Inability to Urinate

The bladder is a hollow balloon-like organ that stores and eliminates urine.

Urinary retention is the inability to completely empty your bladder. Urinary retention may be sudden in onset (acute) or gradual in onset and chronic (long-standing). When you cannot empty your bladder completely, or at all, despite an urge to urinate, you have urinary retention. To understand how urinary retention occurs, it is important to understand the basics of how urine is stored in and released from the body.

The bladder is a hollow balloon-like organ in the lower part of the belly (pelvis) that stores and eliminates (expels) urine.

• Urine is composed of waste chemicals and water filtered from the blood by the kidneys.
• It travels down two thin tubes called ureters (one from each kidney) to empty into the bladder.
• When about 1 cup (200 ml-300 ml) of urine has collected in the bladder, a signal is produced from nerves within the bladder wall in response to filling and stretching of the bladder. This signal is sent to the nerves in the spinal cord and ultimately to the brain. The brain controls the bladder and when it is appropriate to urinate, the brain returns a signal that starts contractions in the bladder wall. Prior to the contraction of the bladder, the muscles surrounding the outlet of the bladder, bladder neck, as well as the muscles surrounding the urethra, relax. This is coordinated (synergistic) urination.
• Urine leaving the bladder passes through the urethra, a hollow tube that is surrounded by muscles.
• Control of urination is for the most part voluntary. One can suppress an urge to urinate by contracting one's pelvic muscles. However, if one tries to hold it too long, urinary incontinence often results. Overactivity of the bladder muscle can also cause incontinence.

Urinary retention is often subdivided into different categories. Urinary retention may be complete in that one is unable to urinate at all, despite having a full bladder. Partial urinary retention is the ability to urinate in small amounts but leaving a large amount in the bladder after each urination. Urinary retention may be acute, occurring suddenly; one feels the need to urinate and cannot urinate at all even despite having a full bladder, or chronic, when one does not empty one's bladder completely. Acute urinary retention is often uncomfortable. Chronic urinary retention is typically not painful (asymptomatic). The amount of urine left behind to be considered chronic urinary retention is not well defined; some state that it is 300 cc (a little over an 8-ounce cupful), yet others state that it is >400 cc. Urinary retention may be due to an obstruction to the outflow of urine or nonobstructive. Lastly, urinary retention can be associated with high bladder pressures or low bladder pressures. The International Continence Society defines chronic urinary retention as a non-painful bladder, which remains palpable or percussable (tapping on the lower abdomen elicits a hollow sound) after the individual has urinated.

Urinary retention may cause harm to the function of the bladder and the kidneys, incontinence, and may increase the risk of urinary tract infections. Thus, it requires urgent medical attention for evaluation and management. In some cases, hospitalization is required.

Urinary retention is not an unusual medical condition, and it is more common in men than in women.

There are a number of medical conditions and medications that may cause urinary retention. These medical conditions and medications may affect the function of the bladder itself, the function of the outlet of the bladder, and/or the urethra. Obstruction may be fixed (due to a mass blocking the bladder outlet) or dynamic (lack of coordination between the bladder and the muscles surrounding the bladder outlet and urethra). There are also infectious causes and surgical causes of urinary retention.

