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Investigating chronic urinary retention

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4590 (Published 25 July 2019) Cite this as: BMJ 2019;366:l4590

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Chronic urinary retention in the elderly

This is a fairly common problem in medical practice, especially in the elderly.

It may happen that the manifestations of urinary retention are not the classic ones (obstructive symptoms, abdominal discomforts, etc.), but that they occur as general manifestations, almost always related to renal insufficiency or complications of a pathological bladder residue (infections, hematuria, lithiasis, diverticula, etc.).

In the elderly, the presentation of chronic urinary retention with alterations in such (agitation, disorientation, delirium) and behavior (behavioral alterations, aggressiveness), secondary to the uretero bilateral hydronephrosis with renal insufficiency caused by bladder distension, is described.

The most common processes in the elderly are:

Diabetic neuropathy: Urinary retention may appear in diabetic neuropathy, almost always related to an autonomic nervous system lesion. Bladder dysflexia has traditionally been linked to a long duration of diabetes, poor metabolic control and involvement of the afferent axons of the urinary bladder.

From the clinical point of view, diabetic bladder dysflexia is characterized by a lack of bladder filling sensation, conditioning bladder distension, detrusor decompensation and urinary retention.

The management of this entity will be aimed at improving insufficient bladder emptying, with intermittent bladder catheterization as the most appropriate technique, and permanent recourse should be used when this technique cannot be performed due to personal or family limitations.

Postoperative: Urinary retention is quite frequent in the postoperative phase in elderly patients, especially after abdominal and orthopedic surgery, ranging in prevalence from 12% to 50%, depending on the characteristics of each patient, the type of surgery and of the anesthetic technique used.

The most common precipitating factors are: functional aspects (immobility, pain), drugs (anesthesia, sedation, analgesia), advanced age and male gender. However, in all cases, the patient's urological history (male with prostatic hypertrophy, previous urological surgery), and its general characteristics (medical pathology, previous physical and functional status) must be considered.

Detrusor hyperactivity with altered contractility: This clinical entity combines urodynamic data of bladder hyperactivity (existence of involuntary contractions), but unable to empty more than 50% of bladder content. According to the "Agency for Health Care Policy and Research Adult Incontinence Guidelines" it would be "patients who have involuntary contractions of the detrusor, despite which they could not manage to empty the bladder completely or incompletely" -

From the clinical point of view, patients can present with both irritative urinary symptoms (mainly polyuria and urinary urgency), as well as obstructive (sensation of incomplete urination, urinary retention), characteristically finding pathological postmictional bladder residues. Therefore, although incontinence and a high postmictional residue are usually presented urgently, it is also possible to manifest with symptoms of obstruction, stress incontinence or overflow.

The typical profile of patients would include advanced age, usually women, and functional impairment. It is currently considered that this entity could be a subtype of bladder hyperreflexia, proposing the possibility of being a highly evolved phase with the appearance of detrusor failure.

This form of bladder hyperactivity is the second cause of incontinence in institutionalized elderly people (with significant functional impairment, physical and / or psychological). The clinical significance of this entity is that an episode of urinary retention could occur when some other factor (drugs, immobility, fecal impaction, etc.) that alters bladder contractility is added to the vulnerability of the frail elderly. Therefore, this entity should be included in the differential diagnosis of urinary retention of the elderly, both acute and chronic.

References
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Competing interests: No competing interests

02 August 2019
Moises A. Santos-Peña
Medical Doctor and Professor. Internal Medicine and Intensive Carte. Advisor to the Board of Directors
Valdes-Castro Yanier
Gustavo Aldereguia University General Hospital
Ave 5 de Septiembre and 51-A street. Cienfuegos, Cuba 55100