Urinary retention is distressing for the patient and can present as a medical emergency. The two main causes of female urinary retention are that it is due to either structural outlet obstruction e.g. urethral stricture or functional outlet obstruction e.g. due to high tone of the external urethral sphincter muscle.
Patients in retention often present in clinic with psychological co-morbidities. However, it is not clear whether psychological distress is antecedent or subsequent to the urinary retention (or both). A retrospective case-note study reported a high prevalence of psychological co-morbidities (1). However, to date no prospective study has been reported. We present a preliminary prospective study.
Aim of study: To assess the psychological co-morbidities in a cohort of young women presenting with chronic urinary retention.

Female patients presenting to an academic Uro-Neurology department within a tertiary referral centre, for assessment of chronic urinary retention underwent a structured assessment by a chartered psychologist. The assessment comprised a semi-structured interview to assess current and history of psychological co-morbidities, current and past psychiatric history, details of current relationships, family.   The patients were also asked about whether they could identify a precipitating factor/ trigger for their urinary retention and asked for their views on their particular constellation of symptoms. Patients who had previously received a diagnosis of Functional Neurological Symptoms (FNS) were asked how they had received this diagnosis, what they understood it to mean and whether they accepted the diagnosis of FNS. At the end of the interview, where applicable, appropriate treatment pathways were sign-posted. For example, a patient reporting anxiety would be referred to their General Practitioner (GP) for treatment.

Between Jan-2018 to Dec-2018, 53 patients presenting with chronic urinary retention as the main issue, underwent a structured psychological assessment. There was one male patient (who is excluded from further study here) and 52 female patients. 
A total of 43/52 (82%) patients were experiencing current psychological difficulties including anxiety and/or depression interfering with at least one area of the patient’s life; 22/52 (42%) patients had experienced one or more traumatic events e.g. were survivors of rape, domestic violence, multiple road traffic accidents (RTAs) and these patients were still experiencing fear, anger, flashbacks. A total of 8/52 (15%) who were survivors of repeated childhood sexual abuse met the criteria for Complex PTSD (ICD-11). 
A total of 41/52 (79%) had chronic urinary retention plus functional symptoms including Functional Neurological Symptoms (FNS) and/or other functional syndromes including Fibromyalgia, Chronic Fatigue Syndrome, Irritable Bowel Disorder. 
In this study, Functional Neurological Symptoms (FNS) i.e. symptoms where no organic cause could be found, included leg weakness, movement disorders, paralysis, stroke, non-epileptic seizures, Bell’s Palsy, functional cognitive problems e.g. memory problems and functional hearing loss.

Findings from this prospective study suggest that a significant proportion of patients in urinary retention have a number of physical and psychological co-morbidities. Future studies should further explore whether there is an association. Drawing on the current literature and treatments for Functional Neurological Symptoms, we hypothesise that a proportion of these patients will be helped by psychoeducation, Guided Self Help (GSH), physical rehabilitation including physiotherapy, Cognitive Behavioural Therapy (CBT) or other psychological interventions (2). We hypothesize that some of these patients will be helped by treatment for trauma. Currently research into the most appropriate treatments for Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) is ongoing (3).

In this prospective study, a significant proportion of patients with urinary retention undergoing a structured assessment by a psychologist were found to have psychological co-morbidities and Functional Neurological Symptoms (FNS). Future study designs should include a battery of validated assessment scales in order to comprehensively describe and phenotype these patients.  Future research needs to be done to develop and test bespoke psychological interventions in this patient group and part of this work will be the development of cross-sectional and longitudinal explanatory case conceptualisations.

Stone, J, Carson, A, Sharpe, M. (2009) Functional Symptoms in Neurology: Management. JNNP; 2005; 76 (suppl 1): i13-i21.
Hoeritzauer, I., Stone, J., Fowler, C., Elneil-Coker, S., Carson, A. & Panicker, J.N. (2016) Fowler’s syndrome of urinary retention: a retrospective study of co-morbidity. Neurourology & Urodynamics; Jun 35 (5): 601-3.
Karatzias, T, Shevlin, M, Fyvie, C, Hyland, P, Efthymiadou, E, Wilson, D, Roberts, N, Bisson, J.I, Brewin, C.R. & Cloitre, M. Evidence of distinct profiles of Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) based on the new ICD-11 Trauma Questionnaire (ICD-TQ). Journal of affective Disorders; 207; 181-187.