URINARY RETENTION
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Current definition and explanatory notes:Urologists commonly subdivide retention episodes by any or all of the following: 1) ability of patient to release any urine (complete or partial); 2) duration (acute or chronic); 3) symptoms (painful or silent); 4) mechanism (obstructive or non-obstructive); 4) urodynamic findings (high or low pressure).
Although acute retention is usually thought of as painful, in certain circumstances pain may not be a presenting feature, for example when due to prolapsed intervertebral disc, post partum, or after regional anaesthesia such as an epidural anaesthetic. The retention volume should be significantly greater than the expected normal bladder capacity. In patients after surgery, due to bandaging of the lower abdomen or abdominal wall pain, it may be difficult to detect a painful, palpable or percussable bladder. Trigger factors, e.g. surgery, UTI, excessive fluid intake or medications, can induce precipitated AUR.
The term chronic urinary retention (CUR) excludes transient voiding difficulty, for example after surgery for stress incontinence, and implies a significant residual urine; a minimum figure of 300mls has been mentioned.
Urinary retention is objectively measured as the volume of either the postvoid residual urine volume (PVR) or the bladder in men who cannot urinate. PVR should be measured by maximum 60 seconds after voiding. There is no actual numerical value or relative increase in the volume of PVR that has been universally accepted or adopted into current practice. The condition of urinary retention is often associated with LUTS, urinary infections and bladder stones. Elevated intravesical pressures may lead to hydronephrosis and renal failure (Negro 2012). CUR may occur in diverse patient populations, including patients with detrusor underactivity, detrusor hyperactivity with impaired contractility or neurogenic bladder conditions and of BOO, both in males and in females.
Abrams et al (1978) were the first to choose a PVR of > 300 mL to define CUR, considering it the minimum volume at which the bladder becomes palpable suprapubically; this seems a widely accepted, although unvalidated, definition of CUR. However, while some investigators have defined CUR as a PVR of > 300 mL (Kaplan 2008), others have defined it as > 400 mL (Ghalayini 2005), or have given it no definite number at all (Thomas 2004). Transabdominal bladder examination has little or no evidence to support its use in diagnosis. There is no consistent evidence that PVR is directly related to the degree of bother (Negro 2012). PVR increases with age (Rule 2005). There is a marked intra-individual variability of PVR (Densmuir 1996).
Old definition:Acute retention of urine is defined as a painful, palpable or percussable bladder, when the patient is unable to pass any urine; chronic urinary retention (CUR) is defined as a non painful bladder, which remains palpable or percussable after the patient has passed urine.
The ICS no longer recommends the term “overflow incontinence”, since this term is considered confusing and lacking a convincing definition.. (Abrams 2002).
Mechanisms:1) obstructive or non-obstructive; 2) high pressure or low pressure, with a cut off of 25 cmH2O (Abrams 1978); the two groups also tended to have different symptoms, the low-pressure group complaining of hesitancy, slow stream, and a feeling of incomplete emptying, while the high pressure group also complained of urgency. An association between upper urinary tract
dilatation and high pressure CUR was noted (O'Reilly 1986, Negro 2012).
Therapies:Many studies suggest that patients in CUR will benefit from disobstructive surgery, whether with TURP or laser prostatectomy, even if the results in terms of IPSS, HRQL, Q max and PVR may be inferior compared with those not in retention. Surgery may be more effective in patients with high-pressure CUR than those with low-pressure CUR, with high-pressure filling patients achieving good bladder emptying by normal detrusor contraction (Abrams 1978, Negro 2012).
Some authors argue that in CUR, in particular with low-pressure retention, there is detrusor underactivity (DUA), and in these cases surgery is no better than catheterization for outcomes (Thomas 2005); Djavan et al . (1997) showed that patients with urinary retention, aged ≥ 80 years, with a retention volume of > 1500 mls, no evidence of instability and maximal detrusor pressure of < 28 cmH2O, are at high risk of treatment failure; he suggested that the detrusor may recover in patients younger than 80 years after surgery, suggesting that prostatectomy should still be performed in this group even if preoperative urodynamics suggest an unfavourable outcome (Negro 2012). Monoski et al. (2006) evaluated the utility of preoperative urodynamics as a predictor of surgery outcome in catheterized men, and found that impaired detrusor contractility (IDC) and detrusor overactivity (DO) helped to predict outcome, and that preoperative IDC is not a contraindication to performing surgery.
