The Management of Acute and Chronic Retention of Urine: ISC versus Indwelling catheterisation. Roisin Hart Senior Urology Nurse Specialist Winchester

Urinary Retention The inability to voluntarily void urine

Categories of Urinary Retention Obstructive Infectious & Inflammatory Pharmacologic Neurologic Other

Causes of Urinary Retention Obstructive Benign prostatic hyperplasia Strictures Bladder calculi Faecal Impactation Phimosis / paraphimosis Benign/malignant pelvic masses Meatal Stenosis

Causes of Urinary Retention Obstructive Organ prolapse eg: cystocele, rectrocele, uterine prolapse Pelvic mass – gynae malignancy Uterine fibroid / ovarian cyst Retroverted impacted gravid uterus Foreign bodies

Infectious and Inflammatory Causes Prostatitis Prostatic abscess Balantitis Cystitis Acute vulvovaginitis Bilharziasis Herpes simplex virus

Pharmacologic causes Drugs with anticholingeric properties eg: tricylic antidepressants (amitriptyline) Opioids Sympathomimetic drugs eg: oral decongestants containing Ephedrine ( Sudafed) NSAIDs in men Antiparkinsonian agents (levodopa) Antipsychotics (chlopromazine) Muscle relaxants (Baclofen)

Neurologic cause AUTONOMIC OR PERIPHERAL NERVE Diabetes mellitus, Guillain-Barre syndrome Pernicious anaemia, radical pelvic surgery BRAIN CVA, MS, Tumour, Parkinson’s disease, concussion SPINAL CORD Haematoma / abscess / tumour, Cauda equine, spina bifida occulta

Other causes Post-op complications Pregnancy-associated retention Trauma eg: penile fracture or laceration Idiopathic detrusor failure

Presentation of AUR Sudden inability to pass urine Suprapubic pain which typically causes spasm Patient is acutely distressed Often longer history of bladder outflow symptoms Bladder is visible,tender and palpable Patient is typically male

Effects of AUR

Chronic Retention of Urine Completely different – maybe painless Incomplete emptying Often deny LUTS, nocturnal enuresis Large bladder, ? uraemic, ?anaemic, ?fluid overloaded Large residual volume May diurese Bladder drainage may cause haematuria

Acute or chronic? Large over distended bladder Pressure on kidneys and surrounding organs

Acute on Chronic Retention Painful inability to empty bladder Previous incomplete bladder emptying Large volume on catheterisation

Normal and overfilled bladder

Management of AUR Decompression by Catheterisation Residual Volume < 800mls U&E’S and Creatinine normal Systemically well Home with catheter Follow-up plan

Management of Chronic Retention Admit for observation including fluid balance chart Check renal function Image upper tracts Manage post obstructive diuresis TWOC maybe unsuccessful May need TURP but may have irreversible detrusor failure ISC an option or LTC

Acute or Chronic

Complications of Chronic retention of urine Bilateral Hydronephrosis Renal Inpairment Infections AUR Stones

Hydronephrosis

Further Management Varying local practices GP/DN→ catheterise→TWOC at home GP/DN →catheterise → refer to urology Attend A&E → catheterise →send home Attend A&E →catheterise→admit→TWOC

Urethral vs. Suprapubic catheterisation URETHRAL Usually quick & easy Competent staff readily available Infection easily introduced Risk of Stricture SUPRAPUBIC technical procedure Fewer staff competent Concerns over safety Easier to TWOC Reduce risk UTI Reduce stricture

Urethral Catheterisation Check for sepsis prior to catheterisation Ensure correct catheter selection Always use an aseptic procedure Never force catheter against resistance Never inflate balloon in urethra Know your limitations Always record details and residual volume Think Paraphimosis

Which Catheter? Nelaton Catheters (ISC) Foley catheters (Indwelling)

Complications of Indwelling Catheter Infection Irritation / Erosion Injury Stricture and False passage Stones / Encrustation causing blockage Spasm / Bypassing / Expulsion Malignant change Haematuria

Complications of Indwelling catheter (cont) Insertion difficulties Removal difficulties- non deflation Pain or discomfort Catheter expulsion Infected peri-urethral glands causing abscess/fistula Reduced bladder capacity Reduced mobility

Benefits of Indwelling catheter Continence Preserves renal function May reinstate social independence Prevents high pressure bladder

Benefits of ISC Lower risk of infection Retains bladder capacity Allows normal function Protects renal function Avoids encrustation

Benefits of ISC (cont) Maintains body image Promotes independence Increases morale and self esteem Reduces dependence on health professionals Maintains sexual function Improves quality of life

Limitations of ISC May not be possible in those with: Profound physical disabilities or poor manual dexterity. Psychological barriers to using technique. Small bladder capacity. Inadequate urethral pressure.

ISC or Indwelling catheter Not mutually exclusive Depends on individuals needs Patient choice