retention In newborns and infants, bladder outlet obstruction due to posterior urethral valves or obstructing ureteroceles must be identified In older children, posterior urethral valves must remain on the differential, as postoperative retention due to narcotics, fear of urination due to recent urethral manipulation, and children with severe constipation An important uncommon etiology that cannot be missed is that of augmented bladders that cannot be catheterized, as these are at risk for perforation Also, the practitioner should question the seemingly “simple” urinary retention with no obvious cause: rhabdomyosarcoma of the bladder or prostate may present with retention as the sole symptom Triage Considerations It is essential to determine who is sick, or who can get sick very quickly Any patient with a bladder augmentation who is in retention and unable to catheterize is at risk for bladder augment perforation—which becomes an emergent surgical matter Clinical Assessment Diagnosis begins with a careful history This will elicit not only medical history, including past surgeries, but also the history of a weak stream or difficulty initiating voiding may offer clues Duration of retention and symptoms experienced are also important in determining the treatment plan Management For the child with voluntary retention, gentle massage of the lower abdomen, combined with a soak in a warm tub, usually leads to spontaneous evacuation of the bladder Rarely does a child’s bladder become so distended, as after an outpatient surgical general anesthetic, that the child is unable to void It should be remembered that a child is able to hold urine voluntarily for longer periods than would be suspected; up to 12 hours is not unusual In order to actively drain the bladder, a catheter must be placed This can be done with a bladder catheter or small feeding tube Once the bladder is drained, a urinalysis and urine culture should be obtained Depending on the history, the catheter should be left indwelling, or can be removed after draining the bladder entirely If a catheter cannot be placed (due to previous surgery, or presence of obstruction or false urethral passage), then drainage via a suprapubic approach must be undertaken This can be performed with a needle if drainage and urine sample are needed alone, or a large tube can be placed with the assistance of interventional radiology or urology