Psychogenic Urinary Retention in Women

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					       Psychogenic Urinary Retention in Women
                                           Report of a Case

                                    A. H. CHAPMAN, M.D.*

IN 1956 WILLIAMS AND JOHNSON 1                        Emmett and co-workers4 reviewed 76 cases
published the first psychiatric study of a            of urinary retention in women seen at the
case of urinary retention in women. Al-               Mayo Clinic and found that organic pathol-
though they urged more attention to emo-              ogy could rarely be demonstrated. Much
tional factors in this common urological              speculation has been made on neurogenic,
problem, I have been able to find no fur-             endocrinological, and inflammatory etiol-
ther psychiatric studies published on the             ogies, but no consistent or significant sub-
problem since then. A second such case of             stantiation of such hypotheses has been
urinary retention, psychiatrically studied            found.
and treated over a 4-year period, is reported            Despite this lack of etiologic understand-
here.                                                 ing, the problem frequently is approached
   Much attention has been devoted in the             surgically. The surgical therapeutic opin-
urological literature to the problem of               ion is put concisely by Emmett when he
urinary retention in women. 2 ' 3 ' 4 The             writes: "Fortunately, successful treatment
problem is, as stated by Emmett, ". . . of            may be carried out without an accurate
more common occurrence than is generally              knowledge of the etiologic factors involved.
appreciated." Williams and Johnson give               Transurethral resection of the neck of the
a good selected bibliography and review               bladder is the treatment of choice." It is
the medical literature on this subject. All           indeed rare in modern medicine for surgi-
of the work on this subject, with the ex-             cal treatment to be advocated routinely in
ception of this study by Williams and                 a condition of which the pathology is un-
Johnson, has been done by urologists, and             clear and the etiology unknown. Williams
the therapeutic orientation has been solely           and Johnson presented a convincing study
surgical. Resection of the vesicle neck of            of such a case in which psychiatric pathol-
the bladder and various other procedures              ogy was clearly relevant and in which psy-
have been advocated.                                  chiatric treatment resulted in the cure of
   The most striking feature of the litera-           the patient. This article presents a similar
ture on this subject is the general agree-            case, psychiatrically studied over a 4-year
ment that anatomic pathology usually can-             period and resulting in therapeutic success.
not be found to explain the disturbance.
                                                                      Case Report
  •Assistant Clinical Professor of Psychiatry, Uni-      This 31-year-old, white, Catholic, married
versity of Kansas School of Medicine, Kansas City,    schoolteacher was seen in hospital consultation
Kansas.                                               after she had been hospitalized for 7 weeks with
  Received for publication December 5, 1958.          intractable urinary retention.
VOL.   xxi,   NO.   2, 1959
120                                      PSYCHOGENIC URINARY RETENTION
   Her first episode of urinary retention had oc-   of her psychotherapy and during a period of 2
curred previously when she was 14 years old,        years since then, no further urinary retention
At that time the patient had been hospitalized      has occurred. The patient received no further
for a minor surgical procedure that did not re-     organic medical treatment for her urinary re-
quire a general anesthesia. After several days in   tention following the psychiatric consultation.
the hospital she had developed urinary reten-          The patient was the younger of 2 children,
tion, which did not respond to any conserva-        having a sister 4 years older than herself. The
tive procedures. For the following several          patient's mother died 6 months following the
weeks, the patient had to be catheterized twice     patient's birth, and the patient was raised by
daily, and upon catheterization amounts ol          her paternal grandmother in a home supplied
urine up to 1100 cc. in volume were obtained.       by her father. Following her mother's death
   Cystoscopy, cystometric studies of bladder       her father went into a prolonged depression
function, retrograde pyelograms, neurological       and during the first several years of the child's
examination, and studies of the cerebrospinal       life had relatively little to do with her. In addi-
fluid dynamics and biochemistry revealed no         tion to the paternal grandmother, a succession
abnormalities. All other physical and bio-          of housekeepers assisted in rearing the patient.
chemical studies, which were extensive, re-             Throughout the first 12 years of the patient's
vealed no abnormalities. In spite of this, surgi-   life, her mother was constantly held up to her
cal intervention with resection of the neck of      as an ideal to be emulated in all respects. Any
the bladder was advocated. The patient's rela-      shortcomings or misdeeds of the patient were
tives demurred, and after a period of time the      contrasted with the alleged exemplary behavior
patient gradually recovered.                        of her mother under all circumstances. Her
   The second episode of urinary retention, and     mother had been a successful and talented
the one for which psychiatric consultation was      woman, and the patient was forced into the
requested, occurred when the patient was 31         various areas of achievement in which her
years old. She had been hospitalized for a rela-    mother had excelled. The patient's perform-
tively mild virus pneumonia, and after several      ance in all these areas was, however, constantly
days of hospitalization she again developed         compared with the superior achievements of
urinary retention. The urinary retention was        her mother. Moreover, certain relatives gave
complete and persistent, and the patient was        the patient the impression that if the patient's
catheterized repeatedly over a 7-week period,       mother had not been pregnant with the patient
with amounts of urine ranging up to 1200 cc.        she could have received medical treatment
in volume being obtained upon catheterization.      much earlier for the condition from which she
Again the extensive urological studies were re-     eventually died and her life therefore saved.
