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.