urinary retention who are able and willing.[46] Patients need instruction in catheterization technique, preparing a cathing schedule, scheduling a urology follow-up appointment, and obtaining an adequate supply of catheters.[47] Whenever possible, written catheterization instructions should also be provided. Self-intermittent catheterization is also used effectively as a treatment for urethral strictures.[48]

Overview of Foley Catheterization

Patients with larger initial post-void residual volumes (>1000 mL) and those unable or unwilling to perform self-catheterization are probably better served by indwelling Foley catheters. Those with large residuals, generally >1500 mL, should also be monitored for possible post-obstructive diuresis. A coude (curved tip) catheter may be used if initial difficulty is visualized passing a standard Foley. Larger-sized Foley catheters are generally unnecessary unless excessive bleeding is determined. No need for a larger balloon size typically exists than the standard 5 to 10 mL. If urethral strictures or prostatic scarring are a concern, a smaller catheter, usually 12-French all silicone, is recommended. If these simple techniques fail, using a 0.035" guidewire, either blindly or with bedside flexible cystoscopy, may be required. After access is provided with a guide wire, urethral dilation with either a balloon dilator or sequential mechanical dilators, such as the Goodwin sounds or Heyman dilators, can be performed.[49] Techniques for difficult Foley catheter placement are described elsewhere. See StatPearls' companion reference, "Difficult Foley Catheterization," for more information.[50]

The underlying etiology, severity, patient preferences, and duration of urinary retention will determine the recommended catheterization protocol. Patients whose underlying etiology is temporary, such as from medications or anesthetics, should have a post-voiding trial as soon as possible, within hours or up to 3 days. The underlying etiology, such as infection, should be treated separately. Medications causing or contributing to urinary retention should be discontinued except in patients using catheterization for bladder emptying, where anticholinergics like oxybutynin are used to suppress bladder spasms.

Catheterization may become chronic in patients with spinal injuries where urinary retention is not likely to resolve. These patients are candidates for clean intermittent self-catheterization or suprapubic tube placement.[10] Whenever possible, intermittent self-catheterization is preferred. Patients with urosepsis, obstruction due to malignancy, or acute myelopathy should be admitted. Patients who have associated acute renal failure, are at risk for post-obstructive diuresis with very large residuals (>1500 mL) or demonstrate an electrolyte imbalance such as hyper- or hyponatremia should also be admitted.

Most cases of acute urinary retention can be managed safely as outpatients with a referral for follow-up urological evaluation. Patients need careful instruction in Foley catheter care, such as how to empty the catheter bag, how to use day and night drainage bags, the need for routine changes, and how to monitor their urine output. Patients should not be placed on antibiotics unless a urinary infection is present. Prophylactic antibiotics have been proven ineffective in preventing infections and will likely contribute to increased bacterial resistance to antimicrobials.[26][38]

Medical Therapy

Alpha-blockers

The primary, first-line medical therapy is α-blockers for urinary retention caused by BPH, especially for those aged over 60. Initial medical treatment of acute retention from BPH includes a daily α-blocker (alfuzosin 10 mg, silodosin 4 mg to 8 mg, or tamsulosin 0.4 mg to 0.8 mg), which should be maximized. All α-blockers are equally effective at equivalent dosages, so no benefit is apparent to switching from 1 to another except for adverse effects. Terazosin and doxazosin are equally effective α-blockers but have more cardiovascular (orthostatic hypotension) adverse effects. They must be titrated and cannot be started at their maximal effective dose. Therefore, they are not generally recommended for acute urinary retention. 

Alpha-blockers work by relaxing the smooth muscles of the bladder, neck, and prostate. This is effective because the stromal component of BPH comprises 80% of the hyperplastic volume, and about half of this is α-adrenergic smooth muscle.[51][52] Relaxing the smooth muscle tissue of the bladder, neck, and prostate quickly eases prostatic urethral compression, dramatically reduces urinary flow resistance, and improves the urinary stream. Patients with acute urinary retention who are not on α-blocker therapy should be started on treatment. If they are already on therapy, they should have maximized dosages if safe and tolerable.[53] Alpha-blockers improve the success of voiding trials but require 72 hours to reach their full effect.[46] See StatPearls' companion references, "Alpha Blockers" and "Benign Prostatic Hyperplasia," for more information.[54][55]

