Case Presentation: A previously healthy 20-year-old male presented with sudden onset urinary retention. He reported mild headaches, fevers, fatigue later followed by acute urinary retention associated with lower abdominal and back pain. Last void was over 24 hours ago. Vitals were stable except for a temperature of 39.9°C. No cervical neck stiffness, meningeal irritation or focal neurologic deficits on physical examination. Rectal tone and prostate examinations were normal with no sensory loss in perineum. Foley catheter was inserted with >1L of clear urine output with resolution of abdominal and back pain. CT head, abdomen and pelvis were unremarkable. Due to acute urinary retention with unexplained fevers and headaches, a lumbar puncture was performed, revealing nucleated cell count of 27/mm3 with monocytic pleocytosis, mildly decreased glucose level of 67mg/dl (serum glucose 198mg/dl), and mildly elevated protein of 71mg/dl. CSF HSV, VZV, EBV, CMV, enterococcus and HTLV were negative with no bacteria identified. Given abnormal CSF analysis suggestive of aseptic meningitis, MRI brain and lumbar spine were performed to rule out Acute Disseminated Encephalomyelitis (ADEM) with unremarkable results. He was started empirically on dexamethasone, vancoymcin, acyclovir, ampicillin and ceftriaxone. He remained afebrile without identifiable source of infection hence antibiotics and antivirals were discontinued. Despite multiple voiding trials, he continued to have high post void residuals and was discharged on clean intermittent catheterization and tamsulosin.
Discussion: Meningitis Retention Syndrome is a combination of aseptic meningitis and acute urinary retention. MRS is a rare disorder with an unknown prevalence, mainly caused by viruses with the reported exception of Neisseria meningitidis and Listeria monocytogenes. Patients typically present with headaches, fever, stiff neck and urinary retention. The diagnosis of MRS is challenging and is often confused with ADEM, which typically presents after vaccination or exanthematous infections along with signs of encephalitis, myelitis, including brain and spinal cord lesions. MRS is considered to be a mild variant of ADEM with selective lower urinary tract involvement usually of 2-10 weeks’ duration. Urodynamic studies demonstrate an acute shock phase of detrusor areflexia with an unrelaxing sphincter, followed by a phase of detrusor overactivity suggesting an upper motor neuron etiology. MRS is a benign, self-limiting disease, diagnosed by exclusion and has a very good prognosis. Early management of acute urinary retention by clean intermittent catheterization prevents bladder injury from over distention. The role of steroids is still unclear.
Conclusions: Acute urinary retention is a urologic emergency and is uncommon except in older males. MRS should be in the list of differentials especially in young healthy adults with acute urinary retention. Patients must be reassured that MRS is a self-limiting disease with an excellent prognosis.