Common Causes/Risk Factors

• Blockage (obstruction): The most common cause of blockage of the urethra in men is enlargement of the prostate. In males, the prostate gland surrounds the urethra. If the prostate becomes enlarged, which is common in older men, it may compress the urethra, causing resistance/blockage to the outflow of urine. The most common cause of prostate enlargement is benign prostatic hypertrophy (often called BPH). Other causes of prostate enlargement include prostate cancer. Acute infection of the prostate (prostatitis) may cause swelling of the prostate and lead to urinary retention. Less common obstructive causes in men include meatal stenosis (narrowing of the opening at the tip of the penis that urine passes through, which may be the result of chronic irritation or prior hypospadias surgery), paraphimosis (in which the foreskin in an uncircumcised male retracts and cannot be pulled back down, resulting in swelling and constriction), penile constricting bands, and penile cancer. Other causes of blockage of the urethra that can occur in both males and females include scar tissue in the urethra from prior trauma, surgery or infection (urethral stricture), injury to the bladder outlet or urethra (as in a car accident or bad fall), blood clots due to bladder infection or trauma, tumors in the bladder or pelvic region, severe constipation, and bladder or urethral stones or foreign bodies in the bladder or urethra. Blockage to the outflow of urine may also be due to lack of coordination between the bladder and the bladder outlet, bladder neck dysfunction, and/or lack of coordination between the bladder and the muscles surrounding the urethra, known as bladder-sphincter dysfunction. Bladder-sphincter dysfunction may be voluntary or involuntary. Voluntary bladder-sphincter dysfunction is seen in individuals who chronically hold their urine and tighten the pelvic floor muscles/sphincter when an urge to urinate occurs. Chronic tightening of these muscles leads to an inability to properly relax the muscles when urinating. Involuntary relaxation of the pelvic floor muscles/sphincter muscles occurs in individuals with neurologic conditions that can affect bladder and sphincter function. Lastly, in women, obstruction to the outflow of urine may be due to a large cystocele, or herniation of the bladder into the vagina, or may be the result of surgeries to treat urinary incontinence, such as sling procedures.
• Nerve problems: Disruption of the nerves between the bladder and the brain can cause you to lose control of your bladder function. The problem may lie in the nerves that send messages back and forth or in the nerves that control the muscles used in urination, or both. Individuals who suffer from such conditions are referred to as having a "neurogenic bladder." Occasionally, urinary retention is the first sign of spinal cord compression, a medical emergency that must be treated right away to prevent permanent, serious disability. The most common causes of this disruption include spinal cord injury, spinal cord tumor, strokes, diabetes mellitus, herniated or ruptured disk in the vertebral column of the back, or an infection or blood clot that places pressure on your spinal cord, and congenital spinal cord problems such as myelomeningocele (spina bifida) and tethered spinal cord. Nerve problems can also affect the ability of the muscles around the urethra to relax during urination, known as detrusor sphincter dyssynergia (DSD), which can lead to urinary retention.
• Infection and inflammation: In males, inflammation of the head of the penis, the glans (balanitis), and infection of the prostate (prostatitis) or an abscess of the prostate may result in urinary retention. In women, infection of the vulva and vagina, vulvovaginitis, as well as chronic inflammation and resultant scarring, lichen sclerosus, may cause urinary retention. In both males and females, bladder infections, Guillain-Barré syndrome, Lyme disease, periurethral abscess, transverse myelitis, tuberculosis affecting the bladder, infection of the urethra (urethritis), and herpes zoster (shingles) can cause urinary retention. Herpes simplex virus can cause pain in the perineum and affect the nerves leading to urinary retention. Infections around the spinal cord can cause retention by placing pressure on the nerves of the spinal cord.
• Trauma to the pelvis, penis, and perineum can cause urinary retention. Fractures of the pelvis can cause damage to the bladder outlet and urethra, and the healing of such injuries can lead to obstruction from scar tissue.
• Surgery: Urinary retention is a relatively common problem after surgery. It can be a direct result of the anesthetic or the type of operation. Relative immobility after a surgery can also contribute to urinary retention. Previous bladder or prostate surgeries can sometimes cause urinary retention because of the formation of strictures (narrowing) due to scar tissue. This can occur after prostate cancer surgery (radical prostatectomy) as well as surgery for benign prostate enlargement (BPH) (transurethral prostatectomy, laser prostatectomy, and cryotherapy).
• Chronic overdistention of the bladder (holding one's urine for long periods of time) or excess alcohol intake can lead to urinary retention.
• Immobility may result in urinary retention.
• Other causes of transient urinary retention include immobility (especially post-operative), constipation, delirium, endocrine (hormone) problems, psychological problems, and prior instrumentation (medical procedures involving placing instruments in the urethra) of the urethra.

