What are the management options for female urinary retention?

Management of Female Urinary Retention

The management of female urinary retention should begin with prompt bladder decompression via catheterization, followed by treatment of the underlying cause, which may include pharmacological therapy, intermittent self-catheterization, or surgical intervention depending on etiology. 1, 2

Initial Management

• Prompt and complete bladder decompression via catheterization is the first step in managing acute urinary retention 1, 3
• Suprapubic catheterization may be superior to urethral catheterization for short-term management, improving patient comfort and decreasing bacteriuria 1, 3
• Silver alloy-impregnated urethral catheters can help reduce urinary tract infections when urethral catheterization is necessary 1

Diagnostic Approach

• Measure post-void residual (PVR) volume to confirm and quantify retention; chronic urinary retention is defined as PVR volume greater than 300 mL measured on two separate occasions and persisting for at least six months 3
• Identify the underlying cause through targeted investigations:
  • Urethral pressure profilometry and sphincter electromyography (EMG) can help diagnose Fowler's syndrome, a common cause of non-obstructive retention in young women 4
  • Pelvic ultrasound to evaluate for pelvic organ prolapse or other anatomical causes 2
  • Urodynamic studies to differentiate between detrusor failure and outlet obstruction 2, 4

Management Based on Etiology

Pharmacological Causes

• Discontinue medications with anticholinergic or alpha-adrenergic agonist properties that may contribute to retention 1, 3
• For postoperative and postpartum non-obstructive urinary retention:
  • Bethanechol (oral) may be used to increase detrusor muscle tone and restore bladder function 5
  • Typical dosing is 10-50 mg orally, with effects usually appearing within 60-90 minutes 5

Neurogenic Causes

• Clean intermittent self-catheterization (CISC) is the cornerstone of management for patients with neurogenic bladder 1, 2
• Low-friction catheters have shown benefit in patients requiring long-term intermittent catheterization 1
• Alpha-blockers have not shown benefit over placebo in female urinary retention and are not recommended 2

Fowler's Syndrome

• Sacral neuromodulation (sacral nerve stimulation) is the only intervention that has been shown to effectively restore voiding in women with Fowler's syndrome 4
• This should be considered in women with confirmed EMG abnormalities of the striated urethral sphincter 4

Obstructive Causes

• Surgical intervention may be required for anatomical causes of obstruction 1, 3
• Urethral dilatation has no proven role in the management of female urinary retention 2

Special Considerations

• Women with apparently idiopathic retention should be referred to a urologist with expertise in bladder dysfunction 2
• For patients with mixed urinary incontinence and retention, treatment should address both components, with careful consideration of how treatments for one condition might affect the other 6
• The retention rate for synthetic slings at the midurethra (used for stress urinary incontinence) is approximately 3%, which is lower than for slings placed at the bladder neck (9-10%) 6

Follow-up Management

• Patients who fail to void after catheter removal should be taught intermittent self-catheterization 2
• Regular follow-up to assess for resolution of retention and complications is essential 3
• Patients with neurological causes should be co-managed with neurology and urology specialists 3

Common Pitfalls to Avoid

• Assuming female urinary retention is psychogenic without thorough investigation of organic causes 2, 4
• Prolonged indwelling catheterization without a plan for definitive management 1, 3
• Using alpha-blockers for female urinary retention, as they have not shown benefit over placebo 2
• Performing urethral dilatation, which has no proven role in management 2