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Urinary Retention in Elderly Women: Diagnosis

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Article in Current Urology Reports November 2014
DOI: 10.1007/s11934-014-0454-x Source: PubMed

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Curr Urol Rep (2014) 15:454

DOI 10.1007/s11934-014-0454-x

LOWER URINARY TRACT SYMPTOMS & VOIDING DYSFUNCTION (H GOLDMAN AND G BADLANI, SECTION EDITORS)

Urinary Retention in Elderly Women: Diagnosis & Management

Rena D. Malik & Joshua A. Cohn & Gregory T. Bales

Published online: 19 September 2014

# Springer Science+Business Media New York 2014

Abstract The management of urinary retention in the elderly

female can present a challenging conundrum for primary care
physicians, geriatricians, and urologists. It is often difficult to
diagnose due to concomitant comorbidities and potential cognitive impairments. Evaluation should include a comprehensive history and physical examination, post-void residual, and
urinalysis with consideration given to urodynamic testing in
select patients. Management varies from conservative to invasive and should be tailored to the individual patient.
Primary goals of care include symptom reduction, prevention
of urinary tract infection, and upper tract deterioration. This
presents an up-to-date review of the presentation, diagnosis,
and management options available for elderly women with
urinary retention.
Keywords Urinary retention . Elderly . Geriatric . Female .
Women . Elevated post-void residual . Incomplete emptying
This article is part of the Topical Collection on Lower Urinary Tract
Symptoms & Voiding Dysfunction
R. D. Malik : J. A. Cohn : G. T. Bales
Department of Surgery, Section of Urology, University of Chicago
Medical Center, Chicago, IL, USA
J. A. Cohn
e-mail: Joshua.Cohn@uchospitals.edu
J. A. Cohn
e-mail: Joshuacohn@gmail.com
G. T. Bales
e-mail: gbales@surgery.bsd.uchicago.edu
R. D. Malik (*) : J. A. Cohn : G. T. Bales
The University of Chicago Medicine & Biological Sciences, 5841 S.
Maryland Ave. Rm. J-653, MC6038, Chicago, IL 60637, USA
e-mail: Rena.malik@uchospitals.edu
R. D. Malik
e-mail: Renamalik@gmail.com

Introduction
The incidence of acute urinary retention in women of all
ages is in general uncommon, with an estimated incidence
of seven in 100,000 per year [1]. However, incomplete
emptying with elevated post-void residual (PVR) is a
frequent finding in geriatric women (up to one third),
and the incidence is increased in frailer patients [2].
Whereas acute urinary retention is by definition always
problematic, elevated post-void residual may be asymptomatic or associated with debilitating problems such as
recurrent infection or urinary incontinence. Furthermore,
urinary retention can be caused by a variety of disease
processes, which in general are associated with either
anatomic outlet obstruction or bladder dysfunction
(Table 1) [3, 4].
The most common etiologies for retention depend largely
on the population studied. Whereas in younger patients disorders causing failure of sphincter relaxation may play a primary
role in the majority of cases [4], in an older population
retention is more likely to be linked to conditions associated
with aging. For example, pelvic organ prolapse [5], diabetes
mellitus [6], polypharmacy [7], and frailty [8] are all conditions associated with urinary retention and disproportionately
impact the elderly.
Furthermore, while elderly is often defined as age 65
or older, comorbid disease and functional status can differ
significantly in patients of the same age [9]. Therefore,
management of retention must be individualized to each
woman based upon degree of retention (i.e., complete
versus elevated post-void residual), her degree of bother,
treatment goals, associated comorbidities, and the underlying cause(s) of retention. This chapter will outline presentation, evaluation, and management of urinary retention
in elderly women in order to assist in developing an appropriate treatment plan for each patient.

454, Page 2 of 7

Curr Urol Rep (2014) 15:454

Table 1 Etiologies of urinary retention in women

Mechanism

Condition

Outlet obstruction
Pelvic organ prolapse
Malignancy
Iatrogenic (e.g. post stress-incontinence
surgery)
Primary bladder neck obstruction
Urethral stricture
Urethral diverticulum
Caruncle
Foreign body
Periurethral abscess
Impaired sphincter relaxation (e.g. Fowlers
syndrome, dysfunctional voiding,
spinal cord injury)
Bladder dysfunction
Neurologic disorders
Longstanding diabetes
Infection
Medications impairing contractility
Pain

