Originally published at Pediatric EM Morsels on Nov. 4, 2020. Reposted with permission.

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Once again the Ped EM Morsels will address a topic that accentuates the fact that children are not aliens to be feared, but rather a special population of humans. Yes, children can be afflicted with conditions traditionally considered in adults (ex, Pulmonary Embolism, A-Fib, and Kidney Stones), but kids will often have different risk factors and associated conditions. Another entity that fits this description I encountered just this week. Let’s take a minute to review (what I had to review) on Urinary Retention in Kids:

Urinary Retention: Basics

• Urinary retention is uncommon in children.
• It is defined as a volume of retained urine > expected bladder capacity
  • Estimated Bladder Capacity in Ounces = Age in years + 2 [Gatti, 2001; Peter, 1993]
    • Remember Fluid Ounce = ~ 30 mL
  • Not defined by duration from last urination
    • May reflect other issues, like dehydration.

• Child may present with:
  • Dribbling or urine
  • Weak stream
  • Unable to initiate bladder emptying
  • Abdominal pain
  • Palpable abdominal mass (bladder above pubic bone)

Urinary Retention: Causes in Kids

• Infection
  • One of the most common causes [Peter, 1993]
  • Examples: Cystitis, Pyelonephritis
  • Systemic viral illnesses also implicated (ex, adenovirus, EBV) [Chu, 2013; Gatti, 2001]
• Neuromuscular Dysfunction
  • Are a prevalent cause in children. [Gatti, 2001]
  • Acute Disseminated Encephalitis (ADEM) [Burla, 2016]
    • Presents with paresthesias, paralysis, ataxia, vision changes, and/or altered mental status.
    • Often preceded by viral illness or vaccine administration.
  • Other examples: Guillain-Barre Syndrome, Multiple Sclerosis, Transverse Myelitis, Spina Bifida, Tethered cord [Burla, 2016; Gatti, 2001; Peter, 1993]
• Congenital Obstructive Lesions
  • Examples: Posterior urethral valves, Polyps [Peter, 1993]
• Constipation
  • Yup… that is a lot of stool!
  • Thought to be due to marked elevation of the bladder floor and posterior urethra by the distended rectum. [Gatti, 2001; Peter, 1993]
• Medications
  • Adverse drug effects are very commonly implicated. [Gatti, 2001]
  • ex, Cold medications, antihistamines, neuroleptics, alpha-adrenergic agonists
• Postoperative
• Renal Stones
• Misc.
  • Hypermagnesemia (newborn exposed to maternal Magnesium)
  • Voluntary overdistention [Peter, 1993]
    • Potty training may lead to avoiding urination, leading to increased bladder volume.
    • Stretching of the bladder beyond its normal capacity impairs its elastic properties and can hinder voiding.
  • Pelvic masses [Binder, 2015; Gatti, 2001]
  • Local inflammatory processes [Gatti, 2001]
    • Meatal stenosis, balanoposthitis, labial adhesions
  • Peri-apendiceal Abscess [Parrish, 1993]
  • Incarcerated inguinal hernia [Gatti, 2001]

• See Table 1 below, courtesy of Binder et al., 2015

Urinary Retention: Management

• Drain the bladder!
  • If the belief is that the cause is temporary (ex, constipation, voluntary overdistention), then may consider in-and-out cath to decompress bladder.
  • If unsure, or concern for other neurologic condition, place foley.
  • If not using a foley, patient will need to demonstrate ability to void on her/his own before discharge.
  • Children with UTIs may be instructed to soak in bath of warm water to help with urination (obviously, this is at their home… not your ED).
• Check for infection!
  • This is a prevalent cause, so don’t overlook UTI.
  • At the same time, don’t be too eager to diagnose UTI and overlook other more ominous signs.
• Perform a thorough Neuro Exam!
  • Of greatest concern – is there a spinal cord or other neurologic condition that is the cause?
  • Inspect the back carefully… look for evidence of occult spinal abnormalities.
  • If a clear reason is not obvious, have a low threshold for considering spinal imaging. [Gatti, 2001]
• What’s the Anatomy?
  • Even those who have a UTI, may have it because of an anatomic abnormality.
  • Consider Ultrasound:
    • Evaluate for hydronephrosis
    • Evaluate for masses
    • If not getting U/S in ED, ensure follow-up to consider imaging.

Moral of the Morsel

• It may be rare, but it does happen. As always, remain vigilant.
• Urinary retention is ominous. Don’t simply send the child home with a foley and a leg bag like you may do for the old gentleman with prostate problems.

Ddx of Urinary Retention

[Binder, 2015]

References