What is the recommended initial management and treatment for a 1½‑year‑old child presenting with acute urinary retention?

Management of Acute Urinary Retention in a 1.5-Year-Old Child

Immediate bladder decompression with urethral catheterization is the first-line treatment, followed by urgent investigation to identify the underlying cause—most commonly urinary tract infection (26.9%), constipation (13%), or obstructive lesions (19%)—and then treat the specific etiology. 1, 2

---

Immediate Emergency Management

Step 1: Bladder Decompression

• Insert a urethral catheter immediately to relieve retention and prevent bladder injury or renal complications. 1, 3
• If urethral catheterization fails (due to urethral obstruction or severe phimosis), perform suprapubic bladder decompression using a wide-bore cannula as a temporizing measure. 4
• Measure the residual volume; retention is defined as inability to void for >12 hours with bladder volume exceeding expected capacity: (age in years + 2) × 30 mL = approximately 105 mL for a 1.5-year-old. 2

Step 2: Obtain Urine for Culture

• Collect urine via the catheter for urinalysis and culture before starting antibiotics, as UTI accounts for 26.9% of pediatric acute urinary retention cases. 1, 5
• Diagnosis of UTI requires both pyuria (≥5 WBC/HPF or positive leukocyte esterase) and ≥50,000 CFU/mL of a single uropathogen. 5, 6

---

Diagnostic Workup to Identify the Cause

History and Physical Examination Priorities

• Assess for fever, irritability, feeding difficulties, and vomiting to identify possible UTI or systemic infection. 5
• Document bowel habits and palpate the abdomen for fecal impaction, as constipation causes 13% of pediatric urinary retention. 2, 1
• Examine the external genitalia for phimosis, meatal stenosis, labial adhesions, or urethral foreign body; palpate the penile urethra for an impacted stone (which can be felt in 63% of anterior urethral stones). 2, 4
• Check for suprapubic or costovertebral angle tenderness to localize infection. 5
• Perform a focused neurological examination (lower extremity tone, reflexes, perineal sensation) because neurological causes account for 6.4–17% of cases. 2, 1

Laboratory and Imaging Studies

• Obtain a complete urinalysis with microscopy and urine culture (already collected via catheter). 5
• Order renal and bladder ultrasound urgently to detect hydronephrosis, bladder wall thickening, posterior urethral valves, urethral stones, pelvic masses, or spinal cord abnormalities. 5, 6
• If no clear cause is identified on history, exam, and ultrasound, proceed with prompt neurological evaluation and spinal MRI to rule out occult spinal dysraphism, tethered cord, or spinal cord tumor. 2

---

Treatment Based on Identified Etiology

If UTI is Confirmed (26.9% of Cases)

• Start empiric antibiotics immediately after obtaining culture: oral amoxicillin-clavulanate (40–45 mg/kg/day divided every 12 hours) or cefixime (8 mg/kg once daily) for 7–14 days (10 days most common). 5
• For toxic-appearing infants or those unable to tolerate oral intake, use parenteral ceftriaxone 50 mg/kg IV/IM once daily, then transition to oral therapy. 5, 6
• Obtain renal and bladder ultrasound during or shortly after hospitalization to detect anatomic abnormalities. 6
• Consider VCUG after a second febrile UTI or if ultrasound shows hydronephrosis or scarring. 5, 6

If Constipation is Identified (13% of Cases)

• Initiate aggressive bowel management with disimpaction using oral polyethylene glycol (1–1.5 g/kg/day) or glycerin suppositories, followed by maintenance laxative therapy. 5, 7
• Implement timed voiding and adequate fluid intake to prevent recurrence. 7

If Obstructive Lesion is Found (19% of Cases)

• For urethral stones impacted at the meatus: perform meatotomy in the emergency setting. 4
• For stones in the penile urethra: perform suprapubic bladder decompression first, then urethrolithotomy. 4
• For stones in the bulbous or posterior urethra: push the stone back into the bladder and remove via suprapubic vesicolithotomy on an elective basis. 4
• For posterior urethral valves or other structural obstructions: urgent pediatric urology consultation for definitive surgical management. 5

If Neurological Cause is Suspected (6.4–17% of Cases)

• Obtain urgent spinal MRI to evaluate for tethered cord, spinal dysraphism, tumor, or transverse myelitis. 2, 1
• Consult pediatric neurology and urology for further management, which may include intermittent catheterization or surgical intervention. 2

If Idiopathic (14.6% of Cases)

• Maintain catheter drainage for 24–48 hours, then attempt trial of voiding. 1
• If retention recurs, perform comprehensive neurological and urological evaluation including uroflow studies and spinal imaging. 2, 1

---

Follow-Up and Monitoring

• Clinical reassessment within 1–2 days after catheter removal to confirm the child is voiding spontaneously and fever (if present) has resolved. 5, 6
• Instruct parents to seek prompt evaluation (within 48 hours) for any future febrile illness to detect recurrent UTI early. 5
• Monitor for recurrence of retention, which occurs in a subset of cases and may indicate an underlying chronic condition requiring long-term management. 1

---

Critical Pitfalls to Avoid

• Do not delay bladder decompression, as prolonged retention can cause bladder injury, hydronephrosis, and renal impairment. 3
• Do not assume the cause is benign without thorough investigation; 17% of pediatric urinary retention cases have a neurological etiology. 2
• Do not use bag-collected urine for culture in this age group; it has an 85% false-positive rate. 5
• Do not treat empirically for UTI without obtaining urine culture first, as this is the only opportunity for definitive diagnosis. 5
• Do not discharge the child without ensuring spontaneous voiding has resumed and a clear follow-up plan is in place. 1