How should I initially evaluate and manage an 80-year-old man in the emergency department presenting with dizziness, headache, vomiting, and acute urinary retention?

Initial Evaluation and Management of an 80-Year-Old Man with Dizziness, Headache, Vomiting, and Urinary Retention

This patient requires immediate bladder catheterization for acute urinary retention, followed by urgent evaluation for hypertensive emergency and neurological complications, as untreated urinary retention can lead to kidney damage or urosepsis while the combination of headache, vomiting, and dizziness suggests possible hypertensive encephalopathy or increased intracranial pressure. 1, 2, 3

Immediate Priorities

1. Address Acute Urinary Retention First

• Perform immediate bladder catheterization (urethral or suprapubic) to decompress the bladder, as acute urinary retention is a urological emergency that can lead to kidney damage, urosepsis, and compromised renal function if left untreated 2, 3
• Measure post-void residual volume to confirm retention and assess severity 3
• Urinary retention itself can cause systemic symptoms including nausea, vomiting, and altered mental status due to pain and autonomic dysfunction, making it a critical first intervention 2, 3

2. Assess for Hypertensive Emergency

• Measure blood pressure in both arms and document any pressure differences, as this patient's constellation of headache, vomiting, and dizziness raises concern for hypertensive encephalopathy 1
• Perform fundoscopy to look for papilledema, hemorrhages, or exudates that would indicate hypertension-mediated organ damage 1
• Obtain ECG to assess for left ventricular hypertrophy, ischemia, or arrhythmias 1

The rate of blood pressure increase is more important than the absolute value in determining hypertensive emergencies, and emergency symptoms include headache, visual disturbances, and gastrointestinal complaints like nausea and vomiting 1

3. Neurological Assessment

• Assess level of consciousness, focal neurological deficits, and signs of increased intracranial pressure (somnolence, lethargy, cortical blindness) 1
• Focal neurological lesions are rare in hypertensive encephalopathy and should raise suspicion for intracranial hemorrhage or ischemic stroke 1
• Document any seizure activity, as this can occur with hypertensive encephalopathy 1

Essential Diagnostic Studies

Laboratory Analysis

• Obtain complete blood count, comprehensive metabolic panel (creatinine, sodium, potassium), and urinalysis to assess for renal dysfunction, electrolyte abnormalities, and evidence of urinary tract infection 1
• Check lactic dehydrogenase and haptoglobin if concerned about thrombotic microangiopathy 1
• Quantitative urinalysis for protein and urine sediment examination for erythrocytes, leukocytes, and casts 1

Imaging

• Obtain urgent CT head without contrast to exclude intracranial hemorrhage, especially given the combination of headache, vomiting, and difficulty urinating (which may indicate neurological cause of retention) 1, 4
• If CT is negative but clinical suspicion remains high, proceed to MRI with FLAIR imaging to evaluate for posterior reversible encephalopathy syndrome (PRES) or other causes of hypertensive encephalopathy 1
• Consider renal ultrasound to assess for hydronephrosis from urinary retention and evaluate kidney size 1

Differential Diagnosis Framework

Causes Linking All Symptoms

The combination of urinary retention with headache, vomiting, and dizziness suggests several unifying diagnoses:

• Hypertensive emergency with encephalopathy: Severe hypertension can cause both neurological symptoms (headache, vomiting, dizziness) and urinary retention through autonomic dysfunction 1
• Neurological causes of urinary retention: Meningitis-retention syndrome, acute spinal cord pathology, or sacral nerve involvement can cause retention plus systemic symptoms 4, 5
• Medication effects: Anticholinergics, sympathomimetics, or other drugs can cause both urinary retention and CNS symptoms 1, 3

Isolated Urinary Retention Causes in Elderly Men

• Benign prostatic hyperplasia (most common) 3, 6
• Urethral stricture 2
• Medications (anticholinergics, sympathomimetics, opioids) 3
• Neurogenic bladder from diabetes, Parkinson's, or other neurological conditions 4

Management Algorithm

If Blood Pressure is Markedly Elevated (>180/120 mmHg with symptoms)

• Initiate controlled blood pressure reduction with IV antihypertensives, targeting 10-15% reduction in the first hour, then gradual reduction over 24-48 hours 1
• Avoid excessive rapid blood pressure lowering, as this can worsen cerebral perfusion in the setting of impaired autoregulation 1
• Admit to intensive care unit for continuous monitoring 1

If Neurological Cause Suspected

• Obtain lumbar puncture if meningitis-retention syndrome is suspected (after ruling out increased intracranial pressure with imaging), looking for elevated myelin basic protein or infectious etiologies 5
• Urodynamic studies may show detrusor areflexia in neurological causes of retention 5
• Neurology consultation for further evaluation 4, 5

Post-Catheterization Management

• Initiate alpha-1 adrenergic receptor blocker (e.g., tamsulosin) before trial without catheter (TWOC), as meta-analysis shows superiority over placebo in achieving successful voiding 6
• Plan catheterization duration of <3 days to minimize catheter-related complications 6
• Consider suprapubic catheter if prolonged catheterization anticipated, as it may provide advantages over indwelling urethral catheter 6

Critical Pitfalls to Avoid

• Do not delay bladder decompression while pursuing other diagnostic studies, as prolonged retention causes bladder injury and can precipitate renal failure 2, 3
• Do not assume urinary retention is simply benign prostatic hyperplasia in an elderly man with neurological symptoms—always consider neurological causes including meningitis, spinal cord pathology, or sacral nerve involvement 4, 5
• Do not attribute all symptoms to urinary tract infection without confirming pyuria and specific urinary symptoms (dysuria, frequency, urgency), as asymptomatic bacteriuria is common in elderly patients and should not be treated 7, 8
• Do not perform emergency prostate surgery—alpha-blockers and trial without catheter should be attempted first, with surgery reserved for failed medical management 6
• Do not miss hypertensive encephalopathy by focusing solely on urinary retention—the combination of headache, vomiting, and dizziness demands urgent blood pressure assessment and neurological evaluation 1

Disposition

• Admit all patients with acute urinary retention plus systemic symptoms for observation, catheter management, and evaluation of underlying cause 3
• ICU admission is indicated if hypertensive emergency, altered mental status, or hemodynamic instability present 1
• Urology consultation for definitive management of urinary retention 3, 6