THE JouRN.t,,L OF UROLOGY
Copyright © 1978
The ·vvil1iarns & '-Nilkins Co.
EVALUATION OF PSYCHOGENIC URINARY RETENTION DAVID M. BARRETT From the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
Urinary retention may develop in the absence of significant organic disease. Patients with psychogenic retention range from those with episodic acute retention to those who have learned to inhibit urination and have retention with a large residual urine volume owing to myotonic detrusor degeneration. A combination of thorough medical, neurologic, psychiatric and urologic evaluation is indicated for all such patients. Management consists of the implementation of bladder training with or without intermittent catheterization, which generally may be accomplished on an outpatient basis. A most perplexing problem in diagnosis and management involves the patient who is unable to void even though findings on neurologic and urologic examinations are normal. Although patients of all ages and both sexes may have transient urinary retention after severe trauma, general anesthesia or a herniated spinal disk, many patients with previously normal voiding histories - most being young or middle-aged women - retain urine in the absence of obvious causes. 1, 2 Further confusion is added because many appear to be stable psychologically. Historically, speculation on the exact cause of this disease process has included urethral or vesical neck obstruction, occult neurogenic bladder dysfunction and a silent protruded lumbar disk. The frustration regarding the cause and treatment has led to various surgical procedures on the urethra, vesical neck, bladder and spinal column.:i· 4 Based on the concept that urinary retention may develop secondarily to centrally mediated, subconscious inhibition of detrusor contraction or vesical outlet relaxation or both we have adopted a specific approach to this problem. 5
have urinary infection. Therapy is started with appropriate antibiotics and, if possible, is converted to intermittent catheterization before instrumentation of the bladder. URODYNAMIC EVALUATION
Urodynamic testing is of paramount importance to exclude the possibility of bladder denervation. Generally, studies include carbon dioxide cystometrography, external sphincter electromyography and a urethral pressure profile. When the patient is voiding a flow study and residual volume check are obtained. Cystometrography is done with the patient in the supine position initially and, if no detrusor reflex is observed, the upright position is used. Because some patients have a large capacity areflexic bladder the bethanechol chloride test is indicated to check for detrusor denervation (table 3). Although an increase in vesical tone was noted in some of the patients tested none met the criteria for denervation. All patients had TABLE
CLINICAL MATERIAL
During the last 2 years 12 patients (11 women and 1 man) with unexplained urinary retention have been examined at our clinic (table 1). At presentation 6 patients had Foley catheters, whereas the other 6 were seen after an episode of acute retention or after having problems related to a large residual volume. Five of the 12 patients had had psychiatric illnesses previously. Only 2 patients were seen after the first episode of retention and, in each, the retention was temporally to psychologic trauma. All patients had voiding difficulty as their main complaint and the urologist became primarily responsible for the complete evaluation. From this experience our group has developed a definite diagnostic study for evaluation. After the retention has been managed, by either an indwelling Foley catheter or intermittent catheterization, every patient undergoes an appropriate medical and neurologic examination (table 2). If obvious mental illness is present a psychiatrist is consulted early in the evaluation. The Minnesota Multiphasic Personality Index is useful in screening patients for subtle emotional illness and is given to all patients. In 9 patients in this series the Minnesota Multiphasic Personality Index suggested psychiatric consultation. Urologic scrutiny should be complete and include excretory urography, cystourethrography, cystoscopy and urodynamic study. Many patients, especially those with a Foley catheter, Accepted for publication November 23, 1977. Read at annual meeting of North Central Section, American Urological Association, Palm Beach, Florida, October 17-24, 1976.
