Female Urinary Retention

What is Female Urinary Retention?

Urinary retention, which is when someone can’t pass urine, is a common reason that men go to the emergency department. There isn’t a clear-cut definition for it, but experts agree that it’s when a person can’t urinate on their own or when there is a lot of urine left in the bladder after urinating. Without treatment, this could lead to serious health issues.

Usually, it is diagnosed by checking for a high amount of leftover urine in the bladder after urinating. This is known as a high post-void residual urine volume. This is often accompanied by the symptoms such as a stomach pain above the pelvic area or inability to urinate. They use scanners or ultrasound to measure how much urine is left in the bladder, or they might use a catheter, which is a tube inserted through the urethra to help empty the bladder. People with a sudden case of urinary retention typically report this type of stomach pain and problems urinating. However, older people, in particular, may not have any symptoms. Normally, the maximum bladder capacity is about 500 mL, so any amount over this is considered abnormal and could indicate urinary retention.

Addressing this condition is crucial because if it’s not treated, it can lead to serious health issues. These can include bladder decompensation (where the bladder can’t hold as much urine), hydronephrosis (when the kidneys swell due to urine buildup), kidney failure, vesicoureteral reflux (when urine flows back from the bladder to the kidneys), kidney stones, and urinary infections. It can also cause symptoms like stomach pain above the pelvic area, feelings of not having fully emptied the bladder, a weak urine stream, a sense of urgency to urinate, and incontinence (not being able to control urination).

What Causes Female Urinary Retention?

Urinary retention in women, the inability to fully empty the bladder, can be classified in several ways. It can be complete or partial, acute or chronic, symptomatic or asymptomatic, due to obstruction or for non-obstruction reasons, and associated with either high or low bladder pressure. There are four general causes for this condition: neurological issues, physical blocking or obstruction, certain medications, and psychological reasons.

A wide range of specific causes can lead to urinary retention. This includes infection in the genital area (acute vulvovaginitis), anesthesia effects, bladder neck narrowing, bladder radiation, various brain issues like tumors or stroke, spinal cord injuries or diseases, cervical cancer, constipation, cysts, surgery related injuries or unnoticed issues, nerve disorders, diabetes, physical intra-abdominal growths or swellings, and various neurological disorders including multiple sclerosis and cerebral palsy. Certain medicines and psychological issues are also considered potential culprits.

Age affects the muscles which are responsible for bladder contraction. Older age comes with increasing residual urine in the bladder post-voiding, heightening the risk of urinary retention. Bladder obstruction in women usually happens due to surgery or physical changes in the pelvic organs. Disorders causing the closing of the urethra as well as external pressures on the urethra can prevent the bladder from fully emptying. Certain fibroids and tumors can also place pressure on pelvic nerves and cause nerve pain. This can cause issues with bladder function. Urethral cancer, although extremely rare, can also cause incomplete bladder emptying.

Diabetic women have higher chances of having larger residual urine volumes post-voiding when compared to non-diabetic women. This is due to the neurogenic changes caused by diabetes, with over half of women with longstanding diabetes likely to develop peripheral neuropathy.

Fowler’s syndrome is a rare condition affecting young women’s ability to urinate. It commonly affects women in their teenage to early adult years. It may be triggered by an event such as surgery or illness, and is often associated with certain issues like polycystic ovary syndrome and the use of opioids. The disease disrupts the brain’s signal to bladder relaxation and contraction, resulting in an inability to urinate or high residual urine volumes after voiding.

Other reasons for urinary retention include faulty contraction or relaxation of the urethral opening during urination. This can be caused by a disorder known as detrusor sphincter dyssynergia, which is characterized by the contraction of the urethral sphincter and surrounding muscles during bladder emptying. It usually requires specific medical tests for diagnosis.

Risk Factors and Frequency for Female Urinary Retention

Urinary retention, or having trouble emptying the bladder, is a problem that often affects men due to a condition called benign prostatic hyperplasia (BPH). It’s rarer in women, with roughly 3 to 7 out of every 100,000 women experiencing it each year. When compared to men, the ratio of females to males with urinary retention is 1 to 13. In fact, about a third of all men over the age of 80 will experience urinary retention. For older women, they might not show symptoms, but up to a third could have issues with incomplete bladder emptying. It’s important to note that the actual number of females with urinary retention is likely higher, as it is often underestimated and underdiagnosed.

