Male Urinary Retention: Acute and Chronic

What is Male Urinary Retention: Acute and Chronic?

Urinary retention is a condition where a person cannot fully empty their bladder by themselves. Acute urinary retention is a sudden inability to urinate, often associated with symptoms like bloating, urgent need to urinate, distress, abdominal swelling and pain above the pubic area. It’s the most common emergency related to the urinary system around the world, predominantly affecting men. This condition often results from an enlarged prostate, a condition also known as benign prostatic hyperplasia (BPH). Acute urinary retention in women is uncommon – men are 13 times more likely to have this problem.

Chronic urinary retention, on the other hand, often does not present immediate symptoms. This is defined by the International Continence Society as a bladder that remains partially full after trying to urinate, and is not in pain.

There are many factors that could lead to urinary retention, which means that the assessment and treatment vary from patient to patient and often includes treating other existing illnesses at the same time. Whether to go for a surgical procedure, medication or non-drug treatment will be decided by the medical professionals taking care of the patient. These decisions are based on an accurate medical history and physical examination.

What Causes Male Urinary Retention: Acute and Chronic?

Acute urinary retention is when you cannot pass urine despite having a full bladder. This uncomfortable condition may happen due to several reasons, grouped as follows:

1. Obstructive causes: This means something is physically blocking the flow of urine. The most frequent reason is due to a narrowing of the tube that carries urine out of the body (the urethra) from conditions such as strictures or Benign Prostatic Hyperplasia (BPH), a non-cancerous enlargement of the prostate gland. Other causes might be constipation, prostate cancer, bladder cancer, bladder stones, and injuries to the urethra.

2. Infections: A condition such as a urinary tract infection or prostatitis (inflammation of the prostate) can cause swelling and inflammation, which may block the flow of urine. Simply put, an infection in the prostate or urinary tract might block the ‘urine-passage’. Genital herpes or varicella-zoster infections can sometimes also affect the nerves controlling the bladder and result in urinary retention.

3. Neurological causes: These are conditions where the normal nerve signals that control urination get disrupted. Nerves play a big part in the process of urination and conditions such as stroke, multiple sclerosis, spinal cord injury, or Parkinson’s disease can interfere with these nerve signals, leading to urinary difficulties or retention.

Full bladder sensation triggers the brain to start the process of urination. Until then, certain nerves keep the bladder relaxed and prevent the release of urine. However, when you decide to pass urine, signals from the brain cause the bladder to contract and help pass the urine. Any disruption in these signals can cause difficulties.

4. Detrusor muscle dysfunction: If the muscles that help to squeeze out urine (detrusor muscles) become weak or ineffective, it can lead to acute urinary retention. This can occur after bladder overfilling, which can happen during long surgical procedures without a catheter.

5. Medications: Sometimes, specific medications can result in urinary retention by affecting muscles and nerves involved in urination. Drugs known to cause urinary retention include certain types of antidepressants, antihistamines, muscle relaxants, and others.

6. Other causes: Trauma to the pelvic, urethral, or bladder region and certain surgical procedures can also cause urinary retention by changing the structure of the urinary tract, damaging these organs, or due to delayed recovery from anesthesia.

Chronic urinary retention refers to the long-term inability to empty the bladder completely. Symptoms can include the feeling of not fully emptying the bladder, frequent urination, a weak or intermittent urine stream, or symptoms of kidney failure. Occasionally, people may not show any symptoms despite a full bladder.

The most common cause of chronic urinary retention is nerve damage or muscle dysfunction, often from conditions like diabetes. Prolonged high blood sugar levels in diabetes can cause damage to the nerves and muscles that control bladder function and voiding, leading to chronic urinary retention. Spinal injuries and certain other conditions can also interfere with bladder function.

Urinary retention can also occur after spinal or general anesthesia, especially in the absence of a catheter to help drain urine. In some cases, an episode of acute urinary retention can result in permanent injury to the bladder muscles, leading to chronic urinary retention, especially if treatment is delayed.

Risk Factors and Frequency for Male Urinary Retention: Acute and Chronic

Acute urinary retention most commonly affects men between the ages of 60 and 80. Within a span of 5 years, about 10% of men over 70 and nearly a third of men in their 80s are likely to experience this condition. The main cause for men is BPH, or an enlarged prostate, which can obstruct the outlet.

• The risk factors for BPH are:
  • Being of Black ethnicity
  • Having diabetes
  • High consumption of alcohol
  • Increasing age
  • Lack of exercise and living a sedentary lifestyle
  • Obesity

This condition can also happen due to neurological causes, which tend to occur more in younger people. The risk of dying within one year of experiencing urinary retention goes up with age, from 4.1% in 45-54 year olds, to 33% in those 85 and older. People with neurological disorders have a higher chance of developing urinary retention than the average population. In fact, among those admitted for rehabilitation therapy, 27% have urinary retention, and 20% of these individuals don’t even have symptoms. So, it’s recommended that anyone admitted to a rehabilitation center is assessed by a urologist, which includes measuring the amount of urine left in the bladder after voiding.