L Clinical data on 12 patients with psychogenic urinary retention
Case No.SexAge (yrs.) l-F-37 2-F-21 3-F-22 4-F-66 5-F-42 6-F-26 7-F-32 8-F-16 9-F-28
10-F-26 11-F-34 12-M-26
TABLE
Retention Acute Acute- episodic Acute Acute - episodic Acute - episodic Incontinence - overflow Chronic- urethral catheter insertion Chronic-urethral catheter insertion Chronic - urethral catheter insertion Chronic-urethral catheter insertion Chronic- urethral catheter insertion Chronic-urethral catheter insertion
None None None Schizophrenia Depression Schizophrenia None None Schizophrenia None None Schizophrenia
2. Suggested studies for psychogenic urinary retention
Management of retention: Urethral catheter insertion Intermittent catheterization Medical evaluation Neurologic evaluation Psychiatric evaluation: Initially for obvious mental illness For all patients during diagnostic studies Minnesota Multiphasic Personality Index Urologic evaluation
191
Previous Psychiatric Illness
192
BARRETT TABLE
3. Results ofgas cystometrography in 12 patients with psychogenic urinary retention
Case
Sensation
Resting Urethral Closing Pressure (cm. water)
Maximal Reflex Capacity (ml.)
1 2 3 4 5 6 7 8 9 10 11 12
Normal Normal Normal Delayed Normal Delayed Delayed Normal Delayed Normal Normal Delayed
70 95 60 60 75 80 60 60 100 90 95 60
(420) Yes (375) Yes (700) No (850) No (500) Yes No (1,800) No (1,500) (450) Yes (750) No (550) Yes (600) Yes No (1,500)
TABLE 4.
Case
Not done Not done Neg. Neg. Not done Neg. Neg. Not done Neg. Not done Not done Neg.
Management of12 patients with psychogenic urinary retention* Hospitalization
1 2 3 4
No No No No
5
No
6
Yes
7
No
8 9 11
No Yes No No
12
Yes
10
Result of Bethanechol Chloride Test (2.5 mg. subcutaneously)
Status on Dismissal Normal voiding Normal voiding Normal voiding Normal voiding, intermittent self-catheterization Normal voiding, intermittent self-catheterization Normal voiding, intermittent self-catheterization Normal voiding, intermittent self-catheterization Normal voiding Intermittent self-catheterization Normal voiding Normal voiding, intermittent self-catheterization Intermittent self-catheterization
* All patients were instructed in the concept of bladder training and intermittent self-catheterization.
bladder sensations but patients with a large capacity bladder had markedly delayed sensations. Findings on the external sphincter electromyogram of these patients were similar to findings noted in many patients with
normal voiding who were studied in our urodynamic laboratory. All patients in the series had voluntary sphincteric control. Those who had demonstrable detrusor reflexes had concomitant relaxation of the pelvic floor musculature. Conversely, those without demonstrable detrusor reflexes had a progressive increase in striated muscle activity to the point of maximal bladder capacity. Results of urethral profilometry generally were normal and all profiles were of a normal parabolic configuration. CLINICAL APPROACH
Management includes the use of the bladder training concept, with or without intermittent self-catheterization, and concomitant psychiatric support when indicated (table 4). Bladder training consists of regulated fluid intake, regular voiding and the proper use of the Crede maneuver. 6 All patients are instructed in intermittent self-catheterization to be used to reduce residual volumes or during episodic acute retention, which frequently debilitates these patients. In this series only 3 patients required the structured environment of the hospital for instruction in bladder training; the other 9 were managed as outpatients. On dismissal from the urologic service 10 patients were voiding normally, although 5 of 10 supplemented the normal voiding with intermittent self-catheterization to reduce residual volumes. Two patients had severe degeneration of the detrusor muscle and were dependent on intermittent self-catheterization. REFERENCES
1. Rowan, E. L.: Psychophysiologic disorders of micturition. J. Amer. Coll. Health Ass., 23: 251, 1975. 2. Larson, J. W., Swenson, W. M., Utz, D. C. and Steinhilber, R. M.: Psychogenic urinary retention in women. J.A.M.A., 184: 697, 1963. 3. Emmett, J. L., Hutchins, S. P. R. and McDonald, J. R.: The treatment of urinary retention in women by transurethral resection. J. Urol., 63: 1031, 1950. 4. Emmett, J. L. and Love, J. G.: Vesical dysfunction caused by protruded lumbar disk. J. Urol., 105: 86, 1971. 5. Bradley, W. E., Timm, G. W. and Scott, F. B.: Cystometry. II. Central nervous system organization of detrusor ret1ex. Urology, 5: 578, 1975. 6. Abramson, A. S.: Advances in the management of the neurogenic bladder. Arch. Phys. Med. Rehabil., 52: 143, 1971.