5-Alpha reductase inhibitors

Finasteride or dutasteride can shrink the prostate by about 20% to 25% and decrease the incidence of acute urinary retention in men with BPH. However, they require at least 6 months for optimal effect and are most beneficial in prostates >30 g in size. Patients need to be on therapy for over 1 year to prevent future episodes of retention and reduce the need for prostate surgery. 5-α-reductase inhibitors reduce PSA levels by about 50% and help reduce prostatic bleeding. See StatPearls' companion reference, "5 alpha-reductase inhibitors," for more information.[56][57]

Studies have shown increased success in voiding in patients with the following characteristics: 

  • Aged younger than 65
  • Detrusor pressure >35 cm of water
  • Drained urinary residual volume <1 liter
  • Identification of the precipitating event [58][59]

Duration of Catheterization

In men with BPH, catheterization should induce bladder decompression, recovery of renal function, resolution of any hydronephrosis, and bladder muscle rest and recovery. In patients with favorable characteristics, 23% to 40% will void spontaneously within 72 hours. Since α-blocker therapy also requires 72 hours to be fully effective, starting such treatment immediately after Foley catheter placement is reasonable to optimize their benefit for a timely voiding trial.[60]

Performing a Voiding Trial

In a catheterized patient, a voiding trial can be performed by removing the Foley early in the morning and then checking a post-void residual later that day. Alternatively, the bladder can be filled in the office to at least 300 mL or as tolerated, and then the patient can void. Inability to void or residuals >400 mL are considered failures, while a residual <200 mL is a success. Shared decision-making is recommended if the patient voids and the post-void residual volume is between 200 and 400 mL. Voiding trials are unnecessary in men on intermittent self-catheterization as the post-void residual volumes are easily monitored.

Suprapubic Catheters

These may be placed surgically for patients with chronic urinary retention who cannot perform clean intermittent self-catheterization. Suprapubic tubes are a reasonable and preferred option for patients who would otherwise require long-term transurethral Foley catheters. They are easier to change, become clogged less often, produce fewer urinary tract infections, do not cause urethral or penile erosions, and are generally more comfortable for patients. Placement of suprapubic catheters is not without risk, as bowel perforation and wound infection are possible, but CT scans and ultrasound have made this unlikely in skilled hands.[61]

In emergent conditions where a urologist is not present and the patient is in distress, suprapubic aspiration via a needle or a suprapubic catheterization set is an option. This procedure is preferred with ultrasound guidance at the bedside. 

Prostate Surgery

The AUA Guidelines recommend that patients with urinary retention due to BPH receive maximal medical treatment and then fail at least 2 voiding trials before considering surgical intervention.[26][46] Other indications for surgery include recurrent urinary tract infections, gross hematuria due to BPH being unresponsive to medical treatment, recurrent bladder stones, significant BPH symptoms in patients who have failed other therapies, and renal failure secondary to BPH.  

Surgical options include transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), laser prostatic vaporization, transurethral electrovaporization, water vapor thermal infusion therapy, prostatic urethral lifts, Holmium and Thulium laser enucleation, open suprapubic prostatectomy, prostatic artery embolization, and suprapubic tube placement.[62] 

Special Conditions Associated with Urinary Retention

Autonomic dysreflexia

This condition occurs with spinal cord injuries or lesions at or above the T-6 level. As a potentially lethal disorder, treatment can be initiated if recognized promptly.[63] The etiology is usually a urological problem in 85% of cases. A common example would be a distended bladder from a clogged Foley catheter. This distended bladder signal cannot reach the brain due to the injury but instead causes sympathetic splanchnic stimulation with lower body vasoconstriction and severe hypertension. Above the spinal lesion, parasympathetic tone increases in trying to lower the blood pressure, but this is inadequate to control the very severe hypertension, which can reach dangerous levels. The risk of a catastrophic or lethal stroke dramatically increases from the combination of cerebral vasodilation combined with dangerously high blood pressure.

Symptoms include pallor and cold skin in the lower body, with flushing in the head and upper body. The hallmark of the condition is the patient complains of a severe headache. In such individuals, an immediate search for the underlying stimulus is conducted, which is urological in 85% of cases. Foley catheters or suprapubic tubes should be flushed or changed. If appropriate, the patient should be straight-cathed. Other causes, such as constipation, should also be checked if a urological etiology is not found. Emergency measures to control blood pressure, such as nitroglycerine 2% paste or nifedipine "bite and swallow" 10 mg, should be instituted if necessary. See StatPearls companion reference, "Autonomic Dysreflexia," for more information.[64]

