Acute Urinary Retention and Catatonia in a Schizophrenic Male Patient

Acute Urinary Retention and Catatonia in a Schizophrenic Male Patient

To the Editor: Aside from the psychiatric manifestations, catatonia can be accompanied by medical comorbidities.1 One such complication is urinary retention.1,2 We describe a case of urinary retention associated with catatonia in which both conditions responded to benzodiazepine treatment.

Case report. The patient is a 35-year-old man with a history of schizophrenia who was initially admitted to an inpatient psychiatric hospital for treatment of an acute exacerbation of his illness secondary to noncompliance with psychiatric medications. While in the psychiatric hospital, the patient refused all medications, and his condition deteriorated. He was subsequently transferred to the medical emergency department for evaluation of a distended abdomen.

With the exception of tachycardia (126 bpm), his vital signs were within normal limits. The laboratory examination found no abnormalities in complete blood count, comprehensive blood panel, or urinalysis. His urine drug screen was negative, and a head computed tomography (CT) scan was unremarkable. The abdominal ultrasound and CT scan showed significant urinary retention (1,200 cc), with no evidence for obstruction noted. The patient underwent urinary catheterization and subsequent Foley catheter placement secondary to continued urinary retention.

The psychiatric consultation and liaison service was consulted and confirmed the above medical and psychiatric history. Psychiatric examination revealed stupor, negativism, mutism, echolalia, waxy flexibility, posturing, and catalepsy. A synthesis of the psychiatric history, course of illness, and the psychiatric and medical evaluations suggested the diagnosis of catatonia (DSM-5 criteria3) with comorbid urinary retention.

Following the administration of lorazepam 3 mg, the patient’s catatonic symptoms resolved. He was admitted to the general medical department for continued monitoring of urinary output and for bladder training. Recommendations were given for maintenance intravenous benzodiazepine treatment (lorazepam at a dose of 1 mg every 8 hours).

During psychiatry consultation liaison rounds the following day, it was noted that the recommendations for maintenance lorazepam treatment had not yet been instituted. The patient was found to be in a catatonic state with continued urinary retention. A second lorazepam challenge test of 2 mg resulted in resolution of the catatonia. Within 2 hours of a second lorazepam challenge, the Foley catheter was removed, and the patient was able to empty his bladder of his own volition. He was continued on a maintenance dose of lorazepam 1 mg by mouth every 8 hours. While the patient’s catatonia and urinary retention continued to demonstrate a favorable response, psychosis remained. After a 4-day medical admission, the patient was transferred back to the inpatient psychiatric facility for continuation of psychiatric care.

While there is a great degree of anecdotal information regarding the relationship between catatonia and urinary retention, we found few published articles describing the phenomenon. Aside from the reported side effects associated with antipsychotic administration,4,5 a PubMed search using the terms catatonic, catatonia, schizophrenia, and urinary retention retrieved only 2 case reports6,7 documenting the relationship. One case6 reported the resolution of both catatonia and urinary retention in a schizophrenic patient status after electroconvulsive therapy treatment. The second case7 reported a temporal relationship between the resolution of urinary retention and the remission of psychotic symptoms in a patient with schizophrenia.

Our patient’s response to the lorazepam suggests that the positive treatment response was mediated by modulation of the γ-aminobutyric acid (GABA) system.8 This effect may be related to the role that the GABA system has on the central nervous system9,10 or possibly an effect on the peripheral nervous system’s ability to modulate sphincter control.11

Catatonia remains an underdiagnosed medical condition.12,13 When catatonia is not diagnosed promptly, treatment of the condition itself as well as the associated medical comorbidities is delayed. Further research is required to assess the relationship between catatonia and urinary retention.

References

1. Jaimes-Albornoz W, Serra-Mestres J. Catatonia in the emergency department. Emerg Med J. 2012;29(11):863-867. PubMed doi:10.1136/emermed-2011-200896

2. Levenson JL. The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill. 2nd ed. Washington, DC: American Psychiatric Pub.; 2011.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

4. Bozikas V, Petrikis P, Karavatos A. Urinary retention caused after fluoxetine-risperidone combination. J Psychopharmacol. 2001;15(2):142-143. PubMed doi:10.1177/026988110101500201

5. Hsu WY, Chang TG, Chiu NY. Aripiprazole associated urine retention in a male schizophrenia patient. Gen Hosp Psychiatry. 2013;35(6):680.e11-680.e12. PubMed doi:10.1016/j.genhosppsych.2013.04.008

6. Regestein QR, Kahn CB, Siegel AJ, et al. A case of catatonia occurring simultaneously with severe urinary retention. J Nerv Ment Dis. 1971;152(6):432-435. PubMed doi:10.1097/00005053-197106000-00007

7. Shiloh R, Weizman A, Dorfman-Etrog P, et al. Association between severity of schizophrenic symptoms and urinary retention. Eur Psychiatry. 2001;16(8):497-500. PubMed doi:10.1016/S0924-9338(01)00612-5

8. Bush G, Fink M, Petrides G, et al. Catatonia, II: treatment with lorazepam and electroconvulsive therapy. Acta Psychiatr Scand. 1996;93(2):137-143. PubMed doi:10.1111/j.1600-0447.1996.tb09815.x

9. Daniels J. Catatonia: clinical aspects and neurobiological correlates. J Neuropsychiatry Clin Neurosci. 2009;21(4):371-380. PubMed doi:10.1176/jnp.2009.21.4.371

10. Northoff G. What catatonia can tell us about "top-down modulation": a neuropsychiatric hypothesis. Behav Brain Sci. 2002;25(5):555-577, discussion 578-604. PubMed doi:10.1017/S0140525X02000109

11. Andersson KE. Treatment-resistant detrusor overactivity—underlying pharmacology and potential mechanisms. Int J Clin Pract suppl. 2006;(151):8-16. PubMed doi:10.1111/j.1742-1241.2006.01184.x

12. Tandon R, Heckers S, Bustillo J, et al. Catatonia in DSM-5. Schizophr Res. 2013;150(1):26-30. PubMed doi:10.1016/j.schres.2013.04.034

13. Carroll BT, Anfinson TJ, Kennedy JC, et al. Catatonic disorder due to general medical conditions. J Neuropsychiatry Clin Neurosci. 1994;6(2):122-133. PubMed doi:10.1176/jnp.6.2.122

Edgar A. Torres Villamil, MDa

Robert Gonzalez, MDa

[email protected]

aDepartment of Psychiatry, Paul L. Foster School of Medicine, Texas Tech University Health Science Center, El Paso

Potential conflicts of interest: None.

Funding/support: None.

Previous presentation: The case was presented in poster format at the Ninth Annual Research Colloquium, Texas Tech University Health Science Center; May 11-14, 2015; El Paso, Texas.

Published online: November 10, 2016.

Prim Care Companion CNS Disord 2016;18(6):doi:10.4088/PCC.16l01941

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