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Acute Urinary Retention
J E Mensah
• 56 yr old man presents with a day’s history of not passing urine and severe Suprapubic pain
• Referred to the urologist as a case of acute urinary retention
• Catheterized successfully and 50 mls of concentrated urine drained
Final diagnosis-1.Ruptured appendix2.Pre-renal renal failure
What is acute retention of urine?
ACUTE RETENTION• Painful inability to void with relief of pain following drainage of
the bladder by catheterization• Suprapubic pain +Suprapubic distension(full bladder350-500mls)
+failure to voidCHRONIC RETENTION• Failure to empty bladder + Gross bladder distention(over 800mls)
+ No Suprapubic pain.Can result in Post -renal renal failure• ACUTE ON CHRONICFailure to empty bladder + Gross bladder distention(over 800mls)
+Suprapubic pain
Physiology of urine storage and voiding
1. bladder filling and urine storage • Relaxation of the detrusor
muscles to accommodate increasing volumes of urine at a low intravesical pressure
• Concomitant contraction of the sphincters to close the bladder outlet(S2-S4)
2. bladder emptying• coordinated contraction of the
detrusor muscles• Concomitant relaxation the
smooth and striated sphincter• Absence of anatomic obstruction
Mechanisms of urinary retention
• Increased anatomic urethral resistance. i.e. bladder outlet obstruction(BOO)
• Low bladder pressure (impaired detrusor muscle contractility)
• Failure of co-ordination of bladder contraction with sphincter relaxation(DSD)
Retention in males• Benign Prostatic
Hyperplasia (BPH)
• Carcinoma of the Prostate
• Urethral Stricture
• Trauma to urethra or bladder neck
Retention in women
• Extrinsic compression of bladder neck or proximal urethra eg fibroid,cystocoel
• Infections • Meatal stenosis
Female genital mutilation(FGM)
Other causes
• Haematuria leading to clot retention
• Drugs• Stones
Retention caused by urethral stone
Physical exam
• Palpable suprapubic mass: A bladder with >150ml of urine should be palpable or percussible
• USG in obese patients
Initial management-Urethral catheterization
• Explain the procedure to the patient
• Aseptic technique-one gloved hand is sterile, the other is ‘dirty’
• Adequate lubrication(5-10mls of xylocain gel
• patience
After catheterization
• Write operation notes(indication, volume drained, nature of urine
• Urine bag for continuous drainage.• Adequate hydration
Urethral catheterization problems
• Urine leakage around catheter• Stuck catheter• Failure
Urine leakage around catheter
• Usually caused by bladder spasm NOT blockage or small catheter size.
Adult males 16/18 FrWomen 14/16 FRChildren 8/10fr
• Antispasmodics . oxybutynin,2.5mg tds
Solefenacin 5 mg daily Tolterodine 2mg daily
Stuck catheter
• Faulty balloon mechanism .(test before use)
• Obstruction of balloon channel by crystals (NaCl.mannitol).use sterile water to inflate balloon.
• Encrustations
Stuck catheter• Gently deflate the balloon • Cut the distal port of the
balloon channel • perforation of the balloon
.a. Passage of a stiff guide wire along the
balloon channel.b. Suprapubic / transvaginal puncture of
the balloon
• formal suprapubic cystostomy
Failure of urethral catherization
• Spasm of external sphincter
• Huge middle lobe• Urethral Stricture or
bladder neck contracture
Suprapubic tap/catherization• Insertion requires at least 200-300cc
of urine in an easily percussible bladder
• 2-3 finger breaths above pubis symphysis
• Instill LA into skin puncture site down to rectus
• Confirm position of bladder by aspirating urine from bladder
Contraindication• Previous lower abdominal surgery
and presence of surgical scars at the Suprapubic area (GO below the scar)
• Clot retention ?bladder tumour• Pelvic fractures
Haematuria and clot retention• Haematuria must be taken
seriously and fully investigated since it may herald the presence of urologic malignancy
• pass a wide bore urethral catheter (22Fr or above )
• Wash out by hand until all the clots have been evacuated
• A three way catheter for continuous bladder irrigation if bleeding is profuse
DEFINATIVE MANAGEMENT OF ACUTE RETENTION FROM BPH
• TRIAL WITHOUT CATHETER• PROSTATE SHRINKING AND RELAXING DRUGS
FOLLOWED BY TWOC• SURGERY• LONG TERM CATHERIZATION
TRIAL WITHOUT CATHETER(TWOC)
• Success depends on whether the retention is precipitated or spontaneous.
• Spontaneous: 50% relapse within 2weeks ,70% within a year.(Temml C, Brossner C, Schatzl G, Ponholzer A, Knoepp L, Madersbacher S. The natural history of lower urinary tract symptoms over five years. Eur Urol 2003;43:374-80.)
Precipitating events• Drugs-sympathomimetics (Ephedrine in cough syrups),
anticholinergics,anesthetic drugs• Constipation• Pain• Abdominal or pelvic surgery• Timing of TWOC???-no evidence based guideline
Drugs followed by TWOC
• Alpha adrenergic blockers-relax smooth muscles.eg tamsulosin (Flomax), alfuzosin (Xatral)
-60 % success McNeill SA, Hargreave TB. Alfuzosin once daily facilitates return to voiding in patients in acute urinary retention. J Urol 2004;171:2316-20.
• 5 α reductase inhibitors-reduce prostate size. eg Finasteride (Proscar)
SURGICAL MANAGEMENT
• Transurethral resection of the prostate(TURP)
• Open prostatectomy
Mortality in men admitted to hospital with acute urinary retention Katia M C Verhamme,
Miriam C J M SturkenboomBMJ 2007;335:1164-1165 doi:10.1136/bmj.39384.556725.80 (Published 8 November 2007
• 176 046 men aged over 45 who were admitted to hospital with a first episode of acute urinary retention.
• 14.7% of men with spontaneous acute urinary retention and 25.3% men with precipitated acute urinary retention died within the first year
• 2-3 times higher than in the general population.• Increased mortality is directly linked to co-
morbidity(CVS,DM,COAD)and age.• Patients with acute urinary retention are a vulnerable group and
may benefit from urgent multi-disciplinary care to identify and treat co-morbid conditions
• FULLY EVALUATE AND REFER TO APPROPRAIT SPECIALISTS
Management of AROU in 907AD