Presentation
Acute (complete) urinary retention is ten times less common
in women than men [10]. In these cases, diagnosis is fairly
straightforward, as patients will typically described either
painful or painless inability to void for a prolonged period.
In addition, upper tract examination obtained for other reasons
(or for workup of vague abdominal pain) may reveal a markedly distended bladder with bilateral hydronephrosis.
However, because retention in elderly women usually presents
less dramatically, it is important to have a high index of
suspicion for its presence.
Onset of symptoms may be gradual and can go unnoticed
by caregivers of patients or by patients with limited bladder
sensation or who are severely cognitively impaired and cannot
report symptoms. In general, the presence of a weak stream
may predict for elevated post-void residual, however, other
voiding lower urinary tract symptoms (LUTS) are unreliable
predictors [11]. Elevated post-void residual may also present
with recurrent urinary tract infections [12] or stress or urgency
urinary incontinence [13]. Awareness of conditions associated with retention can also alert physicians to the possibility
of urinary retention when urinary symptoms may be subtle or
absent. In addition to urinary tract infection and past history of
retention, constipation, impaired mobility, stroke, and diabetes
with microvascular complications have been associated with
increased odds of elevated post-void residual (>100 mL) in
elderly women [11].

Evaluation
Urinary retention in an elderly patient generally represents a
singular issue that must be considered within the context of
the patients other medical comorbidities. Therefore, a detailed
history as part of the initial evaluation is imperative. In significantly cognitively impaired patients, obtaining a history
from the patient can be challenging, and it is helpful if a
dedicated caregiver (or family member) is present.
The history of present illness should distinguish between
complete retention versus elevated post-void residual with or
without associated symptoms such as recurrent urinary tract
infections, presence of voiding LUTS, or urinary incontinence. If symptoms are present, patients should be asked
about the degree of bother from these. Estimates of frequency
and volume of voids may be helpful along with an attempt to
quantify the degree of and provocative factors for incontinence, if present. Patients should also be asked about timing,
type (i.e., alcohol or caffeine) and volume of fluid intake. It is
also important to assess history of prolapse symptoms or
surgeries, previous incontinence surgeries, bowel habits, and
medical conditions such as diabetes or history of cerebrovascular accident or other neurologic conditions such as multiple
sclerosis or Parkinsons. In addition to the impact on bladder
function, neurologic conditions and generalized frailty with
upper extremity weakness and limited coordination can impact the potential for clean intermittent catheterization.
Assessment of medications can identify potential contributors to retention (Table 2) as well as highlight potentially
important medical diagnoses that may not have been addressed in the HPI. Past medical and surgical history should
assess comorbid conditions or any previous urologic or obstetric intervention that may impact management. Social history should obtain information related to the patients level of
independence, social functioning, and support from family
and caretakers.
In patients able to describe their symptoms in detail, surveys may be helpful to obtain an objective measure of severity
of symptoms and degree of bother associated with LUTS.
Although originally developed for the evaluation of benign
prostatic hyperplasia in men, the American Urological
Association Symptom Index Score (AUA-SI) has been validated as an appropriate assessment of LUTS in women [14].
The AUA-SI can be administered at regular intervals to document response to therapy or progression of symptoms over
time [15] as well as changes in quality of life [16]. Surveys
designed specifically to assess quality of life and mental health
are important research tools but may not be practical for
widespread clinical use [16, 17]. Nevertheless, it is important
to be aware of the negative impact LUTS and urinary retention
can have on mental health in the elderly.
In addition to history, a comprehensive physical examination should be performed at the initial visit. The attentive

Curr Urol Rep (2014) 15:454

Page 3 of 7, 454

Table 2 Medications that can cause or exacerbate urinary retention

Medication

Examples

Side effects that contribute to retention

Sedatives
Anticholinergics

long-acting benzodiazepines
Sedation, immobility, delirium
anti-muscarinics (e.g. oxybutynin), dicyclomine, disopyramide Impaired detrusor contractility, sedation, delirium,
constipation (general side effects of all anti-cholinergics)
Anti-histamines (sedating) diphenhydramine
Anti-psychotics
haloperidol
Tricyclic antidepressants
Anti-Parkinsonians
Narcotics
Calcium channel blockers
Chemotherapeutic agents
alpha-adrenergic agonists

amitriptyline, desipramine, imipramine

benztropine
morphine, hydromorphone, oxycodone
amlodipine, nifedipine, felodipine, verapamil
vincristine, cisplatin
pseudoephedrine

