What is the best approach to manage urine retention in a patient with ankylosing spondylitis (Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Disease-Modifying Antirheumatic Drugs (DMARDs) treated)?

Management of Urine Retention in Ankylosing Spondylitis Patients

Urine retention in ankylosing spondylitis patients requires immediate urological evaluation to identify the underlying cause, with particular attention to medication-induced retention from NSAIDs or opioid analgesics, cauda equina syndrome (a rare but serious AS complication), or unrelated urological pathology—while continuing AS-directed therapy unless specific medications are implicated.

Immediate Assessment and Urological Evaluation

The first priority is determining whether urine retention is related to AS complications, medication side effects, or independent urological disease. 1

• Evaluate for cauda equina syndrome, a rare but devastating complication of AS that can present with urinary retention, saddle anesthesia, lower extremity weakness, and bowel dysfunction 1
• If significant changes in disease course occur, consider non-inflammatory causes including spinal fracture or neurological complications, requiring appropriate imaging evaluation 1
• Assess current medication regimen for drugs that can precipitate urinary retention, particularly opioid analgesics and anticholinergic agents 1

Medication Review and Adjustment

NSAIDs themselves rarely cause urinary retention directly, but their renal effects and use of adjunctive medications require careful consideration. 1

NSAID Management

• Continue NSAIDs as first-line therapy for AS symptoms unless contraindicated by acute renal dysfunction 1
• Monitor renal function closely, as NSAIDs carry renal risks that could complicate urinary retention management 1
• Consider switching between NSAIDs or adjusting to continuous versus on-demand dosing based on disease activity 1

Analgesic Considerations

• Discontinue or minimize opioid analgesics if currently prescribed, as these are known to cause urinary retention and are only recommended for residual pain after other treatments have failed 1
• Paracetamol may be considered as an alternative analgesic with lower risk of urinary retention 1

DMARD Continuation

• Continue sulfasalazine or methotrexate if prescribed for peripheral arthritis, as these do not cause urinary retention and should not be discontinued 1
• DMARDs have no efficacy for axial disease but are not implicated in urinary retention 1

Neurological Evaluation for AS-Specific Complications

Cauda equina syndrome, though rare in AS (occurring in <1% of patients), is a surgical emergency requiring urgent neurosurgical consultation. 1

• Perform detailed neurological examination including perineal sensation, rectal tone, and lower extremity motor/sensory function 1
• Obtain urgent MRI of the lumbosacral spine if cauda equina syndrome is suspected 1
• Consult spinal surgery immediately if acute vertebral fracture or cauda equina compression is identified 1

Multidisciplinary Collaboration

Management requires coordination between rheumatology and urology, with potential neurosurgical involvement. 1

• Collaborate with urologists for catheterization, post-void residual measurement, and urodynamic studies as indicated 1
• Extra-articular manifestations and comorbidities should be managed with respective specialists 1
• The rheumatologist should coordinate overall care while addressing the urological complication 1

Continuation of AS-Directed Therapy

Do not discontinue effective AS therapy unless specific medications are directly implicated in urinary retention. 1, 2

• Continue anti-TNF therapy if patient is currently receiving it, as biologics do not cause urinary retention and discontinuation leads to disease flares in 60-74% of patients 2
• Maintain physical therapy and exercise programs as these are cornerstone non-pharmacological treatments 1
• Regular disease monitoring should continue according to individual patient needs 1

Common Pitfalls to Avoid

• Do not assume urinary retention is AS-related without excluding common urological causes (benign prostatic hyperplasia in men, pelvic floor dysfunction, etc.) 1
• Do not discontinue NSAIDs reflexively, as they are first-line therapy and rarely cause urinary retention directly 1
• Do not delay neurosurgical evaluation if cauda equina syndrome is suspected, as permanent neurological damage can occur within hours 1
• Do not stop DMARDs or biologics without clear evidence they are contributing to the problem, as this will lead to AS disease flare 1, 2