Gait function is associated with urinary retention outcomes in hospitalized older patients
Original Article

Gait function is associated with urinary retention outcomes in hospitalized older patients

Masaaki Imamura1 ORCID logo, Yuuki Watanabe2, Kayo Kusagaya2, Momoka Masuda3, Yurika Sei3, Keisuke Hashimoto3, Chihiro Saito3, Mariko Inokawa3, Masakatsu Ueda1, Koji Yoshimura1

1Department of Urology, Shizuoka General Hospital, Shizuoka, Japan; 2Department of Rehabilitation, Shizuoka General Hospital, Shizuoka, Japan; 3Department of Nursing, Shizuoka General Hospital, Shizuoka, Japan

Contributions: (I) Conception and design: M Imamura; (II) Administrative support: None; (III) Provision of study materials or patients: Y Watanabe, K Kusagaya, M Masuda, Y Sei, K Hashimoto, C Saito, M Inokawa; (IV) Collection and assembly of data: Y Watanabe, K Kusagaya, M Masuda, Y Sei, K Hashimoto, C Saito, M Inokawa; (V) Data analysis and interpretation: M Imamura, M Ueda, K Yoshimura; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Masaaki Imamura, MD, PhD. Department of Urology, Shizuoka General Hospital, 4-27-1 Kita Ando Aoi-ku, Shizuoka 4208527, Japan. Email: m69ima8907@gmail.com.

Background: Acute urinary retention in older patients is a major problem that prolongs hospitalization and requires appropriate management. We investigated whether gait function is associated with the resolution of urinary retention in hospitalized patients treated with catheterization to determine its association with urinary retention.

Methods: Patients with post-void residual (PVR) urine of ≥200 mL were treated with intermittent catheterization, medication, and physical rehabilitation, while their gait function was assessed between January and December 2020. The patients were divided into two groups according to their voiding status after treatment: voluntary voiding with PVR urine of <200 mL or continued catheterization. Variables potentially associated with voiding function, including age, sex, bladder outlet obstruction, neurological disorders, comorbidities, medication use, and gait function (walker or non-walker), were compared between the groups.

Results: We analyzed data from 104 patients (62 men, 42 women; median age 78 years, range, 60–95 years). Voluntary voiding with PVR urine of <200 mL was achieved by 64 (62%) patients. Before treatment, 55 (53%) patients were non-walkers. The patients who became walkers after treatment were 13 of 22 (59%) in the voiding group and 2 of 33 (6%) in the catheterization group. Multivariate analysis showed that gait function, but not age, was significantly associated with post-treatment voiding function. Among pretreatment non-walkers, the number of post-treatment walkers was significantly greater in the voluntary voiding group than in the catheterization group [n=13 (59%), P<0.001].

Conclusions: Gait function is associated with voiding outcomes, suggesting that physical rehabilitation to improve mobility may facilitate recovery from acute urinary retention in hospitalized older adults.

Keywords: Gait function; voluntary voiding; catheterization; physical rehabilitation

Submitted Aug 15, 2025. Accepted for publication Oct 12, 2025. Published online Nov 26, 2025.

doi: 10.21037/tau-2025-584

Highlight box

Key findings

• Gait function was significantly associated with spontaneous voiding in hospitalized older patients with urinary retention. Among patients who were unable to walk at baseline, those who regained walking ability were significantly more likely to achieve catheter-free voluntary voiding.

What is known and what is new?

• Urinary retention in older adults commonly leads to prolonged hospitalization and is managed with catheterization, medication, and physical therapy. Predictors of successful recovery of voiding function remain unclear.

• This study shows that gait function is independently associated with recovery of spontaneous voiding. In patients initially unable to walk, improvement in gait function during hospitalization significantly increased the likelihood of discontinuing catheter use.

What is the implication, and what should change now?

• Assessment and rehabilitation of gait function should be considered essential components of urinary retention management in older patients. Enhancing mobility through physical therapy may facilitate recovery of bladder function and reduce catheter dependence, potentially improving clinical outcomes and shortening hospital stays.

Introduction

Acute urinary retention in hospitalized older patients, whether treated surgically or non-surgically, is a major problem that contributes to catheter-associated urinary tract infections (1,2). Acute urinary retention is also associated with neurological decline, increased healthcare costs, and prolonged hospitalization (1,2). Therefore, prompt and appropriate management is essential for hospitalized patients with impaired voiding.

