Urinary retention presents with a dull low abdominal discomfort and frequent urge to urinate without being able to do so for many hours. A distended bladder can be palpated on exam. To treat urinary retention, a Foley catheter should be inserted into the bladder to drain the urine after ensuring aseptic technique. The cause of obstruction should then be determined by examining the patient and checking renal and urinary function with tests. The catheter should not be removed from the ED if the bladder was significantly distended to prevent it from refilling.

1. Urinary Retention
Presentation
The patient may complain of increasing dull low abdominal discomfort and the urge to
urinate, without having been able to urinate for many hours. A firm, distended bladder
can be palpated between the symphysis pubis and umbilicus. Rectal exam may reveal
an enlarged and/or tender prostate or suspected tumor.
What to do:
• Delaying only long enough for good aseptic technique pass a Foley catheter into
the bladder and collect the urine in a closed bag. Reassuring the patient and
having him breathe through his mouth may help relax the external sphincter of
the bladder and facilitate the passage of the catheter.
• If passage remains difficult in a male patient, distend the urethra with lubricant
(K-Y jelly;or diluted lidocaine jelly) in a catheter-tipped syringe (Uroject) and try
a 16, 18, or 20 French Foley.
• If the problem is negotiating the curve around a large prostate, use a Coude
catheter.
• If you still cannot drain the bladder, obtain urologic consultation for stylets,
sounds, filiforms, and followers.
• Check renal and urinary function with a urinalysis, a urine culture and serum
BUN and creatinine determinations. Examine the patient to ascertain the cause
of obstruction.
• If there is an infection of the bladder, give antibiotics.
• If the volume drained is modest (1-2 liters) and the patient stable and
ambulatory, attach the Foley catheter to a leg bag and discharge him, for
followup (and probably, catheter removal) the next day.
• If the volume drained is small (100-200ml), remove the catheter and search for
alternate etiologies of the abdominal mass and urinary urgency.

2. What not to do:
• Do not use stylets or sounds unless you have experience instrumenting the
urethra--these devices can cause considerable trauma.
• Do not remove the catheter in the ED if the bladder was significantly distended.
Bladder tone will take several hours to return, and the bladder may become
distended again.
• Do not clamp the catheter to slow decompression of the bladder, even if the
volume drained is greater than 2 liters.
• Do not use bethanechol (Urecholine) unless it is clear that there is no
obstruction, the only cause of the distension is inadequate (parasympathetic)
bladder tone and there is no possibility of gastrointestinal disease.
• Do not routinely treat the bacteria cultured from a distended bladder--they may
only represent colonization which will resolve with drainage.
Discussion
Urinary retention may be caused by stones lodged in the urethra or urethral strictures
(often from gonorrhea); prostatitis, prostatic carcinoma, or benign prostatic
hypertrophy; and tumor or clot in the bladder. Any drug with anticholinergic effects or
alpha adrenergic effects such as antihistamines, ephedrine sulfate and
phenylpropanolamine can precipitate urinary retention. Neurologic etiologies include
cord lesions and multiple sclerosis. Patients with genital herpes may develop urinary
retention from nerve involvement. Urinary retention has also been reported following
vigorous anal intercourse. The urethral catheterization outlined above is appropriate
initial treatment for all these conditions.
Sometimes hematuria develops midway through bladder decompression, probably
representing loss of tamponade of vessels injured as the bladder distended. This should
be watched until the bleeding stops (usually spontaneously) to be sure there is no great
blood loss, no other urologic pathology responsible, and no clot obstruction.