Urinary Retention

How’s it going, Bestie? I’m happy to have you here! Let’s chat about urinary retention today. Urinary retention can affect a wide range of folks, from pregnant ladies to those that recently underwent surgery. It can be a pretty serious issue so let’s get right into it.

What is Urinary Retention?

Urinary retention is the experience of being unable to pass urine despite trying. Those suffering from urinary retention can’t pee even when they have a full bladder. In those with acute urinary retention, meaning the condition arose quickly and hasn’t been around for long, the bladder will likely be painful (1). In those with chronic urinary retention, meaning the condition has been ongoing for quite some time, the bladder may not be painful (1). In both cases, the it is possible for one to feel the bladder by lightly pressing on the area of skin right above the pubic bone.

What are the symptoms of Urinary Retention?

Urinary retention results in symptoms such as urinary hesitancy, weak stream of urine, and straining to urinate. It may also feel like the bladder is not emptying completely. Folks with urinary urgency spend time trying to void with little to no urine being expelled and then still feel like they have a full bladder afterward. Also, people with urinary retention may experience recurrent urinary tract infections (UTIs) (2).  

What are the causes of Urinary Retention?

There are tons of causes for urinary retention. It is essential to determine the cause of urinary retention in order to treat it appropriately because treatments for urinary retention are dependent on the cause of the condition. When it comes to causes of acute urinary retention, there are two main categories: bladder outlet obstruction and bladder hypotonicity.

A bladder outlet obstruction is a physical block along the pathway that urine takes as it exits the bladder and urethra to be expelled. One example of a bladder outlet obstruction is an enlarged prostate. Like we talked about last time, in folks with Benign Prostatic Hyperplasia (BPH) the prostate may be so enlarged that it obstructs the flow of urine out of the body. Another example is advanced pelvic organ prolapse (POP). If you recall from our earlier chat about prolapse, POP involves the descent of one or more of the pelvic organs (bladder, uterus, rectum/bowel). If one of the pelvic organs has moved far enough down, it may impede the flow of urine out of the body, causing urinary retention.

A third type of bladder outlet obstruction comes from a specific surgical procedure in which a surgeon places something called a midurethral sling in the pelvic region. This type of surgery is used in folks with urinary incontinence. A tension-free vaginal tape (TVT) sling is placed around the urethra and it helps the urethra to stay in place in order to reduce episodes of stress urinary incontinence (SUI). However, a common complication after this surgery is urinary retention (3).

While rare, pregnancy can also be a risk factor for urinary retention. Things such as a retroverted uterus or an incarcerated uterus can cause urinary retention in pregnancy (4). Other bladder outlet obstructions could be bladder stones, fecal impaction (a.k.a so much poop in the rectum that it puts pressure on all of the other pelvic structures), and UTI.

Bladder hypotonicity, or underactive bladder, occurs when the bladder is not contracting the way it should. Remember, the bladder is a muscle called the detrusor muscle. It is relaxed as your bladder fills and it contracts and squeezes when you urinate. The contraction of the detrusor muscle is what pushes urine out of the bladder and into the urethra so that the urine can exit the body. If the bladder is not contracting well, urinary retention can occur. A hypotonic bladder can occur post-operatively due to pain, medications, intravenous fluid administration, and lack of mobility (5). This will usually improve on its own once you return to normal life after an operation. Medications can also impact bladder contractility. Calcium channel blockers (for lowering blood pressure), anticholinergics (for a range of conditions), and antidepressants can all impact the detrusor’s ability to contract appropriately.

Chronic urinary retention can result from acute urinary retention. In acute urinary retention, the bladder is filled with more fluid than is typical and in order to avoid incontinence, muscles of the urethra work harder. This extra muscle activity over a long period of time can make it more difficult for fluid to exit the urethra. It is kind of a downward spiral if you really think about it: increased fluid in the bladder means increased urethral muscle activity to avoid urine leakage which causes the urethra to be harder to open and makes it more difficult for fluid to escape which causes more fluid to accumulate in the bladder. Ahh!

Chronic urinary retention might also occur in relation to neurogenic bladder. Neurogenic bladder describes a number of urinary conditions that occur as a result of an injury to the brain, spinal cord, or nerves that makes bladder control more difficult. As we’ve touched on before, the bladder is controlled by nerves that receive signals from the brain. When there are injuries to any of the nerves along the way, bladder control can be lost.  

How is Urinary Retention Treated?