Acute urinary retention can result from multiple causes, including anatomical factors that induce bladder outlet obstruction, such as prostate enlargement in men or pelvic organ prolapse in women, pharmacological factors such as anticholinergic medications, and neurological disorders (3,4). The standard initial treatment for patients with urinary retention involves catheterization, with intermittent catheterization recommended in the U.S. Centers for Disease Control and Prevention guidelines (5). In addition, medications such as alpha-adrenergic antagonists or cholinergic agents are commonly used (6-8). Currently, a combination of intermittent catheterization and pharmacotherapy is typically employed to address the underlying causes of urinary retention.

Physical activity has attracted increasing attention as a contributor to functional recovery, including the restoration of voluntary voiding after surgery or onset of disease (9-11). Poor gait function has been identified as a risk factor for urinary retention (12). However, the relationship between gait function and recovery of voiding ability has remained poorly understood. Therefore, we sought to evaluate the association between gait function and voiding outcomes in hospitalized older patients with acute urinary retention. The findings may clarify whether improvements in gait function contribute to the recovery of spontaneous voiding function. We present this article in accordance with the STROBE reporting checklist (13) (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-584/rc).

Methods

We included retrospective data from older patients who consulted the Department of Urology of Shizuoka General Hospital (referred to as our hospital) for the development of postoperative dysuria or urinary retention during their stay in our hospital (surgical) or for the onset of disease without surgery (nonsurgical) between January and December 2020. The inclusion criteria were an age of ≥60 years, the absence of an indwelling urethral catheter, and treatment with all options, including medication, catheterization, and physical rehabilitation. Patients with post-void residual (PVR) urine of <200 mL before treatment or those with insufficient medical records were excluded. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Shizuoka General Hospital (approval No. 2022038) and individual consent for this retrospective analysis was waived.

The pretreatment assessments included bladder outlet obstruction, neurological disorders, and gait function. Bladder outlet obstruction was defined as the presence of prostatic hyperplasia in which the volume was >30 cm3 with ≥5 mm of intravesical prostatic protrusion in men or pelvic organ prolapse in women, as shown by ultrasonography or computed tomography (4,14,15). Neurological disorders were defined as a history of neurogenic diseases, diabetic neuropathy, or alcoholic neuropathy as determined by the medical records (16,17). Pre- and post-treatment gait function was evaluated by physical therapists in our hospital using Functional Ambulation Category (FAC) scores (18,19). The patients were divided into three groups: non-walkers in group 1 (FAC score 0, patients were not able to ambulate), dependent walkers in group 2 (FAC score 1–3, patients were able to ambulate with assistance), and independent walkers in group 3 (FAC score 4–5, patients were able to ambulate without assistance) (18,19). PVR urine was measured with ultrasonography. The patients were treated using α-1-adrenoceptor antagonists (tamsulosin, silodosin, or urapidil), cholinergic agents (bethanechol), and physical rehabilitation for 1 h, 5 days each week. Physical rehabilitation involved a range of exercises, including lower limb and core stretching, maintaining a seated position, and walking training with assistance. If a patient was able to walk with assistance, the training program progressed to the next step of walking without assistance. Cholinergic agents were excluded in patients who had Parkinson’s disease, ischemic heart disease, or obstructive pulmonary disease. In addition to medical treatment and physical rehabilitation, the patients underwent clean intermittent catheterization. The frequency of catheterization was based on a catheterized urine volume within 400 mL of the normal bladder volume, considering the daily urine volume (20). The catheterization was discontinued if the PVR urine was <200 mL during the intervention (21,22), and the patients then had voluntary voiding. The patient’s voiding status was confirmed by reevaluation 2 weeks after initiating the intervention and then weekly until discharge (up to 12 weeks).

After treatment, the patients were divided into two groups based on their voiding status before their discharge: a voluntary voiding group with PVR urine <200 mL or continued catheterization. Factors potentially associated with the voiding status, including age, sex, bladder outlet obstruction, neurological disorders, pretreatment use of anticholinergics, comorbidities, background status (surgical or nonsurgical), treatment with cholinergics, and pretreatment gait function (non-walker or walker), were compared between the groups. Among pretreatment non-walkers, post-treatment gait function was compared between the groups to evaluate the association of an improvement in gait function with their voiding status.

Statistical analyses

To compare the factors associated with voiding status between the two groups, an unpaired t-test was used for continuous variables and a Chi-squared test was used for categorical variables. Multiple logistic regression analysis was performed using factors that were significant in the univariate analysis using the unpaired t-test or Chi-squared test. Data were analyzed using JMP version 15.1 (SAS Institute, Cary, NC, USA), and differences were considered significant when P<0.05.

