What is the management of acute urinary retention in a woman?

Management of Acute Urinary Retention in Women

Immediate catheterization is the first-line management for acute urinary retention in women, followed by investigation and treatment of the underlying cause. 1, 2

Initial Assessment and Management

• Obtain a detailed history including assessment of lower urinary tract symptoms (dysuria, frequency, urgency, nocturia, incontinence, hematuria) and risk factors for urinary retention 3
• Perform physical examination including abdominal and pelvic examination to identify structural abnormalities such as vaginal atrophy and pelvic organ prolapse 3
• Immediate bladder drainage via urethral catheterization is the primary intervention to relieve discomfort and prevent complications 4, 5
• If urethral catheterization is difficult, consider obtaining a catheterized specimen to avoid contamination 3
• For cases where urethral catheterization fails, suprapubic catheterization may be necessary 5

Diagnostic Evaluation

• Obtain urinalysis and urine culture to rule out infection as a cause of retention 3, 6
• Perform pelvic and renal ultrasound as baseline investigations to assess for structural abnormalities 6
• Cystoscopy and upper tract imaging should not be routinely obtained in uncomplicated cases 3
• Consider urodynamic testing in specific situations where the cause remains unclear after initial evaluation 6

Common Etiologies in Women

Acute urinary retention in women can be categorized into several groups:

• Structural causes: Pelvic organ prolapse, urethral stenosis, post-surgical complications 6, 5
• Neurological causes: Multiple sclerosis, spinal cord injury, Fowler's syndrome 4, 6
• Infectious causes: Urinary tract infection, herpes genitalis 6
• Pharmacological causes: Anticholinergics, opioids, alpha-adrenergic agonists 6
• Functional causes: Detrusor underactivity, dysfunctional voiding 4

Treatment Approach

1. Immediate management:

   • Bladder drainage via catheterization 2, 5
   • Monitor for post-obstructive diuresis and hematuria as potential complications 5

2. Treatment of underlying causes:

   • For infectious causes: Appropriate antimicrobial therapy based on culture results 3
   • For medication-induced retention: Discontinue or modify causative medications 6
   • For pelvic organ prolapse: Consider pessary placement or surgical correction 5
   • For urethral stenosis: Limited role for urethral dilatation 4, 6

3. Follow-up management:

   • If retention persists after catheter removal, teach intermittent self-catheterization 4
   • Alpha-blockers are not effective for female urinary retention (no better than placebo) 4
   • Avoid labeling symptoms as "psychogenic" without thorough evaluation 6

Special Considerations

• Unlike in men, prostatic enlargement is not a cause of urinary retention in women, making the etiology often more complex 5
• Detrusor failure rather than outlet obstruction is often the underlying abnormality in women 4
• Fowler's syndrome (primary disorder of urethral sphincter relaxation) represents a challenging clinical scenario requiring specialized management 6
• Urethral dilatation has a limited role and should only be considered in cases of confirmed urethral stenosis 4, 6

Complications of Untreated Urinary Retention

• Decreased kidney function 5
• Long-term detrusor hypocontractility 5
• Urinary tract infection 6
• Bladder distension and potential injury 2

Referral Criteria

• Patients with apparently idiopathic retention should be referred to a urologist with expertise in bladder dysfunction 4
• Consider referral for urodynamic testing when the cause remains unclear after initial evaluation 6
• Persistent retention after treatment of reversible causes warrants specialist consultation 4