Signs and Symptoms of Male Urinary Retention: Acute and Chronic

Acute urinary retention is a medical condition that causes a person to experience lower abdominal pain and an inability to urinate, among other symptoms. These may include a weak or nonexistent urinary stream, urinary leakage and voiding in small amounts (a sign of overflow incontinence, commonly associated with chronic urinary retention), and an increasingly severe history of lower urinary tract symptoms. Patients may also experience lower abdominal distension or a feeling of bloating.

Chronic urinary retention symptoms can vary, with some patients showing no signs, but most exhibit urinary symptoms such as:

• Inability to fully empty the bladder after urination
• Feeling of incomplete bladder emptying
• Frequent urination in small amounts
• Difficulty or delay in starting urination
• Slow or weak urinary stream
• Urgent need to urinate with little success
• Feeling the need to urinate again shortly after doing so

In addition to these symptoms, it’s important to take a specific urological history into account, looking for symptoms like blood in the urine, painful urination, fever, lower back pain, and neurological symptoms like tremors or weakness. Past history of prostate diseases, surgeries, kidney stones, prostate infections, sexually transmitted infections, and exposure to radiation should also be considered.

Medications should also be scrutinized as some can cause or worsen urinary retention. Past surgical procedures and anesthesia should also be reviewed. The American Urological Association Symptom Score system can be used to evaluate the severity of urinary symptoms and track therapy progress.

Points in this scoring system are allocated based on the patient’s responses to a series of questions regarding their urinary tract symptoms over the past month. The scoring system assesses how frequently the patient needs to urinate again shortly after doing so, how often they’ve had difficulty postponing urination, the strength of their urinary stream, how often they’ve had to strain to start urination, and how many times they’ve needed to urinate during the night.

This score can help identify mild, moderate, and severe prostate-related symptoms and inform treatment decisions. For example, a score of 10 or more typically indicates a need for treatment for benign prostatic hyperplasia (BPH).

Physical examination should focus on the lower quadrants of the abdomen, pelvis, and genitals. Through palpation, a distended bladder can be detected. A digital rectal exam may uncover an enlarged prostate, fecal impaction (which can impinge on the bladder neck or prostatic urethra), or poor sphincter tone indicative of a potential spinal cord issue. A neurological exam should also be performed to identify potential neuropathy. A careful patient history and physical exam typically confirm a diagnosis and identify the cause of the urinary retention.

Testing for Male Urinary Retention: Acute and Chronic

A bladder ultrasound can help identify if you’re having acute urinary retention, which is when you can’t urinate even though your bladder is full. This is typically diagnosed and treated immediately by inserting a Foley catheter, which is a thin tube inserted into your bladder to drain urine. But sometimes, factors like your body shape, swelling, previous surgery, fluid in the abdominal cavity, or scarring can make the ultrasound less accurate. In such cases, your doctor may opt for a more formal bladder ultrasound, a CT scan without contrast, or a surgery to insert the Foley cathet er.

Normally, your bladder should empty almost completely after urination, leaving less than 100 mL of urine. If there’s between 100 to 200 mL left, it shows there’s a problem with your bladder emptying completely but is acceptable in most patients. Anything over 200 mL is considered abnormal, and more than 400 mL usually indicates retention-the bladder’s maximum capacity is about 500 mL.

The urine volume obtained through the catheter should be recorded. If the volume is over 400 mL, it usually means you have retention, and the catheter should remain in place. For volumes between 200 to 400 mL, the doctor will decide whether to keep the catheter in place based on your condition. If you have less than 200 mL of urine left, you most likely don’t have acute urinary retention and should have more evaluations.

The amount of urine left in the bladder after voiding, and how long you’ve had retention can help predict how well the bladder will recover. The larger the amount of residual urine and the longer the period of retention, the less likely the bladder muscles will recover. The bladder muscle needs to generate at least 30 to 35 cm of water pressure to enable bladder emptying.

The recovery potential for bladder based on residual urine volume is:

• Very good for retained bladder volumes less than 1000 mL, especially if it’s short-term.
• Fair to good for post-void residual volumes between 1000 to 1500 mL.
• Fair for volumes between 1500 to 2000 mL.
• Problematic for volumes above 2000 mL.

The larger the residual volume and the longer the retention has taken place, the more time the catheter will be needed to help the bladder muscle recover. In severe cases, it can take up to a month. If a large amount of urine remains in the bladder (usually above 2000 mL), it’s possible the bladder muscles could lose their ability to contract. Treatments for such situations could involve a permanent Foley catheter, self-catheterization, or a tube placed directly into the bladder.

