UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Chronic urinary retention in women

Author
Leslie M Rickey, MD, MPH
Section Editor
Linda Brubaker, MD, FACS, FACOG
Deputy Editor
Kristen Eckler, MD, FACOG

INTRODUCTION

Chronic urinary retention (CUR) is the accumulation of urine in the bladder that results from incomplete or inadequate bladder emptying. Incomplete bladder emptying is most commonly described and measured as the volume of urine left in the bladder after voiding, also known as the postvoid residual. The two common causes of CUR are bladder muscle dysfunction (detrusor underactivity) and obstruction. CUR is generally a gradual process.

This topic will review the etiology, evaluation, and treatment options for women with CUR. Issues of acute urinary retention and postoperative urinary retention are discussed separately. (See "Acute urinary retention" and "Postoperative urinary retention in women".)

DEFINITION

Clinically relevant CUR is the accumulation of urine that results in adverse clinical outcome in the absence of intervention [1]. CUR is typically determined by measuring a postvoid residual urine volume (PVR). PVR is defined by the International Continence Society as the volume of urine left in the bladder at the completion of micturition [2]. While there is no standardized PVR that defines CUR, a PVR of more than 150 mL is commonly used. (See 'Diagnosis' below.)

While there is no standard time frame that distinguishes chronic from acute urinary retention, it is reasonable to consider urinary retention to be chronic when a woman has persistently abnormal PVR over six to eight weeks.

PATHOPHYSIOLOGY

Normal voiding requires coordinated urethral and pelvic floor muscle relaxation followed by bladder contraction [2]; any disruption to these actions can result in urinary retention. The voiding reflex is triggered in the pontine micturition center and leads to relaxation of the external striated urethral sphincter (via sympathetic innervation from the hypogastric nerve) and pelvic floor muscles (via somatic innervation by the pudendal nerve) (figure 1) [3]. The resultant drop in urethral pressure is followed by contraction of the bladder detrusor muscle, which is mediated by parasympathetic innervation from the pelvic plexus. Incomplete emptying can result from abnormal function anywhere along the above pathway or when there is obstruction at the outlet level.

                                          