Conservative management, in particular clean intermittent self-catheterization (CISC), can be used as an adjuvant to transurethral surgery, to recover bladder function in men with CUR (Ghalayini 2005, Negro 2012).
Recently it has been observed that urodynamics are optional, and although they help predict postoperative symptoms, even men with poor detrusor function will usually void well after surgery; primary CISC is an interesting and underresearched alternative (Negro 2012).
Perspectives and controversies:There is a clear need for standardized internationally accepted definitions of retention to allow both treatment and reporting of outcomes in men with LUTS, and for such definitions to be used by all investigators in future trials (Negro 2012).
The fine threshold between elevated PVR and CUR is unclear and is not necessarily linked to the presence of complications; the lack of a good definition of CUR makes epidemiological studies impossible. The current ICS definition: ‘ a non-painful bladder, which remains palpable or percussable after the patient has passed urine. Such patients may be incontinent ’, is a remnant from a pre-ultrasound era and should probably be reconsidered. From a clinical standpoint, we need to understand which patients may benefit from relief of BOO and clinical studies suggest that an elevated PVR with a weak detrusor is associated with an increased risk of poor outcome after surgery. The critical issue is in detrusor function, something that we usually quantify in terms of pressure rather than in the amount of work the muscle is able to perform. What we really need is a clinical translation of ‘ bladder decompensation', that is a measure in terms of muscle contractility. In patients with an elevated PVR, the clinical question is whether the detrusor muscle still functions
or not. In cases of good contractility, surgery will restore normal voiding dynamics, in cases of a very week detrusor relief of BOO may not improve voiding function (Tubaro 2012).


Resources and References
  • Negro C. L.A., Muir G. H.: Chronic urinary retention in men: How we define it, and how does it affect treatment outcome. BJU Int 2012; 110: 1590 – 1594
  • Abrams PH , Dunn M , George N . Urodynamic fi ndings in chronic retention of urine and their relevance to results of surgery . Br Med J 1978; 2: 1258 – 60
  • Kaplan SA , Wein AJ , Staskin DR , Roehrborn CG , Steers WD . Urinary retention and post-void residual urine in men: separating truth from tradition . J Urol 2008; 180: 47 – 54
  • Ghalayini IF , Al-Ghazo MA , Pickard RS . A prospective randomized trial comparing transurethral prostatic resection and clean intermittent self-catheterization in men with chronic urinary retention . BJU Int 2005; 96: 93 – 7
  • Thomas AW , Cannon A , Bartlett E , Ellis-Jones J, Abrams P. The natural history of lower urinary tract dysfunction in men: the infl uence of detrusor underactivity on the outcome after transurethral resection of the prostate with a minimum 10-year urodynamic follow-up . BJU Int 2004; 93: 745 – 50
  • Rule AD, Jacobson DJ, McGree ME, Girman CJ, Lieber MM, Jacobsen SJ. Longitudinal changes in post-void residual and voided volume among community dwelling men . J Urol 2005; 174: 1317 – 22
  • Dunsmuir WD, Feneley M, Corry DA, Bryan J, Kirby RS. The day-to-day variation (test-retest reliability) of residual urine measurement . Br J Urol 1996; 77: 192 – 3
  • Abrams P , Cardozo L , Fall M et al ., Standardisation Sub-committee of the International Continence Society . The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002 ; 21 : 167 – 78
  • O’ Reilly PH, Brooman PJ, Farah NB, Mason GC. High pressure chronic retention. Incidence, aetiology and sinister implications . B r J Urol 1986; 58: 644 – 6
  • Thomas AW, Cannon A, Bartlett E, Ellis-Jones J, Abrams P. The natural history of lower urinary tract dysfunction in men: minimum 10-year urodynamic follow-up of untreated detrusor underactivity. BJU Int 2005; 96: 1295–300
  • Djavan B, Madersbacher S, Klingler C, Marberger M. Urodynamic assessment of patients with acute urinary retention: is treatment failure after prostatectomy predictable? J Urol 1997; 158: 1829–33
  • Monoski MA, Gonzalez RR, Sandhu JS, Reddy B, Te AE. Urodynamic predictors of outcomes with photoselective laser vaporization prostatectomy in patients with benign prostatic hyperplasia and preoperative retention. Urology 2006; 68: 312–7
  • Tubaro A. Editorial comment to Negro C. L.A., Muir G. H.: Chronic urinary retention in men: How we define it, and how does it affect treatment outcome. BJU Int 2012; 110: 1590 – 1594

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