Cauda equina syndrome

The syndrome is caused by damage or compression of the spinal nerve roots from L1 to L5, especially L3 to L5. The most common cause (45%) is a herniated intervertebral disc. Other etiologies include spinal hematomas, diskitis, primary or metastatic spinal neoplasms, epidural abscess, trauma, aortic obstruction, and spinal stenosis.[65] The incidence is very low at an estimated 1:30,000 to 1:100,000 population.[66] Typical symptoms include back pain, sciatica, neuropathy or weakness of the lower extremities, saddle anesthesia, urinary retention, and bowel dysfunction. The syndrome should be suspected whenever urinary retention is associated with unexplained bowel dysfunction. The risk increases with decreased rectal tone, saddle anesthesia, or back pain. MRI makes the diagnosis. Immediate surgical correction can help minimize long-term complications, but this requires early clinical suspicion and proper imaging. Unfortunately, almost half of these patients (47.7%) develop long-term urinary retention, usually managed with intermittent self-catheterization after corrective surgery.[67] See StatPearls' companion reference, "Cauda Equina and Conus Medullaris Syndromes," for more information.[68]

Detrusor-Sphincter dyssynergia

In this condition, detrusor muscular contractions coincide with an involuntary, inappropriate contraction of the external urethral sphincter.[69] The condition is caused by various neurological disorders involving the suprasacral spinal cord. The most common causes are spinal cord injury, multiple sclerosis, and spina bifida. Dyssynergia causes nonspecific urinary symptoms, including frequency, intermittency of voiding, urinating in small amounts, incomplete emptying, chronic urinary retention, and incontinence without urgency (reflex incontinence). Various associated neurological symptoms or deficits may exist.

The diagnosis is made by urodynamic testing, which may include electromyography (EMG), fluoroscopy, voiding cystourethrography, video urodynamics, and urethral pressure profile studies. Cystoscopy is recommended to establish that no urethral strictures affect the urodynamic results. The specific diagnosis of detrusor-sphincter dyssynergia is made by finding increased sphincteric activity during a detrusor contraction without Valsalva. A voiding cystourethrogram would show the opening of the bladder neck and prostatic urethra during voiding to the level of the external sphincter muscle, which would be closed and constricted. 

Treatment can include α-blockers like tamsulosin, diazepam, oxybutynin, clean intermittent self-catheterization (usually with oxybutynin or similar drugs), sacral neuromodulation, and permanent Foley catheters or suprapubic tubes. When conservative measures fail, botulinum toxin injections can be effective and durable, lasting from 2 to 13 months, when the treatment can be repeated.[70][71][72] See StatPearls's companion reference, "Bladder Sphincter Dyssynergia," for more information.[73]

Post-Obstructive diuresis

This may develop after decompression of the bladder, especially if the fluid drained immediately from the bladder was >1500 mL, or renal failure occurs, especially if bilateral hydronephrosis is present. Post-obstructive diuresis primarily occurs with chronic urinary retention and is more common in patients with azotemia or congestive heart failure who are fluid overloaded. The excessive and prolonged diuresis represents an attempt by the kidneys to excrete excess fluid retained when obstructed. This situation is best managed by increasing oral fluid intake unless the patient cannot do so, in which case intravenous (IV) fluids are required. 

If IV fluids are needed, the replacement volume is guided by measuring the urine output, replacing 50% to 75% of the previous 1-hour to 2-hour urinary volume with isotonic saline. The replacement fluid can be adjusted depending on whether hyper- or hyponatremia is found.[74][75] The urine-specific gravity should be frequently monitored. A urine specific gravity of 1.010 or less would indicate that the kidneys cannot concentrate the urine and that the post-obstructive diuresis is continuing. (A specific gravity of 1.010 is iso-osmolar to serum.) The renal concentrating ability is restored after the specific gravity reaches 1.020 or more, and the pathological post-obstructive diuresis resolves. This will typically happen within 24 to 48 hours.[44] See StatPearls' companion reference, "Postobstructive Diuresis," for more information.[76]

Spinal cord injury

This refers to acute traumatic damage to the spinal cord. The incidence is reportedly 54 per million population per year. The National Spinal Cord Injury Statistical Center estimates that approximately 280,000 surviving spinal cord-injured patients are in the US. The incidence of nontraumatic spinal cord injuries may be larger. (Nontraumatic causes include spinal injuries caused by autoimmune disorders, degenerative disease, hereditary disorders, infections, malignancies, myelopathies, and vascular disorders, among others.)[77] 

A final determination of long-term therapy for the patient's neurogenic bladder will depend on the patient-specific situation after the period of spinal shock has resolved. Many patients are treated long-term with clean, intermittent self-catheterization and anticholinergic medications.[78] For others, long-term treatment with a Foley catheter or, preferably, a suprapubic tube may be necessary. Other treatment options include botulinum toxin bladder injections, urinary diversion, sphincterotomy, bladder augmentation surgery, and sacral neuromodulation. Each patient's specific medical condition, home care assistance, individual capabilities, financial situation, expectations, and preferences must be considered for an individualized long-term care plan.