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Jan 22 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Juma S. Urinary retention in women. Curr Opin Urol 2014; 24:375.
  2. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29:4.
  3. Tanagho EA, Miller ER. Initiation of voiding. Br J Urol 1970; 42:175.
  4. Jeon S, Yoo EH. Predictive value of obstructive voiding symptoms and objective bladder emptying tests for urinary retention. J Obstet Gynaecol 2012; 32:770.
  5. Groutz A, Gordon D, Lessing JB, et al. Prevalence and characteristics of voiding difficulties in women: are subjective symptoms substantiated by objective urodynamic data? Urology 1999; 54:268.
  6. Adelowo AO, Hacker MR, Merport Modest A, Elkadry EA. Do symptoms of voiding dysfunction predict urinary retention? Female Pelvic Med Reconstr Surg 2012; 18:344.
  7. Osman NI, Chapple CR, Abrams P, et al. Detrusor underactivity and the underactive bladder: a new clinical entity? A review of current terminology, definitions, epidemiology, aetiology, and diagnosis. Eur Urol 2014; 65:389.
  8. Suskind AM, Smith PP. A new look at detrusor underactivity: impaired contractility versus afferent dysfunction. Curr Urol Rep 2009; 10:347.
  9. Abarbanel J, Marcus EL. Impaired detrusor contractility in community-dwelling elderly presenting with lower urinary tract symptoms. Urology 2007; 69:436.
  10. Pfisterer MH, Griffiths DJ, Schaefer W, Resnick NM. The effect of age on lower urinary tract function: a study in women. J Am Geriatr Soc 2006; 54:405.
  11. Hald T, Horn T. The human urinary bladder in ageing. Br J Urol 1998; 82 Suppl 1:59.
  12. Collas DM, Malone-Lee JG. Age-associated changes in detrusor sensory function in women with lower urinary tract symptoms. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7:24.
  13. Griffiths D, Tadic SD, Schaefer W, Resnick NM. Cerebral control of the bladder in normal and urge-incontinent women. Neuroimage 2007; 37:1.
  14. Kaplan SA, Te AE, Blaivas JG. Urodynamic findings in patients with diabetic cystopathy. J Urol 1995; 153:342.
  15. Brown JS, Wessells H, Chancellor MB, et al. Urologic complications of diabetes. Diabetes Care 2005; 28:177.
  16. Lee WC, Wu HP, Tai TY, et al. Effects of diabetes on female voiding behavior. J Urol 2004; 172:989.
  17. Fernyhough P, Roy Chowdhury SK, Schmidt RE. Mitochondrial stress and the pathogenesis of diabetic neuropathy. Expert Rev Endocrinol Metab 2010; 5:39.
  18. Vincent AM, Russell JW, Low P, Feldman EL. Oxidative stress in the pathogenesis of diabetic neuropathy. Endocr Rev 2004; 25:612.
  19. Obrosova IG. How does glucose generate oxidative stress in peripheral nerve? Int Rev Neurobiol 2002; 50:3.
  20. Edwards JL, Vincent AM, Cheng HT, Feldman EL. Diabetic neuropathy: mechanisms to management. Pharmacol Ther 2008; 120:1.
  21. Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care 2005; 28:956.
  22. Panicker JN, Fowler CJ, Kessler TM. Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. Lancet Neurol 2015; 14:720.
  23. Andrews KL, Husmann DA. Bladder dysfunction and management in multiple sclerosis. Mayo Clin Proc 1997; 72:1176.
  24. Betts CD, D'Mellow MT, Fowler CJ. Urinary symptoms and the neurological features of bladder dysfunction in multiple sclerosis. J Neurol Neurosurg Psychiatry 1993; 56:245.
  25. Mahajan ST, Frasure HE, Marrie RA. The prevalence of urinary catheterization in women and men with multiple sclerosis. J Spinal Cord Med 2013; 36:632.
  26. Tsai CH, Chou EC, Chou LW, et al. The evaluation of bladder symptoms in patients with lumbar compression disorders who have undergone decompressive surgery. Spine (Phila Pa 1976) 2010; 35:E849.
  27. Verhamme KM, Sturkenboom MC, Stricker BH, Bosch R. Drug-induced urinary retention: incidence, management and prevention. Drug Saf 2008; 31:373.
  28. Gratzke C, Bachmann A, Descazeaud A, et al. EAU Guidelines on the Assessment of Non-neurogenic Male Lower Urinary Tract Symptoms including Benign Prostatic Obstruction. Eur Urol 2015; 67:1099.
