1. Acute Urinary Retention
Laura Oakley FY1 Urology

2. Definition
Acute Urinary Retention refers to the inability to empty the bladder
Most common in men
Increasing incidence with increasing age

3. Case Study: History 1 67 yr old man PC 1) Unable to pass urine
2) Lower abdominal pain

4. Case Study: History 2 HxPC 24 hours of inability to pass urine at will
4 yr Hx of prostatic symptoms.
Patient c/o gradual worsening of prostatic symptoms over the past 2/12
Frequency
Nocturia  x2-3 night
Hesitancy
Poor stream

5. Case Study: History 3 12hrs of lower abdominal pain