British Journal of Urology (1976), 47, 793-796 0

Acute Urinary Retention in the Female

J. DORAN

and

MICHAEL ROBERTS

Department of Urology, Royal Infirmary, Bristol

A review of the literature reveals little about the incidence and aetiology of acute urinary retention in the female. Traditional textbook opinion would suggest that it is a very rare phenomenon, the commonest causes being gynaecological problems, neurogenic bladder and hysteria. An originally retrospective and subsequently prospective survey was undertaken in the Bristol Clinical Area in the years 1972, 1973 and 1974 in an attempt to uncover the true incidence and aetiology of the condition. The criteria for inclusion in the survey were that the retention was painful, acute in onset and that on catheterisation less than 1 litre of urine was obtained. These strict criteria were used in order to exclude doubtful cases of chronic retention. Despite the rigid application of the criteria defined above and the difficulties involved in collecting cases from several centres the survey revealed 103 cases. After exclusion of those occurring postoperatively (25) and post-partum (33) there were 45 cases, all of whom had been admitted to hospital because of their retention. These cases fall naturally into 5 groups when considering the causes of the retention (Table I) and these groups have been analysed in further detail.

Table I
Aetiology of Acute Urinary Retention in 103 Female Patients in Bristol Clinical Area 1972-74
Cause Postoperative Post-partum Others 1. Gynaecological 2. Urological 3. Neurological 4. Psychiatric 5. Rectal

No. of patients
25 33 45 17 15

I
3 3

Gynaecological

The importance of intrapelvic tumours as causative agents in acute urinary retention has been stressed previously (Ward, Lavengood and Draper, 1968) and is confirmed in this series (Table 11). The diagnosis will usually be obvious if a thorough pelvic and bimanual examination is performed and this is therefore essential. A pelvic mass causes retention either by exerting extrinsic pressure on the bladder neck or urethra, or by overstretching these structures, and the same mechanisms are probably responsible for retention, secondary to procidentia and vulva1haematoma All the patients in this group recovered normal micturating habits following treatment or resolution of the precipitating factor.
793

794

BRITISH JOURNAL OF UROLOGY

Table I1 Gynaecological Causes

Cause Fibroids Gravid retroverted uterus Retroverted uterus Ovarian cyst Pessary Procidentia Vulva1 haematoma

No. of patients
5 4 2 1 1 2 2

Urological
15 patients were judged to have retention secondary to abnormalities in the urinary tract (Table 111). At endoscopy, 7 were found to have definite obstructive lesions-2 believed to be at the bladder neck and 5 in the urethra. The diagnosis of bladder neck obstruction in the female is difficult but in both these patients the acute urinary retention was associated with a normal calibre urethra, a trabeculated bladder and in each case responded dramatically to transurethral resection of the bladder neck. A further 7 have been classified as inflammatory and these all had heavily infected urine on presentation. At endoscopy, 5 of these had trabeculation of the bladder wall and a 6th had a normal lower tract. 1 patient was not endoscoped. The one iatrogenic case was a woman in whom a gracilis sling had been fashioned. Return to normal micturition was obtained following resection of the bladder neck in the cases with obstruction at this level. The patients with urethral stenoses underwent urethral dilatation and were less successfully treated, in that 4 out of the 5 have required subsequent dilatation. Antibiotics were given to the inflammatory group and all were able to micturate normally following removal of the urethral catheter. None of this group has required further treatment. The woman with the gracilis sling has subsequently had urinary diversion into an ileal conduit.

Neurological The presence of 7 cases in this group (Table IV) underlines the importance of full neurological assessment of the patient presenting with acute urinary retention. Table III Urological Causes
Cause Bladder neck Obstruction Urethra Inflammatory Iatrogenic
5

No. of patients.

I
1

ACUTE URINARY RETENTION IN THE FEMALE

795

Table IV
Neurological Causes
Cause Disseminated sclerosis Traumatic paraplegia Sacral agenesis Cerebral metastasis Parkinsonism Senile dementia
No. of patients.
2 1 1 1 1 1

In only 2 cases was the neurological condition known to exist at the time of presentation. Considerable concern is caused by the initial diagnosis of hysterical retention in 2 of the patients in this group. The dangers inherent in the placing of a label of hysteria on females with urinary retention have been forcibly commented on by previous authors (Emmett and Love, 1968; Ivanovici, 1970) and are again found to be very real. It is also of interest that these neurological lesions can produce an acute as well as a chronic urinary retention.

Psychiatric
In 3 patients no organic cause was found for the retention of urine despite thorough general, pelvic and neurological investigation. 2 of these patients were children with profoundly disturbed home backgrounds and the third was a woman of 56 years with severe endogenous depression. All three underwent management in psychiatric units and have had no further episodes of urinary retention.

Rectal
There were 3 patients in this group. 2 had faecal impaction while the third was suffering from severe colitis. None have suffered a second episode of retention. Faecal impaction is well recognised as a cause of retention in the male but may also produce this effect, though much less commonly, in the female.

Summary
The causes of acute urinary retention in the female are discussed in relation to 103 cases recorded over a 3-year period. The authors feel that the findings are at variance with traditional teaching on the subject. Rather than being very rare the condition is found, in fact, to be not uncommon. It is found to occur postoperatively and following childbirth. Gynaecological and neurological lesions are reaffirmed as important causes and pathology within the urinary tract is found to be a more frequent component than is usually appreciated. Our findings do not support the view that hysteria is a common cause of acute urinary retention in females.

796

BRITISH JOURNAL OF UROLOGY

References
EMMETT, JOHN L. and LOVE, G . (1968). Urinary retention in women caused by asymptomatic protruded lumbar J. disc; report of 5 cases. Journal of Urology, 99,597-606. IVANOVICI, (1970). Urine retention: an isolated sign in some spinal cord disorders. Journal of Urology, 104, F. 284-286. WARD, N., LAVENGOOD, W. and DRAPER, (1968). Pseudo bladder neck syndrome in women. Journal Q/ J. R. J. W. Urology,99, 65-68.

The Authors
J. Doran, BSc, MB, BS, Registrar. Michael Roberts, ChM, FRCS,Consultant Urological Surgeon.