Results

We initially included data from 117 patients in this study. Data from two patients were excluded because of insufficient records, and data from 11 patients were excluded because they had a PVR urine of <200 mL. Ultimately, data from 104 patients were included in this study.

Table 1 shows the patient characteristics. The median age of the patients (62 men and 42 women) was 78.0 years (range, 60–95 years). Sixty-one (59%) patients have neurological disorders, but there were no irreversible disorders, including spinal cord injury or multiple sclerosis. The main comorbidities were neurological disease in 44 (42%) patients, cardiovascular disease in 31 (30%), gastrointestinal disease in 13 (13%), orthopedic disease in 7 (7%), pulmonary disease in 6 (6%), and urological disease in 3 (3%). The background status was surgical in 53 (51%) patients and nonsurgical in 51 (49%) patients. Median treatment period was 4 weeks (range, 2–12 weeks). Before treatment, 49 (47%) were walkers, and after treatment, 64 (62%) were walkers. The details of the patient’s gait function are shown in Figure 1. The post-treatment voiding status was voluntary voiding in 64 (62%) patients. All patients with voluntary voiding sustained their voiding status until discharge.

Table 1

Patient characteristics

Characteristics Data (n=104)
Age (years) 78 [60–95]
Sex
   Male 62 [60]
   Female 42 [40]
Bladder outlet obstruction
   Yes 28 [27]
   No 76 [73]
Neurological disorders
   Yes 61 [59]
   No 43 [41]
Pretreatment anticholinergics
   Yes 10 [10]
   No 94 [90]
Background diseases
   Neurological 44 [42]
   Cardiovascular 31 [30]
   Gastrointestinal 13 [13]
   Orthopedic 7 [7]
   Pulmonary 6 [6]
   Urological 3 [3]
Background status
   Surgical 53 [51]
   Nonsurgical 51 [49]
Cholinergic agents
   Yes 59 [57]
   No 45 [43]
Pretreatment gait function
   Group 1: non-walker (FAC 0) 55 [53]
   Group 2: dependent walker (FAC 1–3) 27 [26]
   Group 3: independent walker (FAC 4–5) 22 [21]
Post-treatment gait function
   Group 1: non-walker (FAC 0) 40 [38]
   Group 2: dependent walker (FAC 1–3) 31 [30]
   Group 3: independent walker (FAC 4–5) 33 [32]
Post-treatment voiding status
   Voluntary voiding 64 [62]
   Catheterization 40 [38]

Data are presented as median [range] or n [%]. FAC, Functional Ambulation Category.

Figure 1 Changes in gait function of patients before and after treatment. FAC, Functional Ambulation Category.

Table 2 presents the univariate analysis of factors potentially associated with voiding status after treatment. Patients in the voluntary voiding group had a significantly younger median age than those in the catheterization group (76 vs. 82 years, P=0.003). Pretreatment gait function (groups 1 vs. 2, 3) also differed significantly between groups, with 42 (66%) walkers in the voluntary voiding group compared with 7 (18%) in the catheterization group (P<0.001). No significant differences were found between the two groups in terms of sex, bladder outlet obstruction, neurological disorders, pretreatment use of anticholinergics, main comorbidities, background clinical status, treatment with cholinergics, or pretreatment gait function (groups 1, 2 vs. 3).