There are specific situations in which women are at higher risk of urinary retention. For example, it frequently occurs after pelvic reconstruction surgeries and incontinence procedures. Those who have trouble with voiding before surgery and show greater volumes of urine left in the bladder after voiding tend to have a higher risk of experiencing urinary retention after surgery.

• Urinary retention is relatively common after a normal vaginal delivery, occurring in up to 14% of women immediately after childbirth. This number increases to roughly 20.6% in women who need assistance in delivery, such as forceps or a vacuum, presumably due to the strain and potential nerve injury to the pelvic muscles.
• About 5% of these women might have long-term bladder emptying problems following childbirth, especially if they initially retain a lot of urine (>1,000 mL).
• Women who have an episiotomy, a small surgical cut made at the opening of the vagina during childbirth, also have a higher chance of experiencing urinary retention after delivery.
• Almost a quarter (25%) of patients can experience urinary retention after a cesarean section performed under epidural anesthesia.
• Hysterectomy surgery, which involves the removal of the uterus, also carries a risk of urinary retention. However, techniques that spare the nerves or minimize disruption to the pelvic area can reduce this risk.
• Urinary retention can also occur due to an unrecognized injury to the bladder known as a cystotomy during gynecological surgery. Such injuries happen in about 1%-3% of hysterectomies and 2%-5% of retropubic sling surgeries, a procedure used to treat urinary incontinence.

Signs and Symptoms of Female Urinary Retention

When diagnosing urinary problems, doctors take into account the patient’s medical history and physical condition. Symptoms can range from discomfort while urinating, blood in urine, unusual discharge, bad-smelling urine, frequent urge to urinate, the feeling of not being able to empty your bladder entirely, or pain in the lower abdomen. Acute conditions often cause discomfort and pain, while chronic conditions might not show obvious symptoms or may have subtler ones like a reduced urge to urinate, slow or intermittent urine flow, difficulty starting urination, or even overflow incontinence.

It’s important to inform the doctor about any past trauma or procedures affecting the pelvis and urinary tract. Other relevant information like a history of back pain, fever, intravenous drug use, and other neurological symptoms can also indicate potential causes of urinary problems. The patient should also provide a list of all medications, including over-the-counter drugs and herbal remedies they’re taking, as some can cause or worsen urinary problems. Some examples of these are antihistamines, anticholinergics, and alpha-adrenergic agonists, which are often found in common decongestants.

The physical examination usually involves checking the lower abdomen and conducting a focused neurological examination. A rectal and pelvic exam is also performed. During the exam, any discomfort, or a detectable bladder in the lower abdomen, is noted. The rectal exam aims to identify any unusual masses, constipation, problems with sensation around the perineal area, and muscle tone of the sphincters. As for the pelvic examination, it can reveal issues like thinning and dryness of the vagina’s lining, tumors, urethral diverticulum, prolapse, and hernias involving the bladder and rectum. In some cases, the neurological exam can uncover potential nerve-related causes for the urinary problems.

The aim is to identify treatable causes of urinary problems in women, such as a maladjusted or stuck pessary, urinary tract infection, pelvic organ prolapse, urethral diverticulum with a stone, fibroids, or complications from previous pelvis surgery.

Finally, the doctor measures the volume of urine left in the bladder after urinating, ideally within 10 to 15 minutes of voiding. This is accompanied by a urine test.

Testing for Female Urinary Retention

Female urinary retention is a condition where a woman is unable to fully empty her bladder. This condition is typically divided into two main types: acute (sudden onset) and chronic (long-standing).

Acute urinary retention can occur suddenly, particularly after a triggering event such as childbirth, trauma, certain medical procedures like Botox injections in the bladder for overactivity, or surgery. Women with this condition often feel a sharp pain in the lower abdominal region, a strong need to urinate, and swelling in the lower abdomen or just above the pubic bone. They are also unable to urinate.

For diagnosing acute urinary retention, advanced testing methods like urodynamic testing (where fluid pressure in the bladder and the flow of urine are measured) aren’t usually necessary. However, such tests can be useful in cases of chronic retention or in patients who have had previous surgeries for urinary incontinence to detect a blocked urethra (tube that carries urine from the bladder out of the body).

The risk of acute urinary retention increases with age, especially for women over 50, and factors such as diabetes, hypertension, pre-existing urinary issues, pelvic trauma, and neurological diseases can contribute to it. Certain medications and surgical procedures can also cause urinary retention.