When undergoing further evaluation for urinary retention:

• The doctor will take a urine sample for testing and possibly culture.
• Then they will perform a bladder scan. However, if the diagnosis is clear, they will prioritize inserting a Foley catheter first.
• Once diagnosis is confirmed, you’ll possibly start or increase medications to help with urinary retention.
• You’ll be asked to come back after three days for a follow-up voiding trial, if suitable.
• For chronic retention, where the bladder hasn’t emptied completely for a long time, both the volume of urine before and after voiding is helpful to measure.
• Your doctor may also conduct a complete blood count and check your kidney functions such as levels of sodium, potassium, bicarbonate, chloride, blood urea nitrogen, and creatinine.
• A renal ultrasound could be needed if your post-void volume is very large, you’ve just been diagnosed with renal failure, or azotemia, a condition where there is too much waste product in the blood.
• If there are signs that a neurological condition might be causing the issue, additional tests such as a CT scan of the head or an MRI of the spinal cord may be required.

Treatment Options for Male Urinary Retention: Acute and Chronic

If you can’t urinate, which is a condition known as acute urinary retention, immediate medical help is needed. Usually, a catheter (a thin tube) is inserted into the bladder through the urethra, which allows urine to flow out. This can help to relieve pain and discomfort from a distended bladder. Some people need a different type of catheter, known as a suprapubic tube, which is inserted directly into the bladder through the lower abdomen. This might be necessary if there’s an obstruction in the urethra that makes it inaccessible. People who recently had pelvic or urethral surgery commonly need this approach.

Results from research studies suggest releasing the urine quickly from the bladder is best, even if there’s a lot. There was a belief that slowly draining large amounts of urine could reduce complications, but this doesn’t seem to be the case. It’s also uncomfortable for the patient and might increase their risk of developing a urinary tract infection.

For patients with less severe urinary retention, another procedure, known as “Clean Intermittent Self-Catheterization” may be recommended. This involves the patient inserting a catheter into their own bladder at intervals, in a clean, non-sterile manner. This tends to have fewer complications compared to Foley catheterization, which involves leaving a catheter in the bladder constantly. It also encourages the return of regular urination and reduces the likelihood of urinary tract infections. Often, patients find this an acceptable method if they have good instructions and support.

The size of the catheter is important as it should be big enough to drain the bladder quickly but small enough to be comfortable. Also, various materials are available for catheters, including latex (soft but can lead to allergies), silicone (medium stiffness) and vinyl (stiff). Some catheters can be coated to make insertion more comfortable. The frequency of catheterization depends on how much urine the bladder is producing and how much it can maximally hold. If over 500mL is regularly being drained, it usually signals a need for more frequent catheterization. Antibiotics are not typically given preventatively for patients on this type of catheterization.

If urine retention is severe (over 1L), typically a Foley catheter is used. This is a catheter that stays in place, but if a person is unable or unwilling to do self-catheterization, a Foley catheter might be necessary. Larger volumes of urine (over 1.5L) require close monitoring for possible side effects. which can include excess urine production after relief of the blockage (a condition known as post-obstructive diuresis). If it’s difficult to insert the Foley catheter, a different type of catheter, known as a coude catheter that has a curved tip, can be used. If even that fails, a guidewire or mechanical dilators might be necessary to widen narrow passages.

Depending on the cause and the duration of the urinary retention, different lengths of catheterization might be required. If the cause is temporary, like medication side effects or anesthesia, the catheter can be removed after a short period (hours to a few days). For serious conditions where urinary retention is unlikely to get better, catheterization may be needed long term. Doctors can use various medications like alpha-blockers to help relax the muscles around the bladder and make it easier to urinate. For those with large prostates, there’s medication that can reduce prostate size, but it takes about 6 months to effectively work.

Self-catheterization is often the preferred option if possible. However, if someone has a urinary infection complication, symptoms of a malignant blockage, or conditions that affect the spinal cord like acute myelopathy, they would need to be hospitalized. Even if urinary retention can be initially managed at home, follow-up with a medical professional, specifically a urologist, is important. Patients must be educated on how to correctly use and care for the catheter, including how to empty the bag and how to keep track of urine output. Until a urinary infection has been confirmed, antibiotics are usually not necessary.

Urinary retention can also occur in various other medical conditions, which include spinal cord injury, autonomic dysreflexia (a potentially life-threatening situation where the lower body receives a harmful stimulus like a distended bladder), cauda equina syndrome (damage or compression of nerves in the lower spine), and detrusor-sphincter dyssynergia (where involuntary bladder contractions occur at the same time as the external bladder sphincter, a condition that coordinated urination, contracts). Depending on the individual’s particular condition, different techniques for dealing with urinary retention are needed.

