In this case series, four elderly patients were admitted to the hospital with catatonia associated with severe depressive illness. There were three males and one female. The ages of the patients ranged from 66 to 84 years old. These patients were additionally diagnosed with urinary retention, a recognized medical complication of catatonia. Due to severe illness in all patients, ECT was pursued as the preferred treatment option. Upon completion of ECT, all four patients experienced resolution of urinary retention concurrent with the improvement of depressive illness and catatonic symptoms. As a result of prompt diagnosis and treatment of catatonia and urinary retention, all four patients clinically improved in the hospital and were discharged without the requirement of urinary catheter insertion.
To our knowledge, this is the first study that describes the severity of catatonia and urinary retention using validated scales and bladder volume measurements throughout the treatment course. Furthermore, there are no prior reports specifically describing catatonia-related urinary retention among geriatric populations despite the recognized impacts and risks of urinary retention in elderly populations.
The precise mechanisms by which catatonia leads to urinary retention remain unclear, athough it is no surprise that the brain and bladder must communicate. Previous studies have explored the connection between anxiety and urinary dysfunction, however, these studies are limited to animal studies or brief clinical case descriptions.13,14 To our knowledge, there are no studies describing the mechanism or link between catatonia and bladder function.
The Role of GABA-A in Micturition, Anxiety, and Catatonia:
Interestingly, gamma-aminobutyric Acid-A (GABA-A) appears to play a significant role in the coordination of bladder function through different pathways linking the brain, spinal cord and bladder.15 GABA-A helps coordinate the timing and control of micturition, ensuring the appropriate sequence of muscle contraction and relaxation for effective bladder emptying.16 However when GABAergic signaling becomes altered or dysfunctional, as in catatonia, it remains unclear how or which specific pathway becomes altered and whether this involves neuronal excitation, disruption of spinal reflex modulation, supraspinal control disruption, or muscle tone dysregulation. One animal study has also demonstrated that the elimination of glutamatergic neurons in the PMC results in urinary retention.17,18
The prefrontal cortex (PFC) plays a key role in the voluntary control of bladder function, allowing individuals to delay or initiate micturition based on social, environmental, or situational factors.19,20 The PFC provides input to the periaqueductal gray (PAG) which subsequently results in activation or suppression of the pontine micturition center (PMC).21 The PMC is then responsible for the supraspinal regulation of micturition via descending fibers throughout the spinal cord.22 (Figure 1). Higher brain centers contain neurons that receive sensory and motor inputs that are responsible for initiating urination while others are responsible for urine storage.23
GABA-A receptors have also been implicated in the modulation of stress and anxiety.24,25 Some researchers have even described catatonia as an outward representation of severe anxiety.26,27,28 As such, one widely accepted theory for catatonia describes alterations in GABA-A receptors and activity throughout various circuitries including the motor loop (i.e., the region between the motor cortex and basal ganglia), and as a result of GABA-A dysfunction occurring in the prefrontal cortex (PFC) and orbitofrontal cortex (OFC).29,30 Alterations in the glutamatergic system, particularly NMDA-receptors, have also been described in catatonia as an additional mechanism, although the evidence remains unclear.31
Therefore, benzodiazepines, which act as positive allosteric modulators of GABA-A, have been historically used to treat anxiety and have been thought to potentially treat catatonia through a similar mechanism.32,33 In fact, the benzodiazepine challenge test is widely used in clinical settings to support a diagnosis of catatonia or to determine benzodiazepine sensitivity.34
The precise mechanism by which ECT addresses and treats catatonia remains unclear, although several studies are supportive of the GABA hypothesis of ECT whereby the release of GABA is central in achieving the therapeutic benefits of ECT in major depression and other neuropsychiatric disorders. 35,36
ECT remains an effective treatment for catatonia, especially in severe illness or when there has been a suboptimal response from benzodiazepines. Response rates to ECT are excellent, with most recent studies reporting responses as high as 80–100%, including cases of nonresponse to benzodiazepines.37 Since the introduction of ECT, mortality associated with catatonia has decreased.3839
Few case reports have described the use of lorazepam to treat catatonia with similar responses in treating catatonia-associated urinary retention, although these reports have all been limited to single case reports.40,41 The decision to use benzodiazepine, ECT, versus combined treatment in catatonia is oftentimes based on clinical discretion, severity of illness, urgency to treat, risk versus benefit and accessibility to ECT. In this case series, all patients presented to the hospital with a severe index of illness and access to ECT was prompt.
Limitations of this study include a lack of urodynamic studies as part of the medical workup for urinary retention, although the invasive nature and sensitive nature of this intervention are important to consider in clinical settings. This case series evaluated data solely from the acute illness episodes and while receiving ECT in the hospital. Therefore, no follow up data were evaluated after discharge from the hospital. Future studies looking at this could be valuable. Despite this case series study being the first study to look at numerous elderly patients with catatonia-associated urinary retention, it still involves a limited number of patients after inclusion and exclusion criteria. A prospective study design, rather than a retrospective study, may also help address this gap. Another limitation of this study was that oral medications were not described above, though dopaminergic blocking agents certainly do carry risks for urinary retention. In this case series, all cases of urinary retention were resolved following ECT without any elimination of these dopaminergic agents. In fact, the dopaminergic blocking agent doses were simultaneously increased for all four patients to adequately treat psychotic symptoms, with most titrations occurring in between the ECT sessions.
In conclusion, it remains unclear exactly how catatonia alters the brain-bladder connection and specifically how or why urinary retention results as a result of catatonia.42 Ultimately, further research on this topic may provide more information on the connection between both catatonia and micturition control. Additional research into the mechanism of action for ECT in catatonia and associated urinary retention may also further contribute to developments in understanding medical complications arising from catatonia.
In conclusion, this case series highlights an interesting phenomenon and is intended to raise awareness to healthcare providers that prompt recognition and intervention for catatonia is of paramount importance. If catatonia is left untreated, life-threatening psychiatric and medical emergencies arise. Urinary retention is among one of the known associated consequences of catatonia. Urinary retention is usually treated with an indwelling catheter however this makes elderly patients susceptible to limited mobility, increased infection, delirium, and impaired quality of life. Catheter use has also been independently associated with increased mortality in nursing home settings. Elderly adults with a longer duration of untreated catatonia are more likely to experience poor outcomes in terms of complications. In a prospective study, the rate of complications among elderly patients with catatonia was estimated to be 40% and the mortality rate was 20%.43 Therefore, identification and prompt treatment are important in catatonia syndrome.