Table 2

Analysis of factors associated with post-treatment voiding status

Factors Post-treatment voiding status P† Unadjusted OR (95% CI)
Voluntary voiding (n=64) Catheterization (n=40)
Age (years) 76 [60–94] 82 [61–95] 0.003 0.95 (0.91, 1.00)
Sex 0.72 0.82 (0.37, 1.90)
   Male 37 [58] 25 [63]
   Female 27 [42] 15 [37]
Bladder outlet obstruction 0.92 0.95 (0.39, 2.31)
   Yes 17 [27] 11 [28]
   No 47 [73] 29 [72]
Neurological disorders 0.30 0.65 (0.28, 1.50)
   Yes 35 [55] 26 [65]
   No 29 [45] 14 [35]
Pretreatment anticholinergics 0.56 1.52 (0.38, 5.64)
   Yes 7 [11] 3 [8]
   No 57 [89] 37 [93]
Background diseases 0.22 NA
   Neurological 25 [39] 19 [48]
   Cardiovascular 20 [31] 11 [28]
   Gastrointestinal 11 [17] 2 [5]
   Orthopedic 2 [3] 5 [13]
   Pulmonary 3 [5] 3 [8]
   Urological 2 [3] 1 [3]
Background status 0.80 0.90 (0.42, 2.05)
   Surgical 32 [50] 21 [53]
   Nonsurgical 32 [50] 19 [48]
Cholinergic agents 0.90 0.95 (0.44, 2.17)
   Yes 36 [56] 23 [58]
   No 28 [44] 17 [42]
Pre-treatment gait function (groups 1 vs. 2, 3) <0.001 9.00 (3.48, 21.98)
   Walker (groups 2, 3; FAC 1–5) 42 [66] 7 [18]
   Non-walker (group 1; FAC 0) 22 [34] 33 [82]
Pre-treatment gait function (groups 1, 2 vs. 3) 0.09 2.53 (0.88, 6.69)
   Independent walker (group 3; FAC 4–5) 17 [27] 5 [13]
   Dependent walker or non-walker (groups 1, 2; FAC 0–3) 47 [73] 35 [88]

Data are presented as median [range] or n [%], unless otherwise stated. †, data were analyzed using an unpaired t-test (age) or Chi-squared test (others). CI, confidence interval; FAC, Functional Ambulation Category; NA, not applicable; OR, odds ratio.

Table 3 summarizes the multivariate logistic regression analysis of the factors independently associated with post-treatment voiding status. Pretreatment gait function (groups 1 vs. 2,3) remained significantly associated with successful post-treatment voluntary voiding status [odds ratio (OR) =8.70; 95% confidence interval (CI): 3.27 to 23.10], whereas age was not independently associated with the voiding outcome (OR =0.96; 95% CI: 0.91 to 1.01).

Table 3

Multivariate logistic regression analysis of factors associated with post-treatment voiding status

Factors Post-treatment voiding status P OR (95% CI)
Voluntary voiding (n=64) Catheterization (n=40)
Age (years) 76 [60–94] 82 [61–95] 0.10 0.96 (0.91, 1.01)
Pre-treatment gait function <0.001 8.70 (3.27, 23.10)
   Walker (groups 2, 3; FAC 1–5) 42 [66] 7 [18]
   Non-walker (group 1; FAC 0) 22 [34] 33 [82]

Data are presented as median [range] or n [%], unless otherwise stated. CI, confidence interval; FAC, Functional Ambulation Category; OR, odds ratio.

For the subgroup analysis, pretreatment gait function (groups 1 vs. 2, 3) was evaluated in the neurological background disease subgroup (n=44). The results showed a significant difference in pretreatment gait function between the groups, with 14 (56%) walkers in the voluntary voiding group and 4 (21%) in the catheterization group (P=0.02, Table S1).

Table 4 presents a subgroup analysis limited to the patients who were non-walkers before treatment. In this group, improvement in gait function (defined as becoming a walker after treatment) was significantly more frequent in patients who achieved voluntary voiding [13 of 22 (59%)] than among those who remained catheter-dependent [2 of 33 (6%), P<0.001].

Table 4

Analysis of pre-treatment non-walkers: effect of improvement in gait function on post-treatment voiding status

Factors Post-treatment voiding status P OR (95% CI)
Voluntary voiding (n=22) Catheterization (n=33)
Post-treatment gait function <0.001 22.39 (4.56, 106.2)
   Walker (groups 2, 3; FAC 1–5) 13 [59] 2 [6]
   Non-walker (group 1; FAC 0) 9 [41] 31 [94]

Data are presented as n [%], unless otherwise stated. CI, confidence interval; FAC, Functional Ambulation Category; OR, odds ratio.

Discussion

The present study revealed that recovery of voluntary voiding function was significantly associated with pretreatment gait function and that gait function improved significantly more often in older patients who recovered voluntary voiding than in those who remained catheter-dependent. To our knowledge, this is the first study to demonstrate such associations in hospitalized older patients.

A strength of the present study is the longitudinal design, allowing us to observe recovery and therapeutic associations over time. We included a diverse cohort with multiple etiologies of urinary retention, enhancing generalizability. Additionally, all patients received standardized medication and catheterization protocols. However, several limitations should be noted. First, the retrospective design introduces a possible selection bias, and bidirectional causality or effects cannot be firmly established because unmeasured factors, including frailty, might affect the results. Second, although disease types were balanced between groups, the inclusion of varied background conditions and comorbidities may have influenced recovery trajectories. Third, we used a PVR urine threshold of ≥200 mL to define urinary retention. This value lacks universal consensus and differs from thresholds used in other studies, which have applied 150 or 300 mL as the cut-off value of PVR urine as the definition of urinary retention (23-25). Finally, gait function was assessed as a binary outcome (walker vs. non-walker), which may not capture nuanced mobility improvements. Binary outcomes can underestimate graded effects, potentially diluting their true efficacy.