peated, including cystoscopy, retrograde pyelo-     The patient was left with the impression that
grams, and cystometric studies of bladder func-     in a sense she had been inadvertently respon-
tioning; also, a neurological examination was       sible for her mother's death.
made. All of these studies, in addition to ex-          The patient's childhood was influenced per-
tensive other biochemical and physical studies,     vasively by her mother's achievements and un-
were within normal limits. Many conservative         timely death. The patient, beginning at the
medical measures failed to relieve the patient's     age of about 4 years, had a florid fantasy life
symptomatology. Surgical intervention was            concerning her mother. In these fantasies, the
suggested again, although it was admitted that       patient imagined her mother as failing at many
no urological pathology had been discovered          activities and her relatives praising the patient
on any of the examinations.                          instead. At times, with painful mixtures of
    At the end of 7 weeks of hospitalization for     pleasure and guilt, she actively fantasied the
 this symptom, psychiatric consultation was re-      death of her mother. She fantasied herself in
quested. A course of psychotherapy was begun         successful competition athletically and artis-
after the consultation, and within several weeks     tically with the mother. During her sixth and
 the patient's symptomatology improved to the        seventh years she had florid fantasies of her
point that she could be discharged from the          mother being tortured and strangled and suffer-
hospital. The patient's psychotherapy con-           ing gruesome punishments at the hands of vari-
 tinued, however, over a 4-year period, during       ous relatives and other persons. The patient
which time there were at first brief recurrences     felt that her father, in his depressed withdrawal
of her symptomatology. During the last 2 years       from her, blamed the patient for the death of
                                                                          PSYCHOSOMATIC MEDICINE
CHAPMAN                                                                                           121
the mother and could not forgive the patient         The patient feared contacts with physicians
for having caused the death of a woman who           and hospitalizations as the preludes to death.
was so much superior to herself.                     Illness of relatives constantly bore for her the
   One of the most painful and recurrent ex-         threat of another death in the family, for which
periences of the patient's childhood was visiting    she would feel another burden of guilt because
the grave of her mother. Two maternal uncles         this death, too, had been necessary for her con-
made a practice of taking the patient to visit       tinued survival. Thus, the 2 periods of urinary
the grave of her mother at least once every          retention occurred when she herself had been
month or 6 weeks. If the patient showed any          hospitalized for some type of illness. At the
reluctance to make the trip, she was greatly         time of these hospitalizations she consciously
criticized. Beginning at the age of 8 or 9 years,    thought that her own time of death had come.
the patient had the persistent experience of a       She envisioned these hospitalizations as the pre-
fullness of the bladder and the urge to urinate      ludes to chains of circumstances that would lead
whenever she went to the cemetery to see her         to her death, in which she finally would be
mother's grave. This became a conscious feel-        caught up in the chain of guilt that had begun
ing that she would like to urinate upon her          with the death of her mother.
mother's grave and thus show her scorn and              One further crucial facet of the patient's
fury toward this woman who had caused her,           psychopathology concerned an obsessive fear
inadvertently, so much grief, bitterness, and        that she was doomed to lead a life patterned
difficulty. She had fantasies of the horror of       after her mother's life. She feared that she
her uncles when she would urinate upon her           would survive into adulthood only to die of
mother's grave. This fantasy of urination upon       some dread disease shortly following the birth
her mother's grave was a frequent experience         of a child. Approximately 1 year following the
over a several-year period and dropped out of        birth of her first child, she was hospitalized,
consciousness only at puberty.                       much again her inclination, for virus pneu-
    Another powerful set of fantasies concerned      monia. The patient consciously feared that this
the influence of numerous deaths in the family       was the dreadful punishment coming due; she
 upon the patient. From early childhood on-           feared that, following her mother's pattern, she
 ward, the patient had the feeling that she was      also was now being hospitalized and a chain
alive only at the cost of her mother's death.        of events was being started that would lead to
During her childhood there were several more         her death. In this way she felt she would, in
deaths of close relatives, including the paternal    a talion manner, finally relieve the terrible
grandmother and 2 close uncles. The patient          guilty debt she had incurred by causing her
developed the fearful, obsessive fantasy that,       mother's death. It was thus an overtly terrified
just as her life had been made possible origi-       woman who entered the hospital for virus
nally by her mother's death, in a sacrificial way     pneumonia, which was followed shortly by her
 her life could be prolonged further only by          second period of urinary retention.