Sedation, constipation, delirium

Impaired detrusor contractility, constipation
Neuropathy-induced impaired bladder contractility
Impaired bladder neck relaxation

Adapted from Resnick NM: Geriatric medicine. In: Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DJ, editors. Harrisons
principles of internal medicine. New York: McGraw-Hill; 2004. p. 34

practitioner can identify important non-urologic medical conditions common in the elderly. Urologic-specific examination
should include an overall assessment of frailty, mobility, and
coordination. Abdominal exam should evaluate for
suprapubic fullness, abdominal or flank masses or fullness to
suggest malignancy or fecal impaction, and costovertebral
angle tenderness. A detailed genitourinary exam should begin
with inspection of the vagina and surrounding perineal skin
for evidence of atrophy, lesions, or scars associated with prior
surgery, as well as urine-related skin breakdown. Levator
musculature should be palpated to assess for pain potentially
contributing to dysfunctional voiding. The urethra should be
examined for the presence of obstructing masses, cysts, or
diverticula. Urethral hypermobility and presence of stress
urinary incontinence can be evaluated during valsalva. Using
half a speculum, the patient can be evaluated for the presence
of anterior, posterior or apical prolapse, which may contribute
to functional obstruction. Furthermore, a bimanual exam is
helpful to evaluate uterine size, position and support as well as
rule out any palpable masses. A rectal exam should also be
performed to evaluate for fecal impaction or masses and assess
sphincter tone. Lastly, neurologic evaluation should be completed with special attention to perineal sensation, presence of
the bulbocavernosus reflex and sensory and motor function of
the sacral nerves.
Additional testing can be a helpful adjunct to history and
exam. The use of ultrasound for assessment of residual urine
after voiding is a convenient noninvasive tool and has been
shown to correlate well with residual determination via catheterization [18]. We routinely bladder scan all patients when
concern for urinary retention is present. A urinalysis with
reflexive culture if suspicious for infection is also recommended in most patients, and is of particular import in the elderly, in
whom urinary tract infections often result in non-localizing
symptoms [19, 20]. In women with significantly elevated

post-void residual or history of acute retention or with risk

factors for chronic kidney disease, testing of serum electrolytes and creatinine is recommended. A voiding diary with a
frequency-volume chart can be useful, however, patient compliance may be limited, particularly in functionally or cognitively impaired patients.
Urodynamic (UDS) testing provides objective measures of
lower urinary tract function and anatomy. Specifically, it permits measurement of bladder capacity, compliance, contractility, continence, sensation, bladder outlet resistance, and
external sphincter function. In patients with urinary retention,
it can help differentiate between detrusor underactivity or
acontractility versus bladder outlet obstruction. However, the
role of UDS in elderly patients is unclear. Specific cognitive
impairments and limitations in mobility may make it difficult
for some women to provide feedback or respond to instructions that would make such testing useful. Furthermore, UDS
may be unnecessary in patients with unequivocal urinary
retention managed with conservative measures or CIC.
However, in elderly women with concomitant storage
LUTS, symptoms often do not correlate with urodynamics
findings, and; therefore, UDS is recommended to help guide
management [21]. Urodynamics may also be of value in
patients with neurologic conditions where there is concern
for decreased bladder compliance and progressive upper tract
deterioration. Lastly, UDS may be helpful to confirm the
diagnosis of bladder outlet obstruction or quantify the degree
of concomitant stress incontinence prior to surgical intervention such as prolapse repair [22], urethrolysis, or sling incision
[23]. Further evaluation with cystoscopy may be warranted in
select patients, particularly those with suspicion for obstruction or urethral pathology and in those with hematuria [24].
Similarly, upper tract imaging with renal ultrasound or CT
scan can be considered in patients with potential for renal
dysfunction or obstructive uropathy. Abdominal and pelvic

454, Page 4 of 7

imaging should also be considered in patients whose history

or urine studies suggest a possibility of urothelial malignancy
or nephrolithiasis [25].