Our findings are consistent with those of other studies showing that pretreatment gait function is associated with better urinary outcomes, such as lower PVR urine and reduced urinary retention rates (12,26). However, earlier work has focused primarily on baseline predictors, without addressing changes in gate function over time. A previous report documented recovery of voluntary voiding after rehabilitation in patients with urinary retention (10), but no data were available regarding improvement in their gait function over time. Thus, our results add new evidence to suggest that not only voiding, but also gait function, is reversible in non-walkers with urinary retention and that improvement in gait function is a strong prognostic marker and may be a valuable component of rehabilitation in the management of urinary retention. Clinicians could consider gait function rehabilitation as the first option for treating patients with urinary retention regardless of comorbidities.

The association between impaired gait and voiding dysfunction likely reflects underlying physical deconditioning in bedridden patients. Patients with limited mobility may be unable to generate sufficient intra-abdominal pressure necessary or adopt postures conducive to voiding efficiently (27). Moreover, prolonged bed rest may impair pelvic floor coordination and bladder dynamics. Conversely, the observation that gait function improved more frequently in patients who recovered voluntary voiding suggests a synergistic effect in which functional recovery in one domain may facilitate or reflect progress in another.

Our findings are consistent with data suggesting even weak mobility, such as walking but with assistance, may be sufficient for voiding recovery (25). This finding has practical implications, especially for patients in non-home care settings. Although cognitive function was not assessed directly in our study, a previous study revealed its relevance to both gait function and voiding dysfunction (10). Improvements in other functions, including cognitive function, with our rehabilitation program may have contributed to improvements in voiding. Further studies to clarify this issue are warranted.

The present findings support an integrated rehabilitation approach that includes gait training for patients with urinary retention. Interventions targeting mobility may help promote spontaneous voiding, reduce catheter dependence, and enhance quality of life. Our results also support the use of clean intermittent catheterization as a first-line management strategy for urinary retention in older adults (5). Clean intermittent catheterization not only decreases infection risk compared with indwelling catheters (28,29) but may also enhance the recovery of spontaneous voiding (30). Nevertheless, maintenance of an indwelling catheter may reduce mortality in selected geriatric patients with comorbidities (31), highlighting the need for individualized decision making.

Our present results revealed that the use of cholinergic agents was not associated with improved voiding, consistent with a review article of reports questioning their efficiency for an underactive bladder after surgery (32). The use of cholinergic agents for patients with urinary retention is controversial. Previous studies have shown that bethanechol has a preventive effect in patients with urinary retention after surgery (7,8). Our study also showed that the use of cholinergic agents was not associated with voluntary voiding, suggesting that the effect of cholinergic agents on voiding dysfunction might be limited. By contrast, we administered α-adrenergic antagonists to all eligible patients based on reports that α-adrenergic antagonists reduce the rate of urinary retention after several types of surgery (6,33). Prospective longitudinal studies are warranted, including the use of more precise gait assessment to validate the role of gait and cognitive functions as modifiable factors to facilitate recovery from urinary retention.

Conclusions

Hospitalized older patients with urinary retention can regain voluntary voiding following treatment with clean intermittent catheterization, pharmacotherapy, and physical rehabilitation. Gait function, both at baseline and following rehabilitation, was significantly associated with recovery or improvement of voluntary voiding in these patients. These findings suggest that gait function may represent a modifiable factor and potential therapeutic focus in the management of voiding dysfunction in this population.

Acknowledgments

We thank Angela Morbden, DVM, ELS, and Robin James Storer, PhD, from Edanz (https://jp.edanz.com/ac) for editing drafts of this manuscript.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-584/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-584/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-584/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-584/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Shizuoka General Hospital (approval No. 2022038) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Imamura M, Watanabe Y, Kusagaya K, Masuda M, Sei Y, Hashimoto K, Saito C, Inokawa M, Ueda M, Yoshimura K. Gait function is associated with urinary retention outcomes in hospitalized older patients. Transl Androl Urol 2025;14(11):3578-3586. doi: 10.21037/tau-2025-584

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