Heterogenous population and diagnosis which can range from being asymptomatic and of little consequence to significant morbidity including renal failure and infections.
Difficult to define:
ICS – Generally (but not always) painless and palpable or percussible bladder, where there is a chronic high PVR where the patient experiences slow flow and incomplete bladder emptying. Overflow incontinence can occur. Some individuals with retention present with impaired renal function and/or hydronephrosis.
AUA white paper – non-neurological CUR, elevated PVR > 300 mL that has persisted for at least six months and is documented on two or more separate occasions
NICE guidelines – residual volume of greater than 1 litre or presence of a palpable or percussible bladder
Largely suggested by high post void residual volumes in the absence of acute pain.
Important to classify as high pressure chronic retention or low pressure chronic retention, usually suggested by the presence of renal compromise or upper tract dilation and confirmed if needed with urodynamics.
Note chronic urinary retention as a clinical syndrome or diagnosis is different to detrusor underactivity which is a urodynamic diagnosis.
Management / work-up
History and examination
- Identify cause, consider neurological cause, medications, malignancy, symptomatology.
Investigations
- Renal function, ultrasound +/- CT, urine culture, +/- UDS
Define as high risk (high pressure, renal impairment, hydronephrosis, UTIs) or low risk
Define as symptomatic or asymptomatic.
High risk patients or high pressure retention should be treated with catheterisation, and the underlying cause treated (i.e., BPH, prolapse, cancer) before catheter removal.
Low risk asymptomatic patients can undergo ‘longitudinal surveillance’ to monitor for changes in symptoms, renal function and upper tract changes, and infections.
It is accepted that the defined risks of IDC/SPC/ISC (infections, pain, cost) outweigh the benefits of treating asymptomatic low risk retention.
The benefit of ‘bladder training’ prior to outlet surgery i.e. ISC or flip-flow taps has not been well studied – some evidence of benefit. Must have compliant patient especially if high risk for upper tract compromise.
Vesical pressures > 25 cm H2O predict high pressure retention – this is the hydrostatic pressure of a column of urine from bladder to renal pelvis.
Underactive bladder
Different entity to chronic retention but may cause chronic retention.
Underactive bladder – symptom complex characterised by slow stream, hesitancy and straining, with or without a feeling of incompletely emptying and occasionally storage symptoms
Detrusor underactivity – urodynamic diagnosis – detrusor contraction of reduced strength/duration, resulting in prolonged bladder emptying and/or failure to achieve emptying in normal time
More common in women and elderly.
Causes:
- Idiopathic
- Age dependent reduction in contractile strength
- Neurogenic
- Sacral cord lesions or injuries, spina bifida, MS, MSA, diabetes (diabetic cystopathy), pelvic nerves
- Myogenic
- Overdistension, bladder outlet obstruction
- Iatrogenic
- Pelvic surgery or spinal surgery
- Pharmacological
- Anticholinergics
UDS – low flow low pressure voiding
DHIC/DODU – detrusor overactivity during filling, detrusor underactivity during voiding
Acontractile detrusor – no rise in pDet during voiding on urodynamics / failure to void – only with abdominal straining
Management:
