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 appendix 2.Pre-renal renal failure

What is acute retention of urine? Painful inability to void with relief of pain following drainage of the bladder by catheterization Suprapubic pain +Suprapubic distension(full bladder350-500mls)+failure to void CHRONIC RETENTION Failure to empty bladder + Gross bladder distention(over 800mls) + No Suprapubic pain. Can result in Post -renal renal failure ACUTE ON CHRONIC Failure 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 Fr Women 14/16 FR Children 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

2-3 times higher than in the general population. Mortality in men admitted to hospital with acute urinary retention Katia M C Verhamme, Miriam C J M Sturkenboom BMJ 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