Acute Urinary Retention

J E Mensah

Definitions

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 failureACUTE 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 ie bladder outlet obstruction(BOO)

• Low bladder pressure (impaired detrusor muscle contractility)

• Interruption of sensory or motor innervation of bladder

• Failure of co-ordination of bladder contraction with sphincter relaxation(DSD)

Retention in males• Benign Prostatic

Hyperplasia (BPH)• Carcinoma of the Prostate• Urethral Stricture• Bladder neck contracture

(late complication of prostate surgery)

• Trauma to urethra or bladder neck

• Phimosis and Paraphimosis in children and uncircumcised men

• Posterior Urethral Valves in children.

Spontaneous or precipitated retention

• Precipitated-retention is less likely to recur • Spontaneous-more likely to recur and therefore

requires definitive treatmentPrecipitating events• Drugs-sympathomimetics (Ephedrine in cough

syrups), anticholinergics,anesthetic drugs• Constipation• Pain• Abdominal or pelvic surgery

Retention in women

• Extrinsic compression of bladder neck or proximal urethra eg fibroid,cystocoel

• Infections • Foreign body • Meatal stenosis • Fowlers syndrome-impaired

relaxation of the external sphincter, associated with polycystic ovaries

Female genital mutilation(FGM)

Other causes • Haematuria leading to clot

retention• Drugs• Stones • Diabetic cystopathy(sensory

and motor dysfunction)• Detrusor sphincter –sphincter

dyssynergia (DSD),Sacral and suprasacral spinal cord injury with loss of coordination of external sphincter relaxation with detrusor contraction.

Retention caused by urethral stone

Physical exam

• Palpable suprapubic mass: A bladder with >150ml of urine should be palpable or percussible

Initial management-Urethral catheterization

• Explain the procedure to the patient

• Aseptic technique-one gloved hand is sterile, the other is ‘dirty’

• Adequate lubrication

After catheterization

• Write operation notes(indication, volume drained, nature of urine

• Urine bag for continuous drainage.• Adequate hydration• Antibiotics?

Post catheterization problems

• Excessive diuresis (>200ml/hr) • Bleeding. (bladder mucosal disruption)• hypotension (vasovagal response )• Urine leakage around catheter• Stuck catheter

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

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

History of catheter