  29. Massey JA, Abrams PH. Obstructed voiding in the female. Br J Urol 1988; 61:36.
  30. Robinson D, Staskin D, Laterza RM, Koelbl H. Defining female voiding dysfunction: ICI-RS 2011. Neurourol Urodyn 2012; 31:313.
  31. Groutz A, Blaivas JG, Chaikin DC. Bladder outlet obstruction in women: definition and characteristics. Neurourol Urodyn 2000; 19:213.
  32. Nitti VW, Tu LM, Gitlin J. Diagnosing bladder outlet obstruction in women. J Urol 1999; 161:1535.
  33. Nitti V, Fischer M. Urodynamics. In: Ostergard's urogynecology and pelvic floor dysfunction, 6, Bent AE, Cundiff GW, Swift SE. (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. p.78.
  34. Lukacz ES, DuHamel E, Menefee SA, Luber KM. Elevated postvoid residual in women with pelvic floor disorders: prevalence and associated risk factors. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:397.
  35. Lowenstein L, Anderson C, Kenton K, et al. Obstructive voiding symptoms are not predictive of elevated postvoid residual urine volumes. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:801.
  36. Romanzi LJ, Chaikin DC, Blaivas JG. The effect of genital prolapse on voiding. J Urol 1999; 161:581.
  37. Wu CQ, Lefebvre G, Frecker H, Husslein H. Urinary retention and uterine leiomyomas: a case series and systematic review of the literature. Int Urogynecol J 2015; 26:1277.
  38. Andrada AO, De Vicente JM, Cidre MA. Pelvic plexus compression due to a uterine leiomyoma in a woman with acute urinary retention: a new hypothesis. Int Urogynecol J 2014; 25:429.
  39. Yazdany T, Bhatia NN, Nguyen JN. Urinary retention and voiding dysfunction in women with uterine leiomyoma: a case series. J Reprod Med 2012; 57:384.
  40. Dohil R, Roberts E, Jones KV, Jenkins HR. Constipation and reversible urinary tract abnormalities. Arch Dis Child 1994; 70:56.
  41. Starer P, Likourezos A, Dumapit G. The association of fecal impaction and urinary retention in elderly nursing home patients. Arch Gerontol Geriatr 2000; 30:47.
  42. Borrie MJ, Campbell K, Arcese ZA, et al. Urinary retention in patients in a geriatric rehabilitation unit: prevalence, risk factors, and validity of bladder scan evaluation. Rehabil Nurs 2001; 26:187.
  43. Gheiler EL, Tefilli MV, Tiguert R, et al. Management of primary urethral cancer. Urology 1998; 52:487.
  44. Carlson KV, Rome S, Nitti VW. Dysfunctional voiding in women. J Urol 2001; 165:143.
  45. King AB, Goldman HB. Bladder outlet obstruction in women: functional causes. Curr Urol Rep 2014; 15:436.
  46. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21:167.
  47. Utomo E, Groen J, Blok BF. Surgical management of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction. Cochrane Database Syst Rev 2014; :CD004927.
  48. Swinn MJ, Fowler CJ. Isolated urinary retention in young women, or Fowler's syndrome. Clin Auton Res 2001; 11:309.
  49. Fowler CJ, Christmas TJ, Chapple CR, et al. Abnormal electromyographic activity of the urethral sphincter, voiding dysfunction, and polycystic ovaries: a new syndrome? BMJ 1988; 297:1436.
  50. Smith MD, Seth JH, Fowler CJ, et al. Urinary retention for the neurologist. Pract Neurol 2013; 13:288.
  51. Brucker BM, Fong E, Shah S, et al. Urodynamic differences between dysfunctional voiding and primary bladder neck obstruction in women. Urology 2012; 80:55.
  52. Dwyer PL, Desmedt E. Impaired bladder emptying in women. Aust N Z J Obstet Gynaecol 1994; 34:73.
  53. Raz R, Gennesin Y, Wasser J, et al. Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis 2000; 30:152.
  54. Omli R, Skotnes LH, Mykletun A, et al. Residual urine as a risk factor for lower urinary tract infection: a 1-year follow-up study in nursing homes. J Am Geriatr Soc 2008; 56:871.
  55. Barabas G, Mölstad S. No association between elevated post-void residual volume and bacteriuria in residents of nursing homes. Scand J Prim Health Care 2005; 23:52.
  56. Hooton TM, Stapleton AE, Roberts PL, et al. Perineal anatomy and urine-voiding characteristics of young women with and without recurrent urinary tract infections. Clin Infect Dis 1999; 29:1600.
  57. Stoller ML, Millard RJ. The accuracy of a catheterized residual urine. J Urol 1989; 141:15.
  58. Fantl JA, et al.. Urinary incontinence in adults: Acute and chronic management. Clinical Practice Guideline No. 2, 1996 Update. AHCPR Publication NO. 96-0682, Agency for Health Care Policy and Research; Department of Health and Human Services, Rockville, MD 1996.
  59. Gehrich A, Stany MP, Fischer JR, et al. Establishing a mean postvoid residual volume in asymptomatic perimenopausal and postmenopausal women. Obstet Gynecol 2007; 110:827.
  60. Haylen BT, Lee J, Logan V, et al. Immediate postvoid residual volumes in women with symptoms of pelvic floor dysfunction. Obstet Gynecol 2008; 111:1305.
  61. Fitzgerald MP, Jaffar J, Brubaker L. Risk factors for an elevated postvoid residual urine volume in women with symptoms of urinary urgency, frequency and urge incontience. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12:237.
  62. Milleman M, Langenstroer P, Guralnick ML. Post-void residual urine volume in women with overactive bladder symptoms. J Urol 2004; 172:1911.
  63. Liang CC, Wei TY, Chang SD, Hsieh CC. Bladder volume determination: two-dimensional versus three-dimensional transvaginal ultrasound. Taiwan J Obstet Gynecol 2009; 48:258.
  64. Al-Shaikh G, Larochelle A, Campbell CE, et al. Accuracy of bladder scanning in the assessment of postvoid residual volume. J Obstet Gynaecol Can 2009; 31:526.
  65. Byun SS, Kim HH, Lee E, et al. Accuracy of bladder volume determinations by ultrasonography: are they accurate over entire bladder volume range? Urology 2003; 62:656.
  66. Brucker BM, Shah S, Mitchell S, et al. Comparison of urodynamic findings in women with anatomical versus functional bladder outlet obstruction. Female Pelvic Med Reconstr Surg 2013; 19:46.
  67. Defreitas GA, Zimmern PE, Lemack GE, Shariat SF. Refining diagnosis of anatomic female bladder outlet obstruction: comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls. Urology 2004; 64:675.
  68. Blaivas JG, Groutz A. Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology. Neurourol Urodyn 2000; 19:553.
  69. Stanton SL, Ozsoy C, Hilton P. Voiding difficulties in the female: prevalence, clinical and urodynamic review. Obstet Gynecol 1983; 61:144.
  70. Haylen BT, Ashby D, Sutherst JR, et al. Maximum and average urine flow rates in normal male and female populations--the Liverpool nomograms. Br J Urol 1989; 64:30.
  71. Diokno AC, Hollander JB, Bennett CJ. Bladder neck obstruction in women: a real entity. J Urol 1984; 132:294.
  72. Zhang P, Wu ZJ, Xu L, et al. Bladder neck incision for female bladder neck obstruction: long-term outcomes. Urology 2014; 83:762.
  73. Mahajan ST, Fitzgerald MP, Kenton K, et al. Concentric needle electrodes are superior to perineal surface-patch electrodes for electromyographic documentation of urethral sphincter relaxation during voiding. BJU Int 2006; 97:117.
  74. Deindl FM, Vodusek DB, Bischoff C, et al. Dysfunctional voiding in women: which muscles are responsible? Br J Urol 1998; 82:814.
  75. Galica V, Toska E, Saldutto P, et al. Use of transvaginal ultrasound in females with primary bladder neck obstruction. A preliminary study. Arch Ital Urol Androl 2015; 87:158.
  76. Chapple CR, Osman NI, Birder L, et al. The underactive bladder: a new clinical concept? Eur Urol 2015; 68:351.
  77. Brasure M, Fink HA, Risk M, et al. Chronic urinary retention: Comparative effectiveness and harms of treatments. Report, AHRQ Comparative Effectiveness Reviews; Rockville, MD 2014.
  78. Jonas U, Fowler CJ, Chancellor MB, et al. Efficacy of sacral nerve stimulation for urinary retention: results 18 months after implantation. J Urol 2001; 165:15.
  79. Aboseif S, Tamaddon K, Chalfin S, et al. Sacral neuromodulation in functional urinary retention: an effective way to restore voiding. BJU Int 2002; 90:662.
  80. In-Flow intraurethral valve-pump and activator http://www.accessdata.fda.gov/cdrh_docs/pdf13/den130044.pdf (Accessed on September 22, 2015).
  81. Chen TY, Ponsot Y, Carmel M, et al. Multi-centre study of intraurethral valve-pump catheter in women with a hypocontractile or acontractile bladder. Eur Urol 2005; 48:628.
  82. Barrett DM. The effect of oral bethanechol chloride on voiding in female patients with excessive residual urine: a randomized double-blind study. J Urol 1981; 126:640.
  83. Wagner G, Husslein P, Enzelsberger H. Is prostaglandin E2 really of therapeutic value for postoperative urinary retention? Results of a prospectively randomized double-blind study. Am J Obstet Gynecol 1985; 151:375.
  84. Hindley RG, Brierly RD, Thomas PJ. Prostaglandin E2 and bethanechol in combination for treating detrusor underactivity. BJU Int 2004; 93:89.
  85. Barendrecht MM, Oelke M, Laguna MP, Michel MC. Is the use of parasympathomimetics for treating an underactive urinary bladder evidence-based? BJU Int 2007; 99:749.
  86. Abrams P, Agarwal M, Drake M, et al. A proposed guideline for the urological management of patients with spinal cord injury. BJU Int 2008; 101:989.
  87. Wyndaele JJ, Kovindha A, Madersbacher H, et al. Neurologic urinary incontinence. Neurourol Urodyn 2010; 29:159.
  88. Barbalias GA, Klauber GT, Blaivas JG. Critical evaluation of the Credé maneuver: a urodynamic study of 207 patients. J Urol 1983; 130:720.
  89. Fitzgerald MP, Kulkarni N, Fenner D. Postoperative resolution of urinary retention in patients with advanced pelvic organ prolapse. Am J Obstet Gynecol 2000; 183:1361.
  90. Lazarou G, Scotti RJ, Mikhail MS, et al. Pessary reduction and postoperative cure of retention in women with anterior vaginal wall prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:175.
  91. Amundsen CL, Flynn BJ, Webster GD. Urethral erosion after synthetic and nonsynthetic pubovaginal slings: differences in management and continence outcome. J Urol 2003; 170:134.
  92. Sergouniotis F, Jarlshammar B, Larsson PG. Urethral complications after tension-free vaginal tape procedures: A surgical management case series. World J Nephrol 2015; 4:396.
  93. Minardi D, d'Anzeo G, Parri G, et al. The role of uroflowmetry biofeedback and biofeedback training of the pelvic floor muscles in the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a randomized controlled prospective study. Urology 2010; 75:1299.
  94. Kessler TM, Studer UE, Burkhard FC. The effect of terazosin on functional bladder outlet obstruction in women: a pilot study. J Urol 2006; 176:1487.
  95. Lee KS, Han DH, Lee YS, et al. Efficacy and safety of tamsulosin for the treatment of non-neurogenic voiding dysfunction in females: a 8-week prospective study. J Korean Med Sci 2010; 25:117.
  96. Low BY, Liong ML, Yuen KH, et al. Terazosin therapy for patients with female lower urinary tract symptoms: a randomized, double-blind, placebo controlled trial. J Urol 2008; 179:1461.
  97. Boyd K, Hilas O. α-adrenergic blockers for the treatment of lower-urinary-tract symptoms and dysfunction in women. Ann Pharmacother 2014; 48:711.
  98. Dasgupta R, Wiseman OJ, Kitchen N, Fowler CJ. Long-term results of sacral neuromodulation for women with urinary retention. BJU Int 2004; 94:335.
  99. Swinn MJ, Kitchen ND, Goodwin RJ, Fowler CJ. Sacral neuromodulation for women with Fowler's syndrome. Eur Urol 2000; 38:439.
  100. Peeters K, Sahai A, De Ridder D, Van Der Aa F. Long-term follow-up of sacral neuromodulation for lower urinary tract dysfunction. BJU Int 2014; 113:789.
  101. Kuo HC. Botulinum A toxin urethral injection for the treatment of lower urinary tract dysfunction. J Urol 2003; 170:1908.
  102. Kumar A, Mandhani A, Gogoi S, Srivastava A. Management of functional bladder neck obstruction in women: use of alpha-blockers and pediatric resectoscope for bladder neck incision. J Urol 1999; 162:2061.