Chronic urinary retention often has less severe but a wider range of symptoms such as difficulty in starting to urinate, a slow urine stream, or incontinence due to overflow of urine. This condition can occur over an extended period, and sometimes women may not have any symptoms at all. The urinary retention might be discovered only when they visit their doctor for a check-up.

Doctors often define chronic urinary retention as a post-void (after urination) residual urine volume of over 300 mL that continues for at least six months. This diagnosis is usually made after measuring this volume on at least two separate occasions. The main risks for patients with chronic urinary retention include persistent bacteria in urine, recurrent bladder infections, kidney stones, and even kidney damage. There is an increased risk of kidney disease if the pressure within the bladder is consistently high.

If you are experiencing urinary retention, your doctor will first conduct a urine test, which may need to be done by inserting a thin, hollow tube into your bladder through the urethra (catheter) if you are unable to pee on your own. The doctor will then measure the amount of urine left in your bladder after you urinate. If there is a large volume of urine left in the bladder (more than 300 mL), it suggests urinary retention. If you’re unable to urinate at all, your doctor may need to insert a catheter to drain the urine. If more than 400 mL of urine passes out through the catheter in the first 15 minutes, it suggests that you have urinary retention.

Advanced testing methods like urodynamic testing can be useful for women with long-term, unexplained urinary retention to determine the cause. Also, an examination of the inside of the bladder (cystoscopy) can sometimes detect physical problems that may be contributing to urinary retention, such as strictures (narrowing), lumps, kidney stones, or damage from surgical material used in previous pelvic surgeries.

Immediate treatment for urinary retention usually involves catheterization, which is the insertion of a tube through the urethra into the bladder to drain urine. If urinary retention is a recurring issue, this procedure may need to be done periodically.

Treatment Options for Female Urinary Retention

Patients diagnosed with urinary retention, a condition when one is unable to empty the bladder completely, are typically first treated with a urethral Foley catheter. This is a thin, flexible tube used to drain urine from the bladder. It’s important to note the amount of urine drained right after the catheter is inserted. Patients with more than 1,500 mL of urine drained immediately are at a higher risk for developing a condition called postobstructive diuresis, especially those who have pre-existing kidney failure, swollen kidneys due to backflow of urine, or congestive heart failure.

Postobstructive diuresis is a disorder characterized by uncontrolled excretion of water and salt from the body. It usually occurs when the urine output is over 200 mL per hour for at least 2 hours or when a patient passes more than 3,000 mL of urine in 24 hours. Patients at risk should have their urine output and blood electrolyte levels regularly monitored. In certain severe cases, or in cases where patients cannot drink freely, they may need to be given intravenous fluids. The severity and progression of the disorder can be tracked using urinary specific gravity, which is a measure of the concentration of substances in the urine. If the specific gravity reaches 1.020 or more, it generally indicates that the condition is resolving. This condition usually gets better within 24 hours in most cases.

If a patient can’t urinate at all or has a very large amount of urine left in the bladder (1,500 mL or more), a Foley catheter is typically the first choice for both monitoring and treatment. If for some reason a urethral catheter can’t be inserted, a suprapubic tube (which is placed through the lower abdomen right above the pubic area) may be used instead.

Overflow of urine beyond the bladder’s capacity can lead to bladder overdistension injury, which can occur if the capacity of the bladder is filled to 120% or more for 24 hours or longer. This process can cause a decrease in smooth muscle contractility due to injury of the bladder muscle fibers and an increase in the level of calcium inside the cells, which decreases the ability of the bladder to contract. This usually gets better after treatment with a Foley catheter.

Patients unable to urinate normally or those with large amounts of residual urine in their bladder can manage the condition with self-catheterization, in which the patient inserts the catheter by themselves on a regular basis to remove the retained urine. It’s recommended to note down the volume of urine sometimes, such as once a day. As normal bladder function returns, the volumes will decrease, indicating that self-catheterization is no longer needed. The patient can also perform self-catheterization if they feel a return of symptoms without having to visit the emergency department.

The risk of a significant decrease in kidney function or permanent bladder damage is minimal in acute urinary retention as long as it is identified and treated promptly. Some sort of catheterization will be needed if a full recovery isn’t likely by six to eight months after the original event, at which point the condition is considered chronic.

Patients who can’t urinate immediately after major pelvic surgery should have their bladders checked for cystotomy, a surgical cut in the bladder, by irrigating the bladder through a Foley catheter with sterile saline. If a cystotomy is suspected, an x-ray should be done next. Small bladders perforations can often be managed just with a Foley catheter, but large leaks or leaks into the abdomen may require immediate surgical repair.