Medication-Related Causes

Certain medications can cause urinary retention, especially in men with prostate enlargement. Many of these medications are found in over-the-counter cold and allergy preparations. These drugs include the following:

• Drugs that act to tighten the urinary channel and block the flow of urine include ephedrine (Kondon's Nasal, Pretz-D), pseudoephedrine (Actifed, Afrin, Drixoral, Sudafed, Triaminic), phenylpropanolamine (Acutrim, Dexatrim, Phenoxine, Prolamine), phenyleprhine (neosynephrine), and amphetamines.
• Antihistamines such as diphenhydramine (Benadryl, Compoz, Nytol, Sominex) and chlorpheniramine (Chlor-Trimeton, Allergy 8 Hr), as well as some older antidepressants, can relax the bladder too much and cause urination problems.
• Anticholinergics, medications commonly used to treat overactive bladder, as well as other conditions such as oxybutynin (Ditropan, Ditropan XL, oxytrol), tolterodine (detrol, detrol LA), darifenacin (Enablex), solifenacin (VESIcare), trospium chloride (Sanctura, Sanctura XR), atropine, belladone and opioid, dicyclomine (Bentyl), flavoxate (Urispas), glycopyrrolate (Robinul), hyoscyamine (Levsin), propantheline (Pro-Banthine), and scopolamine (transdermal scopolamine)
• Certain antidepressants may affect bladder/sphincter function, including amitriptyline (Elavil), amoxapine, doxepin, imipramine (Tofranil), and nortriptyline (Pamelor).
• Cox-2 inhibitors, used for treating such conditions as sports injuries, arthritis, colorectal polyps, and menstrual cramps
• Some medications used to treat heart arrhythmias may affect urination, including disopyramide (Norpace), procainamide (Pronestyl), and quinidine.
• Certain antihypertensive medications, including hydralazine and nifedipine (Procardia)
• Antiparkinsonian medications, including amantadine (Symmetrel), benztropine (Cogentin), bromocriptine (Parlodel), and levodopa
• Antipsychotics, including chlorpromazine (Thorazine), fluphenazine, haloperidol (Haldol), prochlorperazine (Compazine), thioridazine (Mellaril), and thiothixene (Navane).
• Muscle relaxants, including baclofen (Lioresal), cyclobenzaprine (Flexeril), and diazepam (valium)
• Beta-adrenergic sympathomimetics, including isoproterenol (Isuprel), terbutaline (Brethine), and metaproterenol (Alupent)
• Opioid-containing medications

Urinary Retention in Children

• A child can have problems from birth that cause an inability to urinate properly. These problems may be identified prenatally. Such conditions include posterior and anterior urethral valves (areas of obstruction in the male urethra), ureterocele (a dilation of the part of the ureter that is within the bladder), and neurologic conditions such as myelomeningocele (spina bifida) and tethered cord. Children may develop urinary retention as a result of scarring from trauma to the urethra (straddle injury, pelvic trauma, or prior urethral instrumentation) and surgical procedures such as hypospadias procedures and continence procedures.
• A child may suddenly become unwilling to urinate. This is generally due to a temporary condition that is causing pain with urination. Pain can be caused by a vaginal yeast infection in girls or an irritation from soap or shampoo used in bathing. Almost always, the child will eventually urinate without further help. Chronic holding of urine and failing to relax the pelvic floor muscles with voiding (dysfunctional voiding) may result in urinary retention.
• Severe constipation may result in urinary retention.
• A history of sexual abuse also is associated with urinary retention.

With urinary retention, there is an inability to urinate or completely empty the bladder despite an urge to urinate. Some people have the following symptoms:

• Most people with acute urinary retention also feel pain in the lower abdomen (pelvis) along with the inability to urinate. Chronic urinary retention is usually painless.
• With acute and chronic urinary retention, a full bladder can often be felt just above the pubic bone and may extend to the belly button (umbilicus). Tapping on the lower abdomen will elicit a hollow sound.
• A small amount of urine may leak out of the bladder but generally not enough to relieve symptoms and the urine stream is often described as being very weak, like a dribble.
• There may be constant leakage of urine, known as urinary incontinence.
• Chronic urinary retention may be associated with decreased urine stream, feeling of incomplete bladder emptying, and/or straining to urinate.
• Back pain, fever, and painful urination may indicate a urinary tract infection.

Call your health care professional immediately if you have symptoms of acute urinary retention.

• This condition requires urgent bladder drainage to prevent damage to the bladder, kidneys, and ureter.
• Your doctor may advise you to go to a hospital emergency department without delay.
• If you have symptoms of chronic urinary retention, you should also let your health care provider know, since chronic urinary retention may lead to urinary tract infections, incontinence, further bladder damage, and damage to your kidneys.