Treatment
Goals for optimal care of urinary retention should include
symptom reduction, prevention of urinary tract infections,
and avoidance of upper tract deterioration [26]. These goals
should be addressed with the patient and potentially include
caregivers and/or family members. Patients with cognitive
impairment can still effectively articulate their treatment preferences and, therefore, should always be included in developing the treatment plan [27, 28]. The appropriate therapy may
differ in patients with the same underlying etiology based
upon functional status, patient preference and caregiver/
living situation, all of which are factors that should be incorporated in determining an optimal care plan. Ultimately, one
should aim to provide the least invasive effective modality to
reach the patients desired outcome while addressing the goals
mentioned above.
Conservative Management
Conservative managementi.e., avoidance of additional
pharmacotherapy or surgical managementis possible in
many patients with chronic complete urinary retention or
elevated post-void residual. Whenever possible, offending
medications should be withdrawn and potentially reversible
conditions should be treated and managed. Constipation is
common in elderly females and results in approximately
4,500 physician visits per 100,000 population in women older
than 65 [29]. Measures to improve constipation can significantly improve bladder emptying and include bowel training,
increased dietary fiber intake, adequate hydration, regular
exercise, and pharmacologic therapy [30]. Pelvic floor rehabilitation has been shown to be useful for elderly women with
voiding dysfunction and may be considered in a multimodal
approach to patients with concomitant chronic urinary retention [31]. Additionally, for patients with voiding LUTS and
elevated PVR, timed and prompted voiding may be a useful.
For patients with anatomic causes of obstruction, specifically
pelvic organ prolapse, manual reduction or pessary use can
allow for resolution of urinary retention [32].
Medical Therapy
Though traditionally used in men, alpha-blockers may be of
use in women with primary bladder neck obstruction. Several
studies have found the use of alpha-blockers in female patients
to reduce post-void residual, increase maximum flow rate,
potentially improve quality of life and decrease the incidence

Curr Urol Rep (2014) 15:454

of urinary tract infection [33, 34, 3538]. However these

studies are limited by their lack of placebo or control comparison, short-term outcomes, and small sample size. At this time,
additional randomized control trials are required to fully evaluate their efficacy in the female population.
Cholinergic drugs such as bethanechol chloride, a choline
ester, and distigmide bromide, a choline esterase inhibitor,
have historically been thought to improve detrusor contractility and enhance bladder emptying for patients with detrusor
underactivity [3941]. However, in a randomized doubleblind study, bethanechol was not been shown to improve
voiding efficiency for women with persistently elevated residual urine in comparison to placebo [42]. By contrast, a more
recent study demonstrated a reduction in residual volume and
improvement in maximum flow rate with the use of
bethanechol in patients with cystometric evidence of detrusor
underactivity. However, this study was limited by its small
number of subjects and limited data on subjective clinical
outcomes [43].
Catheterization
Acute urinary retention in all patients must be treated with
immediate decompression via urethral or suprapubic catheterization. To avoid circulatory collapse and decompressive hematuria, gradual decompression was previously advocated.
However, a randomized control study demonstrated no benefit
to gradual decompression, and; therefore, rapid decompression represents the most appropriate initial management [44].
After relief of acute retention, patients at risk for postobstructive diuresis should be monitored with b.i.d. to t.i.d.
serum electrolyte studies and encouraged to hydrate orally if
able or, in certain circumstances, be provided intravenous
hydration until the diuresis has resolved.
Clean intermittent catheterization (CIC) is the ideal management for chronic complete urinary retention or elevated
post-void residual associated with recurrent urinary tract infection or renal dysfunction that has failed to improve with
conservative management alone. First described by Lapides
and colleagues in 1972, CIC is associated with a significant
reduction in urinary tract infection in comparison to indwelling catheterization [45]. However, in elderly patients CIC may
provide a unique challenge due to limitations in cognition,
mobility, and manual dexterity. Patients learning CIC may
also experience psychological stress, which may be an obstacle to implementation of CIC if not adequately addressed [46].
Despite these limitations, elderly patients have shown similar
abilities to the general population in learning CIC [47] and
should whenever possible be offered CIC preferentially over
indwelling catheterization.
In cases where CIC is not possible due to limited patient
dexterity or access to assistance from family/caregivers, patients may require an indwelling transurethral or suprapubic

