Urinary retention is a pathological condition characterized by a violation or impossibility of normal emptying of the bladder. Symptoms are pain in the pubic region and lower abdomen, very strong persistent urge to urinate and the resulting psychomotor agitation of the patient, a noticeable weakening of urine excretion or its absence. Diagnosis is based on a patient’s survey, the results of a physical examination, ultrasound methods are used to determine the causes of the condition. Treatment – catheterization or cystostomy to ensure the outflow of urine, elimination of etiological factors of ischuria.
ICD 10
R33 Urinary retention
Meaning
Urinary retention (ischuria) is a fairly common condition that accompanies a significant number of different urological pathologies. Young men and women suffer from it about the same way, as the age increases, male patients begin to prevail. This is due to the influence of prostate pathologies, which are usually determined in the elderly and are often manifested by urination disorders. Approximately 85% of all cases of ischuria in men over 55 years of age are caused by prostate problems. Urinary retention rarely occurs in isolation, more often it is part of a symptom complex caused by urological, neurological or endocrine pathologies.
Causes
Urinary retention is not an independent disease, it is always a consequence of various pathologies of the excretory system. It should be distinguished from another condition, also characterized by the absence of urine excretion – anuria. The latter occurs due to kidney damage, leading to a complete absence of urine formation. When urination is delayed, fluid forms and accumulates inside the bladder cavity. This difference causes a different clinical picture, similar only in the volume of diuresis. The main reasons that prevent the normal discharge of urine are considered to be:
- Mechanical blockage of the urethra. The most common and diverse group of causes that cause ischuria. This includes strictures of the urethra, its obturation by a stone, a tumor, blood clots, severe cases of phimosis. Neoplastic and edematous processes in nearby structures – mainly the prostate gland (adenoma, cancer, acute prostatitis) can also cause blockage of the urethra.
- Dysfunctional disorders. Urination is an active process, for the normal provision of which an optimal contractility of the bladder is necessary. In certain conditions (dystrophic changes in the muscular layer of the organ, innervation disorders in neurological pathologies), the contraction process is disrupted, which leads to fluid retention.
- Stress and psychosomatic factors. Some forms of emotional stress can lead to ischuria due to inhibition of reflexes that ensure the process of urination. This phenomenon is especially often observed in people with mental disorders or after severe shocks.
- Medicinal ischuria. A special type of pathological condition caused by the action of certain medications (narcotic drugs, hypnotics, cholinergic receptor blockers). The mechanism of development of urinary retention is complex, due to the complex effect on the central and peripheral nervous system and the contractility of the bladder.
Pathogenesis
Pathogenetic processes in different variants of urinary retention differ. The most common and studied is mechanical ischuria, due to the presence of an obstacle in the lower urinary tract. These may be cicatricial constrictions (strictures) of the urethra, severe phimosis, urolithiasis with the release of concretion, prostate pathology. After some manipulations on the bladder (operations, mucosal biopsy) or bleeding, blood clots form in the urine, which can also obstruct the lumen of the urethra and prevent the outflow of urine. Strictures, phimoses, and prostate pathologies usually lead to slowly progressive ischuria, whereas when a concretion or blood clot exits, the delay occurs abruptly, sometimes at the time of urination.
A more complex pathogenesis of urinary excretion disorders is characterized by dysfunctional disorders of the urinary tract. There are no obstacles to the outflow of fluid, however, due to a violation of contractility, the emptying of the bladder occurs weakly and not completely. Violations of innervation can also affect the urethral sphincters, as a result of which the process of their disclosure, necessary for urination, is disrupted. Stressful, pharmacological variants of this pathology are similar in their pathogenesis – they arise reflexively due to disorders in the central nervous system. There is a suppression of natural reflexes, one of the manifestations of which is ischuria.
Classification
There are several clinical variants of urinary retention that differ in the suddenness of development and duration of the course.
- Acute delay. It is characterized by a sudden abrupt onset, most often due to mechanical causes – obstruction of the urethra by a stone or a blood clot, sometimes a neurogenic variant of the condition is possible.
- Chronic delay. It usually develops gradually against the background of urethral strictures, prostate diseases, dysfunctions, bladder tumors, urethra.
- Paradoxical ischuria. A rare variant of the disorder, in which, against the background of filling the bladder and the impossibility of arbitrary urination, there is a constant uncontrolled release of a small amount of fluid. It can be of mechanical, neurogenic or medicinal etiology.
There is a less common and more complex classification of urinary retention based on their relationship with other diseases of the excretory, nervous, endocrine or reproductive systems. But, given the fact that ischuria is almost always a symptom of some disorder in the body, the relevance and validity of such a system remains in question.
Urinary retention symptoms
Any type of ischuria is usually preceded by manifestations of the underlying disease – for example, renal colic caused by the release of a stone, pain in the perineum associated with prostatitis, urination disorders due to strictures, etc.
Acute urinary retention
Acute delay begins abruptly, an extreme option is a situation when the jet is interrupted during urination, further outflow of urine becomes impossible. This is how ischuria can manifest itself with urolithiasis or obstruction of the urethra by a blood clot – the foreign body shifts along with the fluid flow and blocks the lumen of the canal. In the future, there is a feeling of heaviness in the lower abdomen, strong urge to urinate, pain in the groin area.