Spinal shock

The shock leads to the sudden and immediate loss of all spinal reflexes and muscular tone below the level of an acute spinal injury, usually traumatic. The average duration is from 4 to 12 weeks. Complete transverse spinal disruptions take longer to recover than incomplete lesions. The duration of the spinal shock and degree of recovery will depend on the severity and location of the injury. Spinal shock is expected after any significant acute injury to the spinal cord.

The bladder is areflexic and noncontractile during spinal shock with low intravesical pressure. The bladder neck is usually closed and competent. Some external sphincteric tone is evident, but less than normal. The guarding reflex is suppressed. The net effect is paralysis of the urinary bladder and urinary retention. The initial urological treatment of spinal shock is the placement of a Foley catheter. To reduce the risk of urinary tract infections, the patient should switch to clean intermittent self-catheterization.[79] Anticholinergics may be used as necessary to reduce uninhibited contractions and bladder spasms. 

Recovery from spinal shock can be identified by the return of the bulbocavernosus and deep tendon reflexes and the resumption of detrusor reflex activity.[80] Urodynamic evaluations should be deferred until the period of spinal shock is over. At that point, a more complete investigation can evaluate voiding potential and carefully consider all appropriate therapeutic options.

Differential Diagnosis

The differential diagnosis for male urinary retention should include the following:

  • Acute renal failure
  • Acute stroke
  • Ascites
  • Bilateral simultaneous renal calculi
  • Bladder neck contractures
  • Bladder stones
  • Bowel obstruction
  • Chronic kidney disease
  • Constipation
  • Dehydration
  • Detrusor-sphincter dyssynergia
  • Neurogenic bladder
  • Meatal stenosis
  • Phimosis
  • Prostate cancer
  • Retroperitoneal fibrosis
  • Urethral strictures

Prognosis

Men with BPH who develop acute urinary retention are usually older than 70 and have more comorbidities with a higher risk of complications than similarly aged men with normal urination. These comorbidities include infection and renal dysfunction, such as chronic kidney disease (CKD) and end-stage renal disease (ESRD).[81] The prognosis is determined by their comorbidities, renal function, degree of permanent damage to the detrusor muscle, duration and severity of the retention, and their response to therapy.

The risk of developing acute urinary retention in symptomatic patients with BPH can be reduced by 85% to 90% by TURP.[82] Patients who undergo immediate surgery following an episode of acute urinary retention are at increased risk of complications, including operative bleeding and sepsis from bacteriuria. Men who underwent immediate prostatectomy for acute urinary retention had an increased risk of death at 30 and 90 days compared to men who underwent elective prostatectomy.[83][84] The older the patient, the higher the complication risk.

Those with acute urinary retention from neurologic conditions are at higher risk of infection and sequelae of the underlying disease.[85][86] Temporary causes of acute urinary retention have a better prognosis than chronic conditions due to complications associated with long-term catheterization. The use of intermittent self-catheterization and suprapubic tubes results in fewer complications.[26][58][87][88]

Complications

Complications from acute urinary retention are from previously untreated conditions, the nature of the underlying cause, the duration and severity of the retention, the degree of bladder damage, and comorbidities. Potential complications include urinary tract infections, renal dysfunction, electrolyte imbalances, urethral strictures, bladder neck contractions, bladder stones, vesicoureteral reflux, kidney failure, bladder decompensation, and permanent detrusor muscle dysfunction. Catheterization for bladder decompression can result in adverse events such as transient hematuria, which occurs between 2% and 16% of patients but is rarely significant. This complication usually resolves by itself or with simple irrigation.[58] Transient hypotension is a complication that sometimes occurs after initial bladder decompensation, and blood pressure generally normalizes without intervention due to a vasovagal response.

Deterrence and Patient Education

Deterrence and prevention strategies play a crucial role in addressing male urinary retention. Educating individuals on risk factors such as prostate enlargement, certain medications, and neurological conditions can aid in proactive measures. Encouraging lifestyle modifications such as maintaining a healthy weight, staying hydrated, and avoiding excessive alcohol consumption can help mitigate the risk. Regular screenings and check-ups, especially for individuals with predisposing factors, can facilitate early detection and intervention. Additionally, promoting awareness about the importance of seeking medical attention at the onset of symptoms can prevent complications associated with untreated urinary retention. By emphasizing prevention through education, lifestyle adjustments, and timely medical intervention, the incidence and severity of male urinary retention can be significantly reduced.