Curr Urol Rep (2014) 15:454

catheter. Unfortunately, indwelling catheterization is associated with an increased risk of recurrent complex urinary tract
infections, bladder stones, and bladder irritation. Long-term
urethral catheterization should be avoided for risk of urethral
erosion or destruction of the bladder neck. Additionally, longterm catheterization by either means (transurethral or
suprapubic) can result in reduced bladder compliance and
subsequent reflex nephropathy and hydronephrosis [48].
Therefore,efforts should be made to limit the length of time
of indwelling catheterization whenever possible. If bladder
catheterization is unavoidable, suprapubic catheterization is
preferred in amenable patients due to the aforementioned risk
of bladder neck deterioration and reduced incidence of urethral complications [49].
Surgical Management
Surgical management should be reserved for patients where
conservative methods have failed, and in patients who are
unable or unwilling to utilize CIC, provided that a patients
comorbid status and treatment goals permit an operation. The
risk to the patient associated with a particular intervention and
likelihood of success as well as the risks of continuing with
nonoperative management should also be considered in each
case.
In women with reduced urethral caliber or urethral stenosis,
urethral dilation may be helpful [50]. However, a paucity of
data exists in regards to long-term objective outcomes, and no
standardization of method or degree of dilation has been
agreed upon. Additionally, studies comparing urethral dilation
to conservative therapy and/or cystoscopy have not demonstrated a benefit to urethral dilation for symptom control [51,
52].
Transurethral incision of the bladder neck provides a potential treatment option for women with urodynamic-proven
detrusor underactivity and urinary retention. A recent study
demonstrated effective initial results with improvement in
PVR, Qmax, and voiding efficiency with transurethral incision of the bladder neck [53]. However, this surgical procedure works primarily by allowing abdominal voiding to occur
at lower abdominal pressures than before surgery. Therefore,
for more debilitated patients unable to generate adequate
Valsalva pressures, this option may not be of benefit, and
long-term outcomes are not available.
Sacral neuromodulation is a minimally invasive treatment
that has demonstrated success in females with urinary retention due to detrusor underactivity. Interstim (Medtronic,
Minneapolis, MN) has received approval by the United
States Food and Drug Administration for treatment of functional, non-neurogenic, and chronic urinary retention. The
mechanism of action is thought to impair excitatory outflow to
the urethral outlet and suppress the guarding reflex restoring
the ability to void volitionally [48]. Rates of successful

Page 5 of 7, 454

elimination of need for catheterization in patients with retention have been reported to be as high as 69-81 % [5457].
However, this data is limited by varying definitions of success,
and data suggesting quality of life improvement is lacking. In
addition, SNM is costly and concerns exist regarding longterm efficacy. Specific surgical risks of SNM include failure
(25 %), requirement of revision (23-54 %), device related pain
(8 %-34 %), sciatica, lead migration or breakage (5-20 %),
infection, nerve injury, and failure of device over time [58].
Posterior tibial nerve stimulation (PTNS) may be a promising
alternative option that avoids the risk and costs associated
with invasive surgery. PTNS response rates for nonobstructive urinary retention have been reported at 41-100 %
[59]. However, PTNS requires weekly visits to the physician
for therapy over a period of 12 weeks [60], thus, potentially
limiting it as an option for debilitated patients, and its specific
role in elderly women and overall long-term efficacy remain
unclear.
Lastly, for patients who have failed all alternative treatment options and in whom major surgery is a viable and
desired option, a continent catheterizable stoma can be
created. This may substantially improve patients quality
of life and improve patient and caregiver compliance,
however, the associated complications of major surgical
intervention are certainly drawbacks. Another urinary diversion option is an ileal conduit (non-continent diversion), which thereby necessitates the wearing of a stoma
appliance. This is simpler for patients insofar as it does
not require catheterization, but again it is a major surgical
endeavor and reserved for only exceptional cases where
conservative options have failed.

Conclusions
Urinary retention is a complex problem in the elderly female.
Diagnosis may require a high index of suspicion based on
non-specific presentation such as recurrent urinary tract infection or vague abdominal discomfort. Management varies from
noninvasive management of easily reversible causes to more
aggressive treatment options. CIC offers a safe and minimally
invasive option for patients whose cognitive and motor skills
permit compliance or who have access to willing and capable
caregivers. For those with a high degree of bother and inability
to self-catheterize, certain surgical alternatives exist and can
be offered to selected individuals following a thorough discussion of risks and likelihood of cure. Treatment must be
thoughtful and tailored to the individual patient and family.
Increased awareness among primary care physicians, geriatricians, and urologists is essential to provide the highest quality
of care possible to our elderly female patients.

454, Page 6 of 7
Compliance with Ethics Guidelines

Curr Urol Rep (2014) 15:454

15.

Conflict of Interest Dr. Rena D. Malik, Dr. Joshua A. Cohn, and Dr.
Gregory T. Bales each declare no potential conflicts of interest.
16.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.

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