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