Urologists (doctors specialized in the urinary tract system) are most often involved in the care of patients with urinary retention. However, women are also often treated by urogynecologists. Internists, family physicians, and emergency-room physicians also frequently treat urinary retention.

Urologists (doctors specialized in the urinary tract system) are most often involved in the care of patients with urinary retention. However, urogynecologists also treat women with urinary retention. Internists, family physicians, and emergency-room physicians also frequently treat urinary retention and will refer you to a urologist or urogynecologist if it is not improving.

Medical evaluation for urinary retention includes a medical and physical examination (including a prostate examination in men) as well as laboratory tests (if indicated) to find the cause of the problem.

On physical examination, the bladder may be visible and/or palpable (be felt by the examiner). A rectal examination in a male may demonstrate an enlarged prostate, an enlarged prostate with hard areas suspicious for prostate cancer, or prostate tenderness suggestive of prostatitis. A penile examination can identify abnormalities of the penile skin and the meatus, the opening at the tip of the penis that urine passes through, or signs of prior penile surgery such as prior hypospadias repair. Examination of the genitalia in a female may demonstrate a large cystocele (prolapse of the bladder into the vagina). A rectal examination in both males and females may reveal fecal impaction.

A bladder scan (portable ultrasound-like evaluation) is often used to determine how much urine is in the bladder to confirm the diagnosis of urinary retention.

A renal (kidney) and bladder ultrasound may be helpful to determine if there is hydronephrosis (a backup of urine in the kidneys) or bladder stones.

A pelvic ultrasound or CT of the abdomen/pelvis may be indicated to check for pelvic, abdominal, or retroperitoneal conditions.

A catheter can be placed in the urethra. This is a thin, flexible tube. It goes up the bladder and drains the urine into a bag.

• This is done both for diagnosis and as a treatment of the immediate problem. Draining urine almost always relieves the symptoms, at least for a while.
• A urine sample will be taken to check for signs of infection, bladder irritation, stones, or other problems.

Other lab tests may be done, depending on your doctor's conclusions from your medical interview and exam.

• Blood may be drawn to check for signs of infection, to check your kidney function, and levels of certain chemicals in your blood that may be altered if your kidneys are not working well, and possibly to rule out certain conditions.
• The blood also may be checked for prostate-specific antigen (PSA). This is the same test used to screen men for prostate cancer.
• A sample of the secretions from your penis (men) or vagina (women) may be checked for signs of infection as well.

People with chronic urinary retention or suspected bladder muscle weakness may be referred to a specialist in disorders of the urinary tract (urologist or urogynecologist).

• The urologist may perform advanced urodynamic testing to see what is causing the problem. A urodynamic test is a specialized test used to determine bladder and urethral function. This study involves the placement of a catheter in the urethra, a separate small catheter in the rectum, and electrode patches on the outside area around the urethra and rectum. The bladder is filled with sterile fluid, and pressures within the bladder during filling and urination are measured. Use of contrast material (dye) allows the physician to take pictures during filling of the bladder and voiding, which may help evaluate other abnormalities. The electrode patches allow assessment of the function of the muscles that surround the urethra during bladder filling and urination.
• The urologist also may recommend cystoscopy. A cystoscope is a thin, flexible tube with a tiny camera on the end. It is inserted through the urethra to examine the bladder, urethra, and prostate for abnormalities that can cause urinary retention.

Acute urinary retention requires immediate drainage for relief and thus a visit to your health-care provider or a hospital emergency department. You can try very limited care at home, but do not delay medical evaluation if you are in pain. Try sitting in a bathtub full of warm water to relax the pelvic floor muscles or running the water in the bathroom to stimulate the flow of urine.

Discuss your prescribed medications, as well as any over-the-counter medications that you may be taking with your doctor, to determine if one or more of your medications may be affecting your ability to urinate normally.

People with limited mobility (for example, after a medical illness or a surgery with prolonged recovery period) resulting in an inability to urinate can be encouraged to get up and walk, as this increased activity may facilitate urination.

Management of constipation with fiber supplements, stool softeners, and laxatives as recommended by your doctor may be helpful.

