Can tramadol (ultram) cause urinary retention?

Tramadol and Urinary Retention

Yes, tramadol can cause urinary retention, particularly in the early course of treatment, occurring in approximately 25% of patients, especially in postoperative settings. 1

Mechanism and Risk Factors

Tramadol, as an opioid medication, can affect bladder function through its effects on the central nervous system. The 2023 ASCO guidelines on opioid use for pain management specifically mention urinary retention as a known adverse effect of opioids, including tramadol 1. This effect occurs through:

• Increased tone of the bladder sphincter
• Impaired detrusor muscle function
• Central nervous system effects on micturition pathways

Risk factors that increase the likelihood of tramadol-induced urinary retention include:

• Advanced age (especially in men with benign prostatic hyperplasia) 1
• Postoperative setting (more frequent after neuraxial delivery) 1
• Polypharmacy with other medications affecting urination 1
• Pre-existing urological conditions

Evidence and Clinical Presentation

Multiple case reports have documented urinary retention with tramadol use, even at standard therapeutic doses (150 mg or less daily) 2. The Netherlands Pharmacovigilance Foundation reported five cases of transient impairment of micturition or urinary retention that occurred in temporal association with tramadol use and resolved promptly after discontinuation 2.

Urinary retention can present as:

• Acute inability to void
• Difficulty initiating urination
• Sensation of incomplete bladder emptying
• Overflow incontinence in severe cases

Management Approaches

For patients experiencing tramadol-induced urinary retention, the ASCO guidelines recommend a stepwise approach 1:

1. Rule out other causes, especially spinal cord compression
2. Review medications and modify regimen if feasible
3. Catheterization in acute cases
4. Consider medication adjustments:
   • Tamsulosin has been reported beneficial in postoperative opioid-induced retention
   • Consider rotating to a synthetic opioid (e.g., fentanyl)
   • Consider methylnaltrexone or low-dose naloxone (0.25 mg/kg/h) infusion

Prevention and Special Considerations

For patients at high risk of urinary retention (elderly males with prostatic hyperplasia, history of urinary issues):

• Start with lower doses of tramadol
• Monitor for early signs of urinary difficulties
• Consider prophylactic tamsulosin in high-risk postoperative patients
• Avoid combining tramadol with other medications known to cause urinary retention

In patients with renal impairment, tramadol should be used with caution or avoided if possible, as recommended by ASCO guidelines 1. This is particularly important since urinary retention can further complicate renal function.

Conclusion

Clinicians should be aware that urinary retention is a recognized adverse effect of tramadol, particularly early in treatment and in high-risk populations. Proper monitoring and prompt intervention can minimize complications from this side effect.