Treatment for urinary retention is based on what is causing the retention. In cases of bladder outlet obstruction, removal of the blockage should improve retention. For example, if someone is experiencing urinary retention due to enlarged prostate in BPH, a treatment would be to surgically or pharmaceutically reduce the size of the prostate. Other examples would be surgical repair of a POP, removal of a bladder stone, or removal of the TVT sling. If a UTI is causing inflammation and swelling, antibiotic medication will help to remove this type of block. Medications can also be helpful in managing urinary retention (such as Flomax for BPH).

In cases of bladder hypotonicity, one option is InterStim Therapy (6). This is an electrical device that stimulates the sacral nerves (the nerves that innervate your bladder and urethra) and allows them to function more optimally.

Urinary retention, especially acute urinary retention can be dangerous and even life-threatening. When there is too much urine in the bladder, it can start to make its way back up the ureters toward the kidneys. In cases of severe and acute urinary retention, catheterization will allow the bladder to empty quickly and will likely improve symptoms.

Pelvic Health Physical Therapy for Urinary Retention:

So, how can your pelvic health physical therapist help you with your urinary retention? There are lots of minimally invasive treatment options for urinary retention in physical therapy. Let’s talk about them:

• Biofeedback training: Biofeedback can be helpful in becoming in tune with the muscles of the pelvic floor. The pelvic floor muscles (PFMs) impact voiding and improving PFM mobility and lengthening can also improve the ability to empty the bladder.

• Timed voiding: Sticking to a voiding schedule can help you avoid a bladder that is too full. When the bladder is too full, it becomes more difficult for the detrusor muscle to generate force and contract optimally. This makes it tough to initiate the flow of urine and to empty the bladder. Using a voiding schedule and emptying the bladder every 2-3 hours can lesson the symptoms associated with urinary retention.

• Manual therapy: I’ve said it before, but I’ll mention it again: the PFMs need to be able to move well in order to empty the bladder well. Tightness and tension in the PFMs can affect bladder emptying. Manual therapy techniques can help improve the tissue quality of the PFMs and reduce tension in order to improve PFM mobility. Your therapist might even teach you how to use a dilator so that you can tackle some of that tension on your own.

• TENS Unit: Using a Transcutaneous Electrical Neuromuscular Stimulation (TENS) unit can be super helpful for urinary retention. Your therapist will get you set up with your TENS unit, talk about which settings you should be working with, and teach you where the pads should be placed. This works similarly to the InterStim Therapy I talked about earlier. The electrical stimulation targets the sacral nerves that innervate the bladder and urethra which can improve the bladder’s contractility and reduce urinary retention. This is a less invasive option than InterStim.

• Education: Your therapist is likely to provide you with a bunch of tips and tricks for urination. These include sitting down to pee, using a squatty potty or stool during urination, deep breathing to encourage PFM relaxation, turning on the water faucet when you want to take a wee, using splinting if a prolapse is present, tapping on the bladder just above the pubic bone, and more.  

Urinary retention can be super painful and pretty scary. Since most of us are used to urinating upwards of eight times per day, to not pee for a whole day would pretty troubling. If you are suddenly having trouble urinating, talk with your medical provider immediately. If you have chronic urinary retention, consider talking to a pelvic health physical therapist to discover new ways of managing your symptoms.

Until next time XOXO,

Your Pelvic Bestie

References:

1.     Negro CL, Muir GH. Chronic urinary retention in men: how we define it, and how does it affect treatment outcome. BJU Int. 2012 Dec;110(11):1590-4.

2.     Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am Fam Physician. 2008 Mar 1;77(5):643-50.

3.     Celik H, Harmanlı O. Evaluation and management of voiding dysfunction after midurethral sling procedures. J Turk Ger Gynecol Assoc. 2012 Jun 1;13(2):123-7.

4.     Chen JS, Chen SC, Lu CL, Yang HY, Wang P, Huang LC, Liu FS. Acute Urinary Retention During Pregnancy--A Nationwide Population-Based Cohort Study in Taiwan. Medicine (Baltimore). 2016 Mar;95(13):e3265.

5.     McLeod L, Southerland K, Bond J. A clinical audit of postoperative urinary retention in the postanesthesia care unit. J Perianesth Nurs. 2013 Aug;28(4):210-6.

6.     Sujka J, Zeoli T, Ciccone JM. Sacral Neuromodulation for Bladder Atony - A Case Report. Urol Case Rep. 2014 Jan 24;2(1):27-9.

*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.