Dr. Sharma is professor and head of psychiatry at Indira Gandhi Medical College & Hospital in Shimla, Himachal Pradesh, India. Mr. Thakur is surgeon at Civil Hospital Rampur in Shimla.
Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Ravi C. Sharma, MD, Professor & Head, Department of Psychiatry, Indira Gandhi Medical College & Hospital, Shimla (171001), Himachal Pradesh, India.
Tel: 91-177-2844644; Fax: 91-177-2658339; E-mail: email@example.com.
Acute urinary retention as a conversion symptom has received little attention in the literature and has been mostly considered as a diagnosis per exclusion. This is a case report of 20-year-old female who presented with acute retention of urine as a conversion symptom with strong psychological antecedents; she recovered completely by removing secondary gain, giving suggestions, and undergoing family counselling.
There is a scarcity of information in the literature about the cause and management of acute urinary retention in females in comparison to males.1 The causes of acute urinary retention can be divided into four etiologic groups: obstructive, neurologic, pharmacologic, and psychogenic.2 Females presenting with urinary retention in the absence of any identifiable neuro-anatomic cause for their symptom pose a diagnostic and management challenge and may be dismissed as psychogenic cases.3 The present case report highlights the importance of identifying and resolving psychological factors leading to acute urinary retention in a young female.
A 20-year-old unmarried female, student of class 12, presented in the Surgical Out Patient Department (OPD) of our hospital with the complaint of acute retention of urine. She gave a history of intermittent catheterization at the local primary health center thrice over the past 5 days after which she was referred to our hospital. There was no history of similar complaints in the past. Examination of the patient was unremarkable except for the palpable bladder. The patient was catheterized and investigated for retention of urine and urinary tract infection. Her urine routine as well as microscopic and culture examination were normal. Plain X-ray of the abdomen region, ultrasound of the abdomen, and pelvic organs were also normal. The patient was put on empirical treatment in the form of tablet ofloxacin 200 mg BID and hyoscine butyl bromide 10 mg TID, and was given a catheter-free trial which proved futile because she again developed retention. Psychiatric opinion was sought as the patient was not responding to the treatment, and urodynamic evaluation was planned.
Psychiatric evaluation revealed that the female who came from a rural nuclear family had been facing severe psychosocial stress due to her father who frequently used to quarrel with his wife and scold the patient quite often after consuming alcohol. Just a day prior to the onset of her symptoms, the patient’s father had created a ruckus in the house and had physically assaulted the patient. The patient was an average student and was described to be sincere, sensitive, and passive by nature. The initial mental state examination was unremarkable; however, on subsequent exploration the patient was found to be preoccupied with her ongoing family stress but was oblivious to her physical symptom (la belle indifference). In the absence of any evident physical cause for urinary retention and strong temporal association of the symptom with the family stress, the patient was diagnosed as a case of “Conversion Reaction” as per the International Classification of Diseases, Tenth Revision,4 criteria.
The secondary gain the patient was receiving from her relatives and medical professionals was minimized and she was given strong suggestions. She was also prescribed fluoxetine 20 mg/day along with alprazolam 0.25 mg at bed time. Her parents were counselled in detail and role of stress in the genesis of this symptom was explained. The father of the patient was enrolled for further evaluation and management of alcohol dependence in the psychiatry OPD. The patient’s catheter was removed the third day; she started passing urine normally and was discharged on the above medications with advice to follow up after 7 days in the psychiatry OPD. On follow-up visit the patient reported that she did not take any medications at home and was completely asymptomatic. The patient had been maintaining well even after 3 months of discharge when she last came for follow-up.
Urinary dysfunction due to psychogenic causes like conversion reaction and anxiety has been reported both in males and females.5 Psychogenic urinary retention has been described more frequently in young adult females with history of childhood enuresis and disturbed social backgrounds. Such patients have been frequently diagnosed as “hysteric,” with their symptom representing a displacement of unacceptable sexual wishes and impulse.6
In one study,7 psychogenic factors have been cited as the second important cause of retention of urine in females. The role of psychological disturbances in the genesis of acute and chronic urinary retention in females has also been reported by other authors.8-10 In the patient presented, there was no evidence of any physical or organic cause to explain her retention of urine, but there was a definite evidence of a family stressor preceding the development of this retention. Furthermore, the symptom resolved completely after appropriate suggestions, cutting down secondary gain, and family counseling. Therefore, the retention of urine in the present case qualifies to be labelled as conversion symptom.
The present case highlights the need for looking in to and resolving precipitating and or perpetuating psychological stressors also as a cause of acute urinary retention, especially in young females, before subjecting them to unnecessary urodynamic investigations and repeated catheterizations. PP
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4. International Classification of Diseases. 10th rev. Geneva, Switzerland: World Health Organization; 1992.
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