 periodic deaths of other relatives. She felt that       In psychotherapy it became clear that the
once every 4 or 5 years some relative had to          urinary retention was felt also to be a talion
die in order that her life could be prolonged.        punishment for her guilty wish of many years
Thus, the patient felt guilty not only for the        to urinate upon her mother's grave and thus
death of her mother but also for the deaths ot        show her scorn and hostility towards her
 the succeeding relatives. All of this material       mother. Her punishment was to be made com-
had never been expressed to any one and came          plete by the onset of an eventually fatal illness
out for the first time as an interpersonal com-       that was being started by urinary retention.
munication in the psychotherapeutic experi-              In the course of a 4-year psychotherapeutic
 ence. Much of this material had been lost to         experience, the above data were worked out
 the patient's conscious memory about the time        and confirmed repeatedly from different facets
 of puberty and was recovered in psychotherapy,       of exploration. Extensive characterological
 although the fearful fantasy that her own life       changes occurred in the patient during this pe-
could go on only at the cost of periodic sacri-       riod of time. At the beginning of treatment she
 ficial deaths by other relatives remained con-       was a very passive, tense girl, who was unable
scious.                                               to assert any angry feelings. She was treated by
    One further and very important feature con-       her relatives as a pleasant but immature per-
cerned the role of doctors and hospitalizations.      son, whom they frequently imposed upon and
VOL.   xxi,   NO.   2, 1959
122                                      PSYCHOGENIC URINARY RETENTION
exploited in numerous ways. At the end of          symptomatology of the patient was a severe
treatment she was a much more confident, self-     obsessive neurosis.
assertive person, who shouldered many respon-         It is felt that these 2 psychiatrically
sibilities and handled her interpersonal rela-     studied cases of urinary retention in wom-
tionships in a much more self-confident man-
ner. Clinical psychological testing done in the    en offer significant evidence that emotional
early part of treatment confirmed the clinical     pathology perhaps may often lie behind the
findings and emphasized the inner turmoil of       symptom of urinary retention in women.
this girl, especially in relationship to her de-   Further psychiatric exploration and study
ceased mother. In psychological testing, anxiety   of this disorder is certainly indicated in
and obsessive features were prominent; there       order to throw light upon a problem that
was no evidence of underlying schizophrenic        now is frequently dealt with by surgical
elements.                                          intervention even though anatomic pathol-
                                                   ogy admittedly is not evident.
   The psychopathology of this patient                                       Summary
differs somewhat from the psychopathology            A case of psychogenic urinary retention
of the patient described by Williams and           in a woman is presented, and the psycho-
Johnson. Their patient had been subjected          pathology behind the symptom is outlined.
to a good deal of sexual trauma by her             The symptom was found to be rooted in
stepfather, culminating in seduction and           severe and extensive emotional trauma in
rape by him. The major part of the                 the patient's childhood, and its relation-
psychotherapy of their patient centered            ship to the urinary tract was evident. Fur-
around the exploration of her murderous            ther exploration and study of this prob-
rage and hostility toward the stepfather.          lem from the psychiatric point of view is
Their patient's bouts of urinary retention         urged.
occurred when her murderous hostility to-
ward her stepfather threatened to become
conscious. Working out these emotional                                       References
traumata and problems resulted in the              1.   WILLIAMS, G.     E.,    and   JOHNSON, A.        M.     Recur-
eventual elimination of her symptomatol-              rent urinary retention due to emotional factors:
ogy-                                                  Report of a case. Psychosom. Med. 18:11, 1956.
                                                   2. YOUNG, H. H. The pathology and treatment of
   The problems of our patient surrounded             obstructions at the vesicle neck in women.
her relationship with her mother, as out-             J.A.M.A. 115:2132, 1940.
lined in the case study. It was clear that         3. WINSBURY-WHITE, H. P. Two cases of retention
woven into the patient's symptomatology               of urine in women. Lancet i:1008, 1936.
                                                   4.   EMMETT, J.     L.,     HUTCHINS, S.   P.   R.,        and   MC-
and neurosis was an extensive and deeply                DONALD, J. R. The treatment of urinary re-
rooted obsessive process. Indeed, it might              tention in women by transurethral resection.
be stated that behind the psychosomatic                 / . Urol. «:1031, 1950.

                                                                                PSYCHOSOMATIC MEDICINE