Copyright © 1978
The ·vvil1iarns & '-Nilkins Co.
EVALUATION OF PSYCHOGENIC URINARY RETENTION DAVID M. BARRETT From the Department of Urology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
Urinary retention may develop in the absence of significant organic disease. Patients with psychogenic retention range from those with episodic acute retention to those who have learned to inhibit urination and have retention with a large residual urine volume owing to myotonic detrusor degeneration. A combination of thorough medical, neurologic, psychiatric and urologic evaluation is indicated for all such patients. Management consists of the implementation of bladder training with or without intermittent catheterization, which generally may be accomplished on an outpatient basis. A most perplexing problem in diagnosis and management involves the patient who is unable to void even though findings on neurologic and urologic examinations are normal. Although patients of all ages and both sexes may have transient urinary retention after severe trauma, general anesthesia or a herniated spinal disk, many patients with previously normal voiding histories - most being young or middle-aged women - retain urine in the absence of obvious causes. 1, 2 Further confusion is added because many appear to be stable psychologically. Historically, speculation on the exact cause of this disease process has included urethral or vesical neck obstruction, occult neurogenic bladder dysfunction and a silent protruded lumbar disk. The frustration regarding the cause and treatment has led to various surgical procedures on the urethra, vesical neck, bladder and spinal column.:i· 4 Based on the concept that urinary retention may develop secondarily to centrally mediated, subconscious inhibition of detrusor contraction or vesical outlet relaxation or both we have adopted a specific approach to this problem. 5
have urinary infection. Therapy is started with appropriate antibiotics and, if possible, is converted to intermittent catheterization before instrumentation of the bladder. URODYNAMIC EVALUATION
Urodynamic testing is of paramount importance to exclude the possibility of bladder denervation. Generally, studies include carbon dioxide cystometrography, external sphincter electromyography and a urethral pressure profile. When the patient is voiding a flow study and residual volume check are obtained. Cystometrography is done with the patient in the supine position initially and, if no detrusor reflex is observed, the upright position is used. Because some patients have a large capacity areflexic bladder the bethanechol chloride test is indicated to check for detrusor denervation (table 3). Although an increase in vesical tone was noted in some of the patients tested none met the criteria for denervation. All patients had TABLE
CLINICAL MATERIAL
During the last 2 years 12 patients (11 women and 1 man) with unexplained urinary retention have been examined at our clinic (table 1). At presentation 6 patients had Foley catheters, whereas the other 6 were seen after an episode of acute retention or after having problems related to a large residual volume. Five of the 12 patients had had psychiatric illnesses previously. Only 2 patients were seen after the first episode of retention and, in each, the retention was temporally to psychologic trauma. All patients had voiding difficulty as their main complaint and the urologist became primarily responsible for the complete evaluation. From this experience our group has developed a definite diagnostic study for evaluation. After the retention has been managed, by either an indwelling Foley catheter or intermittent catheterization, every patient undergoes an appropriate medical and neurologic examination (table 2). If obvious mental illness is present a psychiatrist is consulted early in the evaluation. The Minnesota Multiphasic Personality Index is useful in screening patients for subtle emotional illness and is given to all patients. In 9 patients in this series the Minnesota Multiphasic Personality Index suggested psychiatric consultation. Urologic scrutiny should be complete and include excretory urography, cystourethrography, cystoscopy and urodynamic study. Many patients, especially those with a Foley catheter, Accepted for publication November 23, 1977. Read at annual meeting of North Central Section, American Urological Association, Palm Beach, Florida, October 17-24, 1976.
L Clinical data on 12 patients with psychogenic urinary retention
Case No.SexAge (yrs.) l-F-37 2-F-21 3-F-22 4-F-66 5-F-42 6-F-26 7-F-32 8-F-16 9-F-28
10-F-26 11-F-34 12-M-26
TABLE
Retention Acute Acute- episodic Acute Acute - episodic Acute - episodic Incontinence - overflow Chronic- urethral catheter insertion Chronic-urethral catheter insertion Chronic - urethral catheter insertion Chronic-urethral catheter insertion Chronic- urethral catheter insertion Chronic-urethral catheter insertion
None None None Schizophrenia Depression Schizophrenia None None Schizophrenia None None Schizophrenia
2. Suggested studies for psychogenic urinary retention
Management of retention: Urethral catheter insertion Intermittent catheterization Medical evaluation Neurologic evaluation Psychiatric evaluation: Initially for obvious mental illness For all patients during diagnostic studies Minnesota Multiphasic Personality Index Urologic evaluation
191
Previous Psychiatric Illness
192
BARRETT TABLE
3. Results ofgas cystometrography in 12 patients with psychogenic urinary retention
Case
Sensation
Resting Urethral Closing Pressure (cm. water)
Maximal Reflex Capacity (ml.)
1 2 3 4 5 6 7 8 9 10 11 12
Normal Normal Normal Delayed Normal Delayed Delayed Normal Delayed Normal Normal Delayed
70 95 60 60 75 80 60 60 100 90 95 60
(420) Yes (375) Yes (700) No (850) No (500) Yes No (1,800) No (1,500) (450) Yes (750) No (550) Yes (600) Yes No (1,500)
TABLE 4.
Case
Not done Not done Neg. Neg. Not done Neg. Neg. Not done Neg. Not done Not done Neg.
Management of12 patients with psychogenic urinary retention* Hospitalization
1 2 3 4
No No No No
5
No
6
Yes
7
No
8 9 11
No Yes No No
12
Yes
10
Result of Bethanechol Chloride Test (2.5 mg. subcutaneously)
Status on Dismissal Normal voiding Normal voiding Normal voiding Normal voiding, intermittent self-catheterization Normal voiding, intermittent self-catheterization Normal voiding, intermittent self-catheterization Normal voiding, intermittent self-catheterization Normal voiding Intermittent self-catheterization Normal voiding Normal voiding, intermittent self-catheterization Intermittent self-catheterization
* All patients were instructed in the concept of bladder training and intermittent self-catheterization.
bladder sensations but patients with a large capacity bladder had markedly delayed sensations. Findings on the external sphincter electromyogram of these patients were similar to findings noted in many patients with
normal voiding who were studied in our urodynamic laboratory. All patients in the series had voluntary sphincteric control. Those who had demonstrable detrusor reflexes had concomitant relaxation of the pelvic floor musculature. Conversely, those without demonstrable detrusor reflexes had a progressive increase in striated muscle activity to the point of maximal bladder capacity. Results of urethral profilometry generally were normal and all profiles were of a normal parabolic configuration. CLINICAL APPROACH
Management includes the use of the bladder training concept, with or without intermittent self-catheterization, and concomitant psychiatric support when indicated (table 4). Bladder training consists of regulated fluid intake, regular voiding and the proper use of the Crede maneuver. 6 All patients are instructed in intermittent self-catheterization to be used to reduce residual volumes or during episodic acute retention, which frequently debilitates these patients. In this series only 3 patients required the structured environment of the hospital for instruction in bladder training; the other 9 were managed as outpatients. On dismissal from the urologic service 10 patients were voiding normally, although 5 of 10 supplemented the normal voiding with intermittent self-catheterization to reduce residual volumes. Two patients had severe degeneration of the detrusor muscle and were dependent on intermittent self-catheterization. REFERENCES
1. Rowan, E. L.: Psychophysiologic disorders of micturition. J. Amer. Coll. Health Ass., 23: 251, 1975. 2. Larson, J. W., Swenson, W. M., Utz, D. C. and Steinhilber, R. M.: Psychogenic urinary retention in women. J.A.M.A., 184: 697, 1963. 3. Emmett, J. L., Hutchins, S. P. R. and McDonald, J. R.: The treatment of urinary retention in women by transurethral resection. J. Urol., 63: 1031, 1950. 4. Emmett, J. L. and Love, J. G.: Vesical dysfunction caused by protruded lumbar disk. J. Urol., 105: 86, 1971. 5. Bradley, W. E., Timm, G. W. and Scott, F. B.: Cystometry. II. Central nervous system organization of detrusor ret1ex. Urology, 5: 578, 1975. 6. Abramson, A. S.: Advances in the management of the neurogenic bladder. Arch. Phys. Med. Rehabil., 52: 143, 1971.
