Urinary retention - red flag symptoms

Refresh your knowledge of red flag symptoms to look out for in presentations of acute or chronic urinary retention.

The patient may present with an enlarged and tender bladder (Photograph: SPL)
The patient may present with an enlarged and tender bladder (Photograph: SPL)

Red flag symptoms

  • Pain
  • Painless acute retention
  • Haematuria or clots
  • History of prolonged bladder outflow obstruction

Urinary retention is a common problem in older men but it also affects women. Acute retention is generally associated with a sudden inability to void and abdominal pain.

History

Ask about pain, dysuria, and whether there has been any visible haematuria. Establish how long the symptoms have been present, and whether the patient experienced any constipation, or symptoms consistent with prostatic enlargement.

Acute painless urinary retention can be the first presenting symptom of a neurological problem and requires emergency referral.

Haematuria or the presence of clots raises suspicion of urinary tract cancer.

Longstanding incomplete voiding of the bladder is termed chronic urinary retention. Often, such patients are asymptomatic.

It is important to be aware of complications, such as bladder overfilling, severe constipation or a urinary tract infection.

In men, bladder outflow obstruction is the most common cause of acute and chronic retention, frequently due to prostatic enlargement.

Retention can also be precipitated by anticholinergic medication, especially in those who already have bladder outflow obstruction.

Urethral stenosis can cause retention and may result from recurrent urinary tract infections or from oestrogen deficiency in postmenopausal women.

Retention can also arise after surgery for stress incontinence. Detrusor muscle failure is the most common cause of chronic retention in women and may be idiopathic or due to an underlying neurological problem.

In acute urinary retention the diagnosis is usually obvious.

In chronic retention the clinical features are more variable and include nocturnal enuresis, recurrent UTIs, and lower urinary tract symptoms associated with bladder outflow obstruction, such as frequency, urgency, hesitancy and poor stream.

Examination and investigation

The patient may present with sudden inability to void, with an enlarged tender bladder.

Many patients are asymptomatic and this condition may just be picked up on incidental finding of an enlarged bladder.

The diagnosis of chronic retention requires a post-voiding urinary sensation scale and sometimes serial scans are necessary for confirmation.

In all cases of retention, urine analysis and renal function should be performed. Acute retention warrants urgent catheterisation and subsequent investigation.

Chronic retention requires urological referral if associated with an elevated creatinine. Catheterisation is not always necessary in chronic retention but is indicated if there is acute renal impairment or a large residual volume.

High pressure chronic retention can result in upper urinary tract damage and long-standing obstruction can damage the bladder.

Long-term management of urinary retention may be surgical or medical depending on the cause and the patient's history.

Possible causes

  • Benign prostatic hypertrophy
  • Bladder neck stenosis
  • Prostate cancer
  • Urethral strictures/stenosis
  • Urethral compression
  • Clot retention
  • Urethral retention
  • Anticholinergics
  • Tricyclic antidepressants
  • Phimosis
  • Spinal cord compression
  • Disc prolapse
  • Multiple sclerosis
  • Parkinson’s disease
  • Idiopathic detrusor failure
  • Urinary tract infection
  • Acute genital herpes
  • Constipation

Dr Anish Kotecha is a GP in Gwent, Wales. This article, originally by Dr Kamilla Porter, first appeared on July 2010 and was updated in October 2019.

Visit MIMS Learning for an interactive version of this article and a CPD certificate.

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