If urinary retention is thought to be acute, severe, or painful, a Foley catheter may be inserted through the urethra into the bladder. This is a small, flexible rubber or silicone tube. Once it has reached the bladder, urine will drain out into a bag and the balloon is inflated to keep the catheter in place.

• The catheter can either be removed immediately or kept in place to provide continuous drainage.
• The decision to remove the catheter will depend on the amount of urine obtained, the cause, and the likelihood that your troubles urinating will come back.
• The normal bladder capacity in adults is about a cup and a half (13.5 oz or 400 ml). If much more urine than this is retained, the catheter may be left in place to allow the bladder to contract to its normal size.
• Sometimes when the retained urine is finally drained, it is bloody or slightly pinkish. This is usually minor and stops on its own in a short time. Your physician will monitor this to make sure it stops.
• The urologist/urogynecologist may recommend clean intermittent catheterization/self-catheterization (CIC) for the short or long term while the physician determines the cause and best form of treatment for the urinary retention. In some cases, if the bladder is no longer functioning adequately, long-term self-catheterization is performed. Self-catheterization involves placing a small catheter through the urethra into the bladder to empty the urine and then removing the catheter at set intervals each day. In those individuals who can urinate some on their own, this is typically performed after urination to ensure that the bladder is completely emptied. The use of a lubricating jelly and/or special lubricated catheters makes the procedure less uncomfortable. Nurses in the clinic often can teach patients how to perform CIC.

If a catheter cannot reach your bladder because of an obstruction in the urethra, an alternative procedure can be tried.

• The most common reason for the obstruction is a narrowing or stricture within the urethra. In this setting, a cystoscopy can often identify the area of narrowing, and a small wire can be passed through the narrowed area, and the area can be dilated with special dilators that pass over the wire and a catheter placed.
• In the situation in which a catheter cannot be placed through the urethra, the catheter can be placed through your skin, over your pubic bone, and through the lower abdominal wall directly into your bladder. This is called the suprapubic route. This procedure is generally performed by urologists. The tube will provide temporary drainage until the situation can be managed via a cystoscopic procedure.

In the last few years, devices have become available that can help some people with chronic urinary retention. For example, an implantable device is available that stimulates the nerves that control the bladder. These devices are typically placed by a urologist and/or urogynecologist for select indications.

There are three types of medications available for treating urinary symptoms in men thought to be related to an enlarged prostate and may be helpful in men with urinary retention secondary to an enlarged prostate (BPH).

The first class of medications (called alpha receptor blockers or alpha-blockers) work by relaxing the muscles at the neck of the bladder, thus reducing the obstruction to the flow of urine. The common medications in this class are terazosin (Hytrin), tamsulosin (Flomax), doxazosin (Cardura), silodosin (Rapaflo), and alfuzosin (Uroxatral). These medications are generally used for treating long-standing obstructive symptoms due to an enlarged prostate, but they may have a role in treating acute obstruction. Some studies have suggested that early initiation of these medications may improve urinary problems upon the removal of a urinary catheter.

Alpha-blockers are also very helpful in individuals with bladder neck dysfunction, a medical condition in which the bladder outlet does not open prior to the bladder contracting. This condition typically requires long-term use of alpha-blockers.

The second class of medications for the treatment of prostate enlargement (called 5-alpha reductase inhibitors) work by shrinking the size of the prostate gland. They inhibit locally (in the prostate) the conversion of testosterone to one of its metabolites which is thought to play a role in increasing prostate size. Finasteride (Proscar) and dutasteride (Avodart) are the two commonly used medications of this type. They are also primarily used to treat long-standing urinary problems due to prostate enlargement. Unlike the other drug class, they play no role in treating acute urinary obstruction because their action of reducing the prostate size may take weeks to months.

The third class of medications for treatment of urinary symptoms related to BPH are PDE-5 inhibitors. Cialis (Sildenafil) is approved for the treatment of BPH symptoms in men. It is not fully known how this medication, which is typically used for troubles with erections, helps with symptoms related to enlargement of the prostate, but studies have shown it as effective as alpha-blockers.

