Urinary retention resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kanwal Khamuani

Urinary retention Resident Survival Guide Microchapters
Overview
Causes
Urinary retention in women
Urinary Retention in Men
Diagnosis
Treatment
Do's
Don'ts

Synonyms and keywords:

Overview

Urinary retention is defined as an inability to pass urine, or incomplete emptying of the bladder. It is one of the most common presenting complaints encountered in the emergency department, and can be acute or chronic. It is commonly seen in males as compared to females due to benign prostate hyperplasia. If undiagnosed or left untreated, this condition can be life-threatening as it may lead to kidney damage and severe urosepsis. Acute urinary retention can be extremely uncomfortable, and is initially managed by urethral or suprapubic catheterization. Chronic urinary retention is often asymptomatic, not easily identified, and is linked to increased post void residual volume. A complete detailed history about current prescription, over the counter and herbal medications is necessary along with focused physical examination that must include neurological evaluation.

Causes

Urinary Retention in Women

Urinary retention is overall very rare in women and can be acute or chronic. Common causes include:

• Nerve injury during surgery-For example Episiotomy-postoperative
• Medications-Atropine, Glycopyrrolate, Bupivacaine
• Fowler's syndrome
• Obstructive causes-Vaginal hematoma, Vaginal packing, Sling, Foreign body, Pelvic organ prolapse, Urethral injury

Urinary Retention in Men

Urinary retention is more common in males, with a male to female ratio of 13:1.

Causes of Acute urinary retention in men
❑ Obstructive causes

❑ Benign Prostate Hyperplasia

❑ Prostate or Bladder Carcinoma

❑ Constipation

❑ Urolithiasis

❑ Urethral Stricture

❑ Phimosis or Paraphimosis

❑ Infectious Causes

❑ Prostatitis

❑ Urethritis

❑ Genital herpes

❑ Neurological Causes

❑ stroke

❑ spinal cord injury

❑ Demyelinating disorders-Guillain barre syndrome, diabetic neuropathy, Multiple sclerosis.

❑ Detrusor Muscle Dysfunction
❑ Medications

❑ Sympathomimetic alpha adrenergic agents-Phenylephrine

❑ Sympathomimetic beta adrenergic agents-Isoproterenol

❑ Antidepressants-Amitriptyline,Imipramine

❑ Antiarrhythmics-Quinidine, procainamide, Disopyramide

❑ Anticholinergics-Atropine, oxybutynin, glycopyrrolate

❑ Antiparkinsonian agents-Amantadine, trihexyphenidyl,levadopa, bromocriptine

❑ Antipsychotics-Haloperidol, fluphenazine

❑ Hormonal agents-estrogen, progesterone, testosterone

❑ Antihistamines-diphenhydramine, hydroxysine

❑ Antihypertensives-Hydralazine,nifedipine

❑ Others-indomethacin, morphine, dopamine, amphetamines

Causes of Chronic urinary retention in Men
❑ Neurological Causes

❑ Diabetic neuropathy

❑ peripheral neuropathy

❑ Spinal injury

❑ Detrusor Muscle Dysfunction

Diagnosis

A detailed history and a thorough physical examination may help in diagnosing the cause behind urinary retention.

History ❑ inquire about lower urinary symptoms ❑ how often patient has this difficulty in voiding ❑ how frequently patient void in a single day ❑ how frequently patient has weak stream of urine ❑ ask patient about difficulty holding urine ❑ ask about nocturia ❑ Does the patient have to strain or push to urinate ❑ ask about dribling after passing urine ❑ Inquire about past history of prostate disease or cancer ❑ Inquire about history of stones, STIs, radiation exposure ❑ Other symptoms ❑ hematuria ❑ Dysuria ❑ fever ❑ low back pain ❑ neurological symptoms ❑ Inquire about recent surgical procedures(patient should void in 6 hours post surgery)

Physical examination ❑ Abdominal examination ❑ Dullness above umbilicus represent 1000 ml urine ❑ dullness just below umbilicus represent about 500 ml of urine ❑ Pelvic examination/rectal examination ❑ Note for enlarged prostate or fecal impaction ❑ Genital examination ❑ poor sphincter tone suggest spinal cord problem ❑ Neurological examination ❑ strength ❑ sensation ❑ reflexes ❑ muscle tone

Evaluation ❑ collect urine sample by placing folley's catheter ❑ perform bladder ultrasound ❑ check pre and post void residual volume ❑ Complete blood count ❑ Chemistry ❑ sodium ❑ potassium ❑ bicarbonate ❑ chloride ❑ BUN and creatinine ❑ urine analysis and culture ❑ if neurological symptoms-CT head, MRI spine

Volume of urine in first 10-15 minutes of catheterization or with bladder ultrasound?

>300ml

<200 ml

❑ suggest urinary retention-keep catheter in place if >400 ml

Urinary retention unlikely

Treatment

Acute urinary retention is treated with immediate bladder decompression with intermittent urethral catheterization or suprapubic catheterization regardless of the cause and gender. Further management depend upon the cause of retention.

Abbreviations: TwoC: trial without catheter; BPH: Benign prostate hyperplasia; TURP: Transurethral resection of prostate;POUR: postoperative urinary retention;I/V: Intravenous

Management of Acute Urinary retention in Men with benign prostate hyperplasia

Clean intermittent Urethral Self Cathterization

successful

failed

Admit the patient and give alpha blocker(for example-alfuzosin) plus TwoC for 2 days

Suprapubic catheterization- Admit if urosepsis, dehydration or signs of renal failure

Successful

failed

follow patient with alpha blocker if uncomplicated BPH OR discuss for elective surgery TURP if complicated BPH

recatheterize and discuss TURP

If recurrent urinary retention-repeat alpha blocker and TwoC

POSTOPERATIVE URINARY RETENTION

Prevention

Treatment

Preoperative

Intraoperative

Postoperative

Use of alpha blocker alfuzosin if known risk factors e.g Diabetes, renal failure, BPH, elderly age

If using I/V fluids it is necessary to catheterize to prevent POUR

Early ambulation and judicious use of systemic opioids can prevent POUR

Catheterization and start alpha blocker tamsulosin if not already started

TwoC after 1-3 days of catheterization and if patient fail to void refer to outpatient urology consultation

Do's

• Keep a close eye on the patient for dehydration and metabolic abnormalities which may result from post obstructive diuresis.
• Perform suprapubic catheterization in patients who had recent surgery and it should be ultrasound-guided.
• Admit the patient with urosepsis, renal failure, electrolyte imbalance, malignancy, or acute myelopathy.
• It is must to educate the patient about catheter care and urine output monitoring.

Don'ts

• Do not perform urethral catheterization if the patient had a recent urologic surgery such as radical prostatectomy or urethral reconstruction.
• Do not start antibiotics until an infection is confirmed.