What is the appropriate workup for a patient with sudden onset urinary retention and incontinence?

Workup for Sudden Onset Urinary Retention and Incontinence

The initial workup for sudden onset urinary retention and incontinence should include assessment of bladder residuals through bladder scanning or intermittent catheterization, urinalysis, and evaluation for neurological causes. 1

Initial Assessment

Immediate Evaluation

• Measure post-void residual (PVR) volume:
  • Bladder scan (non-invasive)
  • Intermittent catheterization if bladder scan unavailable 1
  • PVR >50-100ml suggests significant retention 2
• Urinalysis to rule out infection or hematuria
• Focused neurological examination
• Medication review for anticholinergics, alpha-adrenergic agonists, and other medications that may affect bladder function 3

Physical Examination

• Abdominal exam for distended bladder
• Genital/rectal examination:
  • In men: prostate size, tenderness (prostatitis)
  • In women: pelvic organ prolapse, vaginal atrophy
  • Perineal sensation and tone
• Neurological assessment:
  • Lower extremity strength and sensation
  • Perineal/perianal sensation
  • Bulbocavernosus reflex
  • Anal sphincter tone 1

Specialized Testing

Urodynamic Studies

• Uroflowmetry to assess:

  • Flow rate pattern (obstructive vs. underactive detrusor)
  • Voiding time
  • Maximum flow rate 1, 2

• Multichannel filling cystometry when:

  • Diagnosis remains unclear after initial assessment
  • Need to determine presence of detrusor overactivity
  • Need to assess bladder compliance 1

• Pressure flow studies to:

  • Differentiate between bladder outlet obstruction and detrusor underactivity
  • Particularly important before considering invasive treatments 1, 2

Imaging

• KUB (kidney, ureter, bladder) X-ray if:
  • History of recent urological procedures
  • Suspected stent migration or stone disease 4
• Consider additional imaging (ultrasound, CT) if:
  • Suspected neurological cause
  • Pelvic pathology
  • Recurrent/persistent symptoms despite initial management

Special Considerations

For Stroke Patients

• Assessment of bladder function is essential in acute stroke patients
• Consider removal of indwelling catheters within 48 hours to reduce infection risk
• Use silver alloy-coated catheters if catheterization is necessary 1

For Women with Pelvic Organ Prolapse

• Perform stress testing with and without prolapse reduction
• Assess if retention is due to detrusor underactivity or outlet obstruction 1

For Patients with Neurological Conditions

• More comprehensive neurological workup may be needed
• PVR assessment should be part of both initial evaluation and ongoing follow-up 2

Pitfalls to Avoid

• Don't assume incontinence is always due to overactive bladder; it may be overflow incontinence from retention
• Don't overlook medication side effects as potential causes
• Don't miss neurological causes that may require urgent intervention
• Don't forget to check for stent migration in patients with recent urological procedures 4
• Remember that absence of detrusor overactivity on a single urodynamic study doesn't exclude it as a cause 1

By following this systematic approach to the workup of sudden onset urinary retention and incontinence, clinicians can identify the underlying cause and implement appropriate management strategies to improve patient outcomes.