Title : “Not just a UTI”: A rare presentation of acute urinary retention in a young woman due to genital herpes
Abstract:
Background: Acute urinary retention (AUR) is an uncommon emergency presentation in women and warrants a broad and systematic diagnostic approach. While obstructive, neurological, pharmacological, and infective causes are well-recognised, genital herpes is rarely considered the primary cause, especially in the absence of overt lesions or disclosure from the patient.
Case Presentation: A woman in her 30s, previously fit and well, presented with sudden-onset urinary retention and dysuria. She was sexually active but denied any history of trauma, recent illness, constitutional symptoms, or prior neurological issues. Her medical history was unremarkable, with no diabetes, no previous urinary symptoms, and no regular medications. Clinical examination revealed a non-pregnant abdomen, mild suprapubic tenderness, and no flank pain or Giordano’s sign. Neurological assessment of the lower limbs was normal.
Despite no volunteered history of genital lesions, a meticulous genitourinary examination revealed vesicular lesions on the vulva, prompting consideration of genital herpes as the cause of her urinary retention. Elsberg syndrome, a manifestation of lumbosacral radiculitis often associated with HSV-2, was also considered as a differential.
She was catheterised and commenced on empirical treatment with oral valaciclovir, topical aciclovir, lidocaine jelly, and metronidazole, following collection of bloods, urine microscopy, culture and sensitivity (MCS), and genital swabs. Blood tests showed mildly elevated CRP (12 mg/L), WCC of 10.4×10?/L, and normal renal and liver profiles. Urine microscopy revealed pyuria and haematuria, though cultures were negative. Genital swabs confirmed HSV-2 infection.
The patient was admitted for analgesia and monitoring for potential development of neurological signs. Over the next 48 hours, her pain improved and there was no clinical evidence of sacral radiculopathy. Post-catheter removal, she was able to void spontaneously. She was discharged with follow-up arranged through genitourinary medicine services.
Discussion: This case underscores the importance of a thorough history and physical examination in young female patients presenting with AUR. HSV-2 should be a differential in sexually active patients, especially when neurological symptoms or lesions are subtle or unreported. Elsberg syndrome should be considered where lumbosacral radiculitis or neurogenic bladder features emerge. While obstructive, infective, and neurogenic causes are common considerations, functional and pharmacological causes should not be overlooked.
Conclusion: AUR in women is a red flag presentation and requires a comprehensive approach to diagnosis. Emergency physicians should be alert to rare infective causes such as genital herpes, even in the absence of overt symptoms. This case illustrates how thorough clinical examination and high index of suspicion can help avoid misdiagnosis and facilitate early targeted treatment.