Physical therapy along with biofeedback, a technique used to help patients control their body functions, such as heart rate and blood pressure, has shown positive results in some patients with urinary retention related to conditions such as prolapse, rectoceles, and other dysfunctions. However, for unresolved cases, bladder function may be improved by surgical intervention or nerve stimulation techniques.

What else can Female Urinary Retention be?

Urinary retention can be caused by several factors. Sometimes, it might seem like urinary retention but could be due to other conditions. The possible reasons include:

• Blockage anywhere in the lower urinary tract
• Nerve dysfunction
• An object obstructing the passage, such as pelvic masses or a urethral stone
• Constipation
• Infections that cause inflammation in the urethra
• Narrowing or tightening of the urethra, known as stenosis or strictures
• A pouch or sack in the urethra, known as urethral diverticulum
• Neurological disorders that affect urinary function

Surgical Treatment of Female Urinary Retention

In the US, a type of cancer called appendiceal neoplasms affects about 1.2 in every 100,000 people. Almost a third of these patients first come to the doctor with severe stomach pain. The most common types of this cancer are Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs), Goblet Cell Carcinoma (GCC), Colonic-type Adenocarcinoma, and tumor-like formations called Mucinous Neoplasm.

GEP-NETs are the most common type of appendiceal neoplasms. These tumors usually do not spread to other parts of the body (metastasize). If they do spread, it often happens to the liver or lymph nodes, clusters of immune cells throughout the body. That’s why, if doctors suspect GEP-NETs, they will often check the liver and lymph nodes in the area around the ileum (part of the small intestine) and colon. The type of surgery done depends on the size of the primary tumor. For small tumor (less than 1 cm), only an appendectomy (removal of the appendix) may be needed; but if the tumor is large (more than 2 cm), a right hemicolectomy (removal of the right side of the colon) may be necessary. It’s still not decided what the best surgery option is for medium-sized tumors (1 to 2 cm).

Goblet Cell Carcinomas are also a common type of appendiceal neoplasms. They share similar characteristics with other cancers like appendiceal adenocarcinoma and neuroendocrine tumors. Doctors will likely perform a thorough check of the abdominal cavity because these cancers commonly spread there. A right hemicolectomy can help patients with non-spreading cancers or large tumors (2 cm or larger).

Non-Hodgkin lymphoma (NHL), a type of cancer that affects the lymph system, might cause similar symptoms as an inflamed appendix. Though it’s a rare condition, the best treatment often includes only removing the appendix. Still, it’s important to have a full body check-up, as this type of cancer may spread to other parts of the body.

Adenocarcinoma of the appendix is another rare type of cancer, which often presents as an inflamed appendix. The standard treatment is a right hemicolectomy, regardless of the size of the tumor or whether it has spread to the lymph nodes.

Appendiceal mucoceles, ball-like formations in the appendix, can cause symptoms similar to an inflamed appendix. They can develop as part of both non-cancerous or cancerous processes where there’s an overproduction of mucus and formation of cyst-like structures in the appendix. Certain findings on scans, like a well-defined cyst in the lower right stomach area, may make doctors suspect a mucocele, but a final diagnosis only comes after surgery and further analysis of the tissue. In treating mucoceles, doctors typically remove the appendix, but always try to prevent rupturing the mucocele, which can lead to spreading of its contents. They may also take a sample of the peritoneal area (the space within the abdominal cavity) to check for any signs of spread. In suspicious cases of mucinous neoplasms in the appendix, doctors perform a thorough inspection of the peritoneal area and document any findings, especially if mucus is present.

What to expect with Female Urinary Retention

Urinary retention, or having trouble fully emptying your bladder, tends to improve if caught early and treated properly. Sudden urinary retention, sometimes seen immediately after big surgeries, generally gets better on its own within a few days or weeks. However, if your urinary retention is caused by a blockage or problem in the urinary tract, it might not get better without surgery to remove the blockage.

In some cases, your bladder might stretch too much because it’s full all the time, or the upper part of your urinary tract might get damaged. Both of these issues can be managed by inserting a catheter regularly or continuously to help empty your bladder. However, it’s more challenging to manage long-term urinary retention, as it depends on what’s causing the problem, your other health conditions, and whether certain treatments, like sacral neuromodulation, are available.

In a study of 600 patients, researchers found that providing adequate nursing care and encouraging patients to drink water early on can help prevent urinary retention after giving birth.

