Differential diagnosis, investigations and treatment
The differential for the acute urinary retention included pelvic floor muscle spasticity, narcotic exposure, and/or vasculopathy secondary to multiple comorbidities. In our patient’s case, her narcotic exposure played the primary role in her retention complaint.
The patient, a former nurse, began intermittent self-catheterization (ISC) upon its onset and began a trial of tamsulosin. Experiencing no benefit with the tamsulosin one week later, the patient declined to continue ISC and stopped the medication. An indwelling urinary catheter was placed. Nitrofurantoin was prescribed for infection prophylaxis while the indwelling catheter was in place.
Multiple voiding trials were performed for up to three weeks following symptom onset. Further diagnostic testing was performed. Cystoscopy showed diffuse inflammation and moderate trabeculations. Urodynamics demonstrated decreased bladder compliance during filling with a decreased bladder capacity. Voiding pressure studies revealed minimal detrusor contraction with a valsalva effort and an intermittent voiding pattern with minimal output. EMG demonstrated no abnormalities during testing.
To determine if the morphine IPP was related to the patient’s urinary retention, the pain management specialist decreased the basal rate of the IPP from morphine sulfate 100 mcg daily to 90 mcg daily. However, the basal rate was increased back to the initial rate within 5 days due to patient complaints of burning in her legs related to peripheral neuropathy.