02 Clinical history

In 2002 Dr Michael Swinn, Prof Fowler and other colleagues looked back at the history of 91 women who had been diagnosed with Fowler’s syndrome (Swinn, Wiseman et al. 2002).

It was shown that patients were typically young women who had become unable to void and presented with painless urinary retention, with a residual volume exceeding 1 litre at some stage of the disorder.

The peak age found in that study is shown in this figure. The peak age was 27.7 years (range 10 to 50).

Peak age graph

Although some women experienced pain if bladder distension had become too extreme they had not reported the expected urgency at such a large bladder capacity. Straining did not help emptying and many women reported that what they felt they needed to do was to relax to get started.

The women often tell of an event prior to the onset of their retention (see figure above), such as an obstetric, gynaecological or urological surgical procedure using regional or general anaesthesia. That the surgical procedure can be distant from the pelvis and as minor as wisdom teeth extraction suggested that the significant factor was the general anaesthetic.

In some women it was possible to get a history of poor voiding with an interrupted flow before the onset of retention. Some said that they had noticed it took them longer to pass urine than other women. Most woman had been untroubled by this but such a history is indicative of a pre-existing abnormality. Why then a transient event such as a general anaesthetic should precipitate retention which does not resolve remains unknown and has undoubtedly been the cause of a number of medico-legal problems.

If a trial without catheter failed girls had either a long term indwelling urethral catheter inserted or were introduced to clean intermittent self catheterisation. Her loss of sensation of urgency and large capacity meant she could go for long intervals without catheterising. However catheterisation is often painful, particularly on removing the catheter, with many women complaining of a sensation of “something gripping” it as is it withdrawn. The discomfort with self catheterisation appears to be much greater for these girls than is reported by similarly aged young women with multiple sclerosis and it is not uncommon for the difficulties to be so extreme that a suprapubic catheter is required. This is clearly a thoroughly unsatisfactory arrangement for an otherwise healthy young woman.