Chronic urinary retention
Develops, as a rule, gradually. Initially, patients may experience a decrease in urine volume, a feeling of incomplete emptying of the bladder and frequent urges associated with this circumstance.
In the absence of progression of the causes causing chronic ischuria, symptoms may weaken, however, studies show the retention of residual urine after each emptying, against this background, inflammation of the bladder mucosa (cystitis) often occurs, which can be complicated by pyelonephritis. The full variety of chronic urinary retention differs from acute only by the period of catheterization of the patient. In almost any form of delay, its first difference from anuria is the excited psychoemotional state of the patient, due to the inability to urinate.
Complications
The delay of urination in the prolonged absence of qualified help leads to an increase in fluid pressure in the overlying parts of the urinary system. In acute forms, this can cause the phenomena of hydronephrosis and acute renal failure, in chronic forms – CRF. Stagnation of residual urine facilitates infection of tissues, therefore, the risks of cystitis and pyelonephritis increase.
In addition, with significant volumes of lingering urine, conditions are created in it for the crystallization of salts and the formation of bladder stones. As a result of this process, the transformation of chronic incomplete delay into acute and complete. A relatively rare variant of the complication is the formation of a diverticulum of the bladder – the protrusion of its mucosa through defects in other layers due to high pressure in the organ cavity.
Diagnostics
Usually, the diagnosis of “ischuria” does not cause any special difficulties for a urologist, a routine survey of the patient, an examination of the suprapubic and inguinal areas is enough. Additional research methods (ultrasound diagnostics, cystoscopy, contrast radiography) are required to determine the severity and causes of the pathological condition, the choice of effective etiotropic therapy. In patients with chronic variants of ischuria, auxiliary diagnostics is used as a monitoring of the progression of pathology and timely detection of complications of urinary retention. The following diagnostic methods are used in the vast majority of patients:
- Survey and inspection. Almost always they allow to determine the presence of acute urinary retention – patients are restless, complain of a strong desire to urinate and pain in the lower abdomen. When palpation of the suprapubic region is determined by a dense filled bladder, in lean patients, bulging may be noticeable from the side. Chronic incomplete varieties of the disorder often proceed asymptomatically, there are no complaints.
- Ultrasound diagnostics. In acute conditions, ultrasound of the bladder, prostate, urethra allows you to determine the cause of the pathology. A stone is defined as a hyperechoic formation in the lumen of the urethra or in the neck of the bladder, but blood clots are not detected by most ultrasound machines. Ultrasound examination of the urethra, prostate gland allows you to diagnose strictures, adenomas, tumors and inflammatory edema.
- Neurological research. Consultation of a neurologist may be required if there are suspicions of neurogenic or psychosomatic causes of ischuria.
- Endoscopic and radiopaque techniques. Cystoscopy helps to determine the cause of the delay – to identify a stone, blood clots and their source, strictures.
Differential diagnosis is performed with anuria, a condition in which urine excretion by the kidneys is disrupted. With anuria, patients have no or sharply weakened urge to urinate, there are manifestations of acute or chronic renal failure. Instrumental diagnostics confirms the absence or extremely small amount of urine in the bladder cavity.
Treatment
There are two main stages of therapeutic measures for ischuria: emergency provision of normal urine outflow and elimination of the causes that caused the pathological condition. The most common method of restoring urodynamics is catheterization of the bladder – the installation of a urethral catheter, which is used to drain fluid.
In some conditions, catheterization is impossible – for example, with pronounced phimoses and strictures, tumor lesions of the urethra and prostate gland, “injected” concretion. In such cases, cystostomy is resorted to – the formation of surgical access to the bladder and the installation of a tube through its wall, output to the anterior surface of the abdomen. If the neurogenic and stressful nature of ischuria is suspected, conservative methods of restoring the outflow of urinary fluid can be used – turning on the sound of running water, washing the genitals, injections of M-cholinomimetics.
The treatment of the causes that caused the delay in urination depends on their nature: for urolithiasis, crushing and extraction of concretion is used, for strictures, tumors and prostate lesions – surgical correction. Dysfunctional disorders (for example, the hyporeflective type of neurogenic bladder) require complex complex therapy with the participation of urologists, neuropathologists and other specialists. If the cause of ischuria is taking medications, it is recommended to cancel them or correct the drug therapy regimen. Urinary retention on the background of stress can be eliminated by taking sedatives.
Prognosis and prevention
In most cases, the prognosis of urinary retention is favorable. In the absence of medical care, acute variants of pathology can provoke bilateral hydronephrosis and acute renal failure. With timely elimination of the causes that caused this condition, recurrences of ischuria are extremely rare.
With chronic variants, the risk of infectious and inflammatory diseases of the urinary tract and the appearance of concretions in the bladder increases, therefore patients should be regularly monitored by a urologist. Prevention of urinary retention is the timely detection and proper treatment of pathologies that cause this condition – urolithiasis, strictures, prostate diseases and a number of others.