Combination therapy, including an alpha-blocker and a 5-alpha-reductase inhibitor, is useful in men with BPH and appears to be more effective than single drug therapy in preventing progression of symptoms. Combination therapy can be with the use of two separate pills or a single combination pill that contains dutasteride and tamsulosin (Jalyn).

It is important that you review your medical conditions with your provider and discuss the side effects and possible drug interactions of these medications prior to taking them. Prescribing information is available in the brochures provided with medications or you can look it up on the Internet prior to starting the medication.

When a catheter is left in place after the initial treatment, a visit to a medical professional, usually a urologist, within a few days is generally recommended.

• Catheters are a common cause of urinary tract infections and need routine care. If catheters are necessary for long-term treatment, it is advisable to change them on a regular schedule (typically every three to four weeks).
• Either of two types of drainage bags can be hooked up to the catheter. A smaller bag can be strapped to the leg (called a leg bag), allowing normal activity without anyone knowing that a catheter is in place. A larger bag may be used at night to prevent waking up at night to empty it. This larger bag is the one typically seen in hospitalized patients hanging by the bedside.
• Contact your doctor if the catheter stops draining. It is possible that a blood clot, tissue, or debris can plug the catheter. Symptoms of urinary retention can potentially come back and there may be leakage of urine around the catheter. In these situations, the catheter will often require irrigation or replacement.

People with a Foley catheter may experience bladder spasms. The catheter is held in the bladder by a balloon at its tip that is inflated with sterile water after the insertion of the catheter. The catheter and the balloon may irritate the bladder, causing the bladder muscles to contract. This may lead to a spasm, or cramp, in the lower abdomen and sometimes leakage of urine around the catheter. If the spasms and/or leakage is severe, medications can be given to quiet the bladder down.

• If the catheter tubing is accidentally pulled, it may pull the catheter backward into the urethra. If this occurs, the catheter may stop draining and you will need to seek emergent help (either in the ER or with your doctor) with the replacement of the catheter.

Catheter removal is a simple procedure that can be performed in any medical office.

• It is best done in the morning, if possible. This allows for the entire day to resume normal urination.
• If urinary retention continues, the catheter can be replaced later in the day or more commonly, clean intermittent catheterization is taught. With clean intermittent catheterization/self-catheterization, a catheter is placed into the bladder periodically during the day to empty the bladder and then removed. In between the catheterizations, if you have an urge to void, you can do so on your own if you are capable. The use of clean intermittent catheterization decreases some of the complications associated with an indwelling catheter and allows you to determine when your bladder is getting better. How often you will need to catheterize will vary with the amount of urine that you drain when you catheterize.

Depending on the cause of the urinary retention, surgery may be indicated to help resolve the urinary retention. Surgery is commonly performed for urethral strictures, bladder stones, enlarged prostate, bladder prolapse, certain neurologic conditions, pelvic tumors, and other conditions. Whether or not you gain the ability to completely empty your bladder after surgery will depend to some extent on the function of your bladder and its ability to improve function after the blockage is relieved.

Good urination habits are essential to keep the bladder functioning normally. Most people normally urinate four to six times per day. Frequent holding of urination for prolonged periods can weaken bladder muscles because of overstretching. This may not seem like a problem initially, but over the course of 20-30 years, it can cause urination problems. Excess alcohol intake may lead to increased urine production and overdistention of the bladder. Lastly, over-the-counter cold medications containing antihistamines and pseudoephedrine (and other medications like it) can increase the risk of urinary retention in men with prostate enlargement.

The prognosis depends on the source of the problem.

• People with urinary retention caused by obstruction, infection, drugs, or the postoperative state generally recover much more easily than those with a nerve problem. The time frame for recovery varies, however.
• People who continue to have urinary retention despite treatment may need long-term therapy. The best option for long-term therapy is clean, intermittent catheterization/self-catheterization.
• You or your caregiver can be taught how to insert a removable catheter into the bladder to allow urine to drain.
• Catheterization can either be a temporary measure until normal urination returns or be more permanent.
• The other option is placing a Foley catheter into the bladder either via the urethra or through the skin. Tubes will be changed monthly to limit the risk of infection.
• Clean, intermittent catheterization/self-catheterization also remains a treatment option for people who are having troubles urinating over the long term and/or are unable to urinate at all after a trial of an indwelling catheter.