Education is also crucial for those patients diagnosed with urinary retention and receiving interventions. The patient with acute urinary retention needs to be fully and patiently educated about catheter care and monitoring urinary output. If the patient is performing clean intermittent self-catheterization, they must be taught proper techniques to avoid complications and adjust their catheterization schedule based on residual volumes. Those with suprapubic tubes must be shown how to properly care for these catheters and keep the suprapubic site clean to prevent dermatitis. Patients may need follow-up home care and education if they have questions or complications. Patients with BPH require education about voiding trials and follow-up care. The surgical options, including risks, benefits, and complications, should be shared with the patient. If the patient's medications contribute to his retention, the patient should understand the adverse effects. 

Pearls and Other Issues

Key points regarding male urinary retention are as follows:

  • Never clamp a catheter; allow all newly placed catheters to drain wholly and freely.                                           
  • Record the amount of urine drained immediately from the bladder.                                                                    
  • Consider inpatient monitoring for post-obstructive diuresis if over 1500 mL is drained immediately after Foley placement.                                                                                                                                           
  • Patients with weight gain, lower abdominal distension, and voiding issues might have chronic urinary retention. This can be easily checked with a post-void residual measurement.                                                          
  • BPH does not require a larger catheter. Standard catheters have no trouble bypassing ordinary prostatic enlargement.                                                                                                                                              
  • Trouble placing a catheter is usually due to strictures, false passages, prior surgeries, or cancer.                                
  • Clean intermittent self-catheterization is a reasonable option.                                                                           
  • Symptoms of renal failure may be the first clue of chronic urinary retention. These symptoms include: 
    • Decreased urine output, although occasionally urine output remains normal
    • Confusion
    • Edema with swelling of the legs, ankles, and feet
    • Fatigue
    • Fluid retention
    • Irregular heartbeat
    • Nausea
    • Shortness of breath
    • Weakness

Enhancing Healthcare Team Outcomes

In addressing male urinary retention, a multidisciplinary approach involving physicians, advanced care practitioners, nurses, pharmacists, and other health professionals is essential to ensure patient-centered care, optimize outcomes, enhance patient safety, and improve team performance. A thorough history using the questions suggested by the AUA can enhance health outcomes. A complete medication review and a thorough physical examination are recommended to rule out a neurological disorder. Patients should receive counseling and education about catheter care and the importance of sticking to a regular schedule to prevent detrusor damage and infections. The nursing team should be aware of the contraindications of catheter placement. Difficult catheterizations should be referred to more skilled personnel and should follow guidelines for complicated placements. See StatPearls' companion reference, "Difficult Foley Catheterization," for more information.[50]

In patients with acute retention where a urethral catheter cannot be passed, timely placement of a suprapubic catheter is recommended. The clinician should know how to perform suprapubic needle drainage or temporary catheter drainage if a urologist is not immediately available and the patient is in extreme discomfort or distress. The patient and their support (family or caregivers) should undergo training regarding clean intermittent catheterization and education on all treatments, including medications, used to treat BPH.

Patients with special conditions, like autonomic dysreflexia, will require additional education and should take extra precautions. Such precautions include carrying catheterization and irrigation supplies, instructions on caring for autonomic dysreflexia, and emergency antihypertensive medications such as nifedipine and nitropaste.

Coordination between primary care clinicians, nephrologists, urologists, nurses, and emergency room personnel is needed. Nurses are integral members of the healthcare team, responsible for implementing treatment plans, providing patient education on self-catheterization techniques, managing catheters, and monitoring for complications such as urinary tract infections.[47] Pharmacists contribute by ensuring appropriate medication selection, dosing, and monitoring for drug interactions or adverse effects, thereby enhancing patient safety. 

Interprofessional communication is vital to ensuring seamless transitions of care and optimizing outcomes for patients with male urinary retention. Regular interdisciplinary team meetings facilitate collaboration, information sharing, and problem-solving, thereby minimizing errors and improving continuity of care. Clear communication pathways and standardized protocols help streamline workflows, reduce treatment delays, and enhance efficiency. By leveraging their respective skills, expertise, and ethical principles, healthcare professionals can work collaboratively to address male urinary retention comprehensively. Through effective interprofessional communication, care coordination, and a patient-centered approach, they can optimize outcomes, ensure patient safety, and enhance team performance.

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Stephen W. Leslie

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