What else can Male Urinary Retention: Acute and Chronic be?

When a man has trouble with urinary retention (not being able to pee), the doctor will consider that it might be due to any of the following possible conditions:

• Sudden kidney failure
• Recent stroke
• Accumulation of fluid in the abdominal cavity (Ascites)
• Kidney stones in both kidneys at the same time
• Narrowing of the bladder opening (Bladder neck contractures)
• Stones in the bladder
• Blockage in the bowel
• Long-term kidney disease
• Constipation
• Dehydration
• Bladder muscle and sphincter (opening) not working together (Detrusor-sphincter dyssynergia)
• Bladder doesn’t work due to nerve damage (neurogenic bladder)
• Narrowing of the opening of the penis (meatal stenosis)
• Tight foreskin (phimosis)
• Prostate cancer
• Fibrous tissue behind the lower abdominal area (Retroperitoneal fibrosis)
• Narrowing of the tube where urine exits the body (urethral strictures)

What to expect with Male Urinary Retention: Acute and Chronic

Men above 70 years with a condition called Benign Prostatic Hyperplasia (BPH), often face difficulties with urination and are prone to more health complications compared to men of the same age group who urinate normally. These complications could include infections and kidney problems like chronic kidney disease (CKD) and end-stage renal disease (ESRD).

How well these patients get better depends on multiple factors like the extent of their existing health issues, how well their kidneys are functioning, the amount of long-term damage to a bladder muscle called the detrusor muscle, how long and how severe the problem with urinating has been, and their response to treatment.

For patients with BPH having difficulty urinating, a surgical procedure called transurethral resection of the prostate (TURP) can drop their risk of developing a severe condition known as acute urinary retention by 85% to 90%. However, patients who need immediate surgery after an episode of acute urinary retention are at a higher risk of complications, including bleeding during surgery, sepsis from bacteria in urine. Men who needed immediate prostate surgery had a higher risk of death within 30 and 90 days after surgery compared to men who could plan their surgery. The older the patient, the higher the risk of complications.

If the acute urinary retention is due to neurological conditions, the risk of infection and worsening of the underlying disease is increased. Temporary causes of this retention generally have a better outcome than chronic conditions as long-term use of catheters can lead to complications. Using self-catheterization (where the person inserts the catheter themselves) or placing suprapubic tubes (tubes inserted in the bladder through the abdomen) usually results in fewer complications.

Possible Complications When Diagnosed with Male Urinary Retention: Acute and Chronic

: Complications from sudden inability to urinate can be due to several factors, such as untreated existing conditions, the cause of the issue, how long it has been there, how severe it is, any damage to the bladder, and other health problems. These complications could be:

• Urinary tract infections
• Problems with kidney function
• Imbalance of body salts
• Narrowing of the urethra
• Tightness around the bladder’s opening
• Bladder stones
• Backflow of urine into the kidneys
• Kidney failure
• Bladder failure
• Permanent bladder muscle dysfunction

Sometimes a tube may be used to help empty the bladder, and this can sometimes cause blood in the urine in about 2% to 16% of patients. This is usually not serious and often resolves on its own or may require simple wash. Sometimes, a person might experience temporary low blood pressure following the initial bladder decompression, but this often returns to normal on its own due to a reflex response in the body.

Preventing Male Urinary Retention: Acute and Chronic

Teaching men about ways to prevent urinary retention, a condition where you cannot fully empty your bladder, is important. Understanding risks such as an enlarged prostate, certain medications, and nerve conditions can help you take steps to prevent the issue. Other beneficial changes could include keeping a healthy weight, drinking enough water, and limiting alcohol intake. Regular health check-ups are important, especially for those who are at a higher risk, as they can catch the issue early, allowing for quick treatment. It’s also important to know that you should seek medical help as soon as symptoms appear to avoid further complications. By focusing on prevention through education, lifestyle changes, and treatment when needed, the number and severity of cases of urinary retention in men can be greatly reduced.

Education is equally important for patients diagnosed with urinary retention who are receiving treatment. For patients with acute urinary retention who need to use a catheter, it’s crucial to take the time to understand how to care for the catheter and keep track of how much liquid it is collecting. If a patient needs to use a catheter themselves for short periods of time, they should be shown the right techniques to avoid problems and adjust their catheter use around how much fluid they have in their bladder. For those with tubes into the bladder through the abdomen, there should be clear instructions on how to look after these catheters and keep the site clean to prevent skin inflammation. Continuous support may be needed at home for any questions or complications. Patients with an enlarged prostate (BPH) need to understand about trying to urinate and follow-up care. They should be aware of surgery options, including the possible risks, benefits, and complications. If a patient’s medications are causing the urinary retention, they should understand the possible side effects.