Given that long-term urinary retention in women could be effectively treated with sacral neuromodulation and percutaneous tibial nerve stimulation, these treatment options are probably not used enough. Implantable tibial nerve stimulators, which are devices put inside your body to stimulate a nerve in your lower leg, could be a promising treatment option in the future, but more research is needed to confirm its effectiveness for female urinary retention.

Intraurethral valve pumps, another treatment option for urinary retention, are silicone catheters inserted into your urethra that come with an internal valve and pump mechanism. You can operate this mechanism using a remote control. While these devices provide an effective treatment option for some, they can be expensive, uncomfortable, and may leak. Nevertheless, these issues may be overcome with newer versions of these devices.

As for follow-up, the American Urological Association Guidelines recommend a yearly check-up that includes a medical history review, physical exam, and measurements of how much urine is left in your bladder after you pee. If you’re at high risk, for example, if you have been diagnosed with kidney failure, kidney stones, or hydronephrosis (a kidney condition where urine cannot drain out from the kidneys to the bladder), you should have yearly tests to measure your kidney function and an ultrasound scan of your kidneys.

Possible Complications When Diagnosed with Female Urinary Retention

Urinary retention can lead to several complications, including acute kidney and bladder injuries, and urinary tract infections. Using a catheter, either via the abdomen (suprapubic) or the urethra, can also have complications. These include urinary tract infections, damage to the urethra, bladder spasms, bladder stones, reflux of urine back into the kidneys, skin infections at the catheter insertion site, bladder or kidney stones, damage to the renal parenchyma (the functional tissue of the kidney), and gradual deterioration of the kidneys. Additionally, using a catheter can sometimes directly injure the urethra during insertion, and suprapubic catheterization can cause harm to the bladder or colon and lead to leaks or skin infections.

Another problem that can surface is post-obstructive diuresis. This occurs when the body starts to excrete large amounts of salt and water after a catheter relieves urinary blockage. While this can happen naturally, doctors need to monitor patients closely as it can lead to dehydration and metabolic imbalances. Patients with azotemia (abnormally high levels of nitrogenous compounds in the blood), fluid retention, and especially high bladder volumes typically over 1500 milliliters are particularly at risk.

While surgical procedures like transurethral resection or incisions have demonstrated some effectiveness, they come with a significant risk of permanent urinary incontinence. Treatment with botulinum toxin injections into the urethra shows promise, but there’s no standardized method or dosage at this point, and data on success rates are limited. Sacral neuromodulation has been effective but requires surgical implantation and routine follow-ups, and often needs repeat surgeries.

Complications from Urinary Retention:

• Acute kidney and bladder injuries
• Urinary tract infections
• Complications from catheterization
• Direct urethral injury
• Bladder or colon trauma from suprapubic catheterization
• Post-obstructive diuresis
• Dehydration and metabolic imbalances
• Permanent urinary incontinence from surgical procedures

Recovery from Female Urinary Retention

It’s strongly advised to have an established procedure for keeping an eye on women after they have given birth, undergone prolonged anesthesia, or had major surgery in the pelvic area. The goal is to spot signs of acute urinary retention, which is the sudden inability to urinate, before there’s extensive damage to the detrusor, the muscle that controls the bladder. An ultrasound of the bladder to check the amount of urine left (residual volume) 4 to 6 hours after surgery is a reasonable minimal practice.

Given that most recovery rooms and hospitals have ultrasound equipment handy, it’s fairly straightforward to check bladder residuals, especially in patients who are at a higher risk.

Rehabilitation centers should emphasize teaching women with urinary retention how to intermittently use a catheter themselves. The catheterization schedule should be tailored to each patient, based on factors like their specific health scenario, bladder size, any existing health conditions, personal abilities, and the amount of urine they usually produce.

Preventing Female Urinary Retention

Urinary retention refers to the inability to fully empty the bladder. It can be a sudden issue (acute) or a long-term problem (chronic). Although it’s less common in women than in men, unnoticed or untreated urinary retention can lead to serious problems like irreversible bladder damage, deterioration of the kidney, formation of stones, infections, and dependence on a Foley catheter – a tube inserted into the bladder to drain urine.

If you’re having problems with urination, like intermittent dripping of urine, unusual smell of the urine, a feeling like you can’t completely empty your bladder, or hesitation before urinating, it’s important to talk with your doctor. By measuring the amount of urine left in your bladder after you go to the bathroom—either by using a straight catheter (a thin, flexible tube) or an ultrasound—they can quickly confirm or rule out whether you have urinary retention.