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The causes of urinary retention (Tables 92-1, 92-2 and 92-3) are categorized into several domains: obstructive, neurogenic, traumatic, infectious, operative, psychogenic, childhood, extraurinary, and pharmacologic.4,5,6,7 A detailed history of the present illness and physical examination, especially the neurologic examination, supported by imaging and urodynamic studies, reveal the cause in the majority of patients.
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The most common presentation is an elderly male with inability to void for several hours and lower abdominal distention or pain, secondary to benign prostatic hyperplasia.
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Collect past medical history to look for a history of prostatism, prostate or urinary bladder cancer, bladder calculi, indwelling urethral catheter or injury to urethra, prostate surgery, or pelvic radiation therapy. Ask about history of urinary urgency, frequency, or hesitancy; decreased force and caliber of stream; terminal dribbling; nocturia; and incontinence (typically due to overflow phenomena). Gross hematuria may indicate infection, bladder calculi, or urinary tract neoplasm. A patient with urethral stricture may have a history of Foley catheter insertion, cystoscopy, trauma, or previous radiation therapy or infection. Collect any history of new medications, including common cold preparations, anticholinergics (including bronchodilators), sympathomimetic agents, and psychogenic and other potential agents (Table 92-3). Obtain a detailed neurologic history, looking for a causative lesion from high cortical function down to peripheral nerves that determine end-organ function. Identify possible spinal cord injury by determining recent activities including any remote trauma.
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Fever, tachycardia, tachypnea, and hypotension suggest infection or sepsis. Hypertension or tachycardia may be transient and may resolve after bladder decompression. Consider urinary retention in patients complaining of lower abdominal pain, even if they do not offer urinary complaints. On abdominal examination, palpitate or percuss from the epigastric area to the lower abdomen to identify a painful mass (distended bladder) in the lean patient. Examine the external genitalia to identify phimosis, paraphimosis, meatal stenosis or stricture, or evidence of urethral or penile trauma.
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Perform digital rectal examination (either before or after relief of obstruction, depending on patient comfort) to evaluate the anal-rectal area and prostate, assessing anal tone, perineal sensation, prostate enlargement, stool impaction, and any possibility of malignancy. A nodular or rock-hard prostate may suggest prostate cancer, which must be confirmed at a later date. Women with urinary retention should receive a pelvic examination to detect possible inflammatory lesions or pelvic or adnexal masses. Perform a neurologic examination to determine any neurogenic cause. After successful drainage of the distended bladder, a repeat physical examination of the lower abdomen is indicated to help exclude an unresolved extraurinary bladder problem (e.g., appendicitis) needing further management.