Urinary retention is 13 times less common in woman than it is in men, and the differential diagnosis is wide. In this EM Cases Best Case Ever we have the return of Dr. David Carr describing a woman with an unusual diagnosis who presents with urinary retention. We discuss issues around the appropriate use of chaperones and what to do in the situation when you are in over your head…

Podcast production by Anton Helman, May 2018

Differential diagnosis of female urinary retention


  • Uterine fibroids
  • Organ prolapse (cystocele, rectocele, uterine prolapse)
  • Gynecologic malignancy
  • Imperforate hymen


  • Vulvovaginitis/STI
  • Ischiorectal abscess
  • Bechet’s


  • Peripheral: Spinal mass/infection/bleed/trauma, cauda equina syndrome
  • Central: e.g. Multiple sclerosis

Medications – anticholinergic and alpha-adrenergic agonists


Summary of recommendations from The Royal College of EM Best Practice Guidelines on chaperones in Emergency Departments

1. The presence of a chaperone should be offered to all Emergency Department patients undergoing a “Sensitive Area Examination”, regardless of patient practitioner genders.

2. Chaperones need to be Emergency Department health care professionals or volunteers that have received appropriate training.

3. The presence or absence of a chaperone should be appropriately documented.

4. Vulnerable Emergency Department patients should be offered a chaperone for any examination or procedure.

5. If an Emergency Department patient declines a chaperone, the fact that one was offered and declined should be documented in the ED record.

6. A local hospital chaperone policy should be tailored to the specific requirements of patients within Emergency Department, and constraints within the Emergency Department.



Selius, B. et al. Urinary Retention in Adults: Diagnosis and Initial Management. Am Fam Physician. 2008 Mar 1;77(5):643-650.

Mevcha A, Drake MJ. Etiology and management of urinary retention in women. Indian J Urol. 2010;26(2):230-5.

The Royal College of EM Best Practice Guideline on chaperones in Emergency Departments. Full PDF