Female urinary retention

Rare.

Causes:

1. Physical obstruction
2. Functional obstruction
3. Underactive detrusor

 

Anatomical obstruction	Functional obstruction	Underactive detrusor
Prolapse / procidentia Obstructing sling Fibroid (massive) Urethrocele / diverticulum Bladder neck stenosis Previous XRT Previous surgery Cervical cancer Other pelvic tumour Poorly fitting pessary Urethral tumour Skene gland tumour Bladder stone	DSD in neuropaths Fowler syndrome Spinal cord lesion Dysfunctional voiding   UTI	Neuropathy MS Pelvic nerve injury Multiple system atrophy Spinal cord lesion Autonomic neuropathy (DM) Medications Botox Anticholinergics Antipsychotics/antidepressants Opiates Anaesthesia Pelvic neuropraxia Post pelvic surgery Post partum Herpesvirus (zoster, HSV)

 

Work-up

Thorough history

• Urinary symptoms prior. Events leading to retention.
• New and current medications.
• Medical history including neuropathies, DM, anything causing nerve injuries as above
• Surgical history.
• Other gynaecological symptoms, O&G history.

 

Examination

• Abdominal masses, palpable bladder, scars.
• Pelvic exam – prolapse, urethral lesion, atrophy, masses, meatal stenosis
• Complete neurological exam

 

Investigations

• Urine culture
• Renal function
• Flow rate and post void residual

 

Imaging

• Ultrasound or CT to exclude pelvic masses
• MRI lumbosacral spine

 

If previous surgery such as TVT, or other suspicions, cystoscopy can be done to rule out foreign bodies and assess urethra.

 

Urodynamics

There may be a role for adjunct tests such a fluoroscopy, EMG and urethral pressure profiles.

May be difficult especially if patient entirely unable to void.

None of the commonly used nomograms are validated and able to confirm diagnoses in females.

Filling phase:

• Reduced / no sensation during filling
• Increased cystometric capacity

Voiding phase:

• Low pressure voiding in keeping with underactive bladder
• High voiding pressures in keeping with obstruction (high pressure, low flow)
• Obstruction at bladder neck during voiding seen on fluoro suggests obstruction
• High post void residuals could be in keeping with both obstruction and underactivity

High resting urethral pressures and maximum urethral closure pressure > 100 cm H2O often found in functional obstruction i.e., Fowler syndrome.

Failure of relaxation of the urethral sphincter is seen on EMG in functional obstruction, with

Treatment of female urinary retention is largely guided by the underlying cause, and self catheterisation as needed.

 

Other oral or conservative options include:

• Pelvic physiotherapy
• Alpha blockers – may improve symptom scores but no change in urodynamic parameters, QMax or PVR
• Baclofen – may improve QMax, improvements in symptoms not reported
• Sildenafil – failed to show improvement cf. placebo

 

Surgical options include:

• Intra-sphincteric botox 100 units – offered in EAU guidelines – good effect in mixed cohort of dysfunctional voiding (men and women) and case series
• Sacral nerve stimulation – majority of women will have a reduction in need for ISC and improvement in spontaneous voiding
• Prolapse repair, if indicated
• Urethral dilation, urethrotomy – in women with strictures
• Bladder neck incision trialled in women with primary bladder neck obstruction based on lack of funnelling at VCMG and high pressure low flow voiding – 80 % improved symptomatically and urodynamically, 3.6 % VVF, 5 % + SUI
• Urethroplasty in strictures
• Division, loosening or incision of sling if appropriate +/- urethrolysis

 

Fowler’s syndrome

Syndrome of young women with failure of relaxation of the external urethral sphincter causing urinary retention, often associated with polycystic ovaries.

Characteristic complex repetitive discharges on EMG. Sphincteric complex may or may not become hypertrophic. Significant raised MUCP.

 

Clinical features

• Classically second to fourth decade
• Most have a triggering event, often gynaecological surgery or other surgery
• Many have ovarian cysts, although relevance is unclear
• History of obstructive type urinary symptoms
• Mean bladder volume 1.2 L at diagnosis, characterised by suprapubic pain rather than urgency to void
• Associated with opioid use in up to 40 % of women presenting / diagnosed with Fowler

 

 

 

Urodynamics in Fowler’s:

• Delayed sensation during filling / large cystometric capacity
• Often unable to void – poor flow but low pressures also (cf. primary obstruction w high pressure)
• Narrowing at mid urethra/EUS on fluoro

 

Dysfunctional voiding (Hinman) vs Fowler

• Dysfunctional voiding is failure of pelvic floor to relax, Fowler is failure of EUS to relax.

 

Management of Fowler’s

• Exclude other causes – e.g MRI, UDS
• Bladder drainage – ISC most appropriate, but often Fowler’s patients find this exceptionally painful (classically urethral “gripping” of catheter)
  • 28 % of patients reportedly end up with SPC
  • May proceed to catheterisable continent channel
• Oral agents – alpha blockers, sildenafil etc as above, limited evidence
• Intrasphincteric botox – not good evidence in this group, may develop SUI
• Sacral neuromodulator – best evidence
  • May restore normal voiding
  • May not help with sphincteric relaxation, but by modulating neural pathways can activate detrusor contractions (which are suppressed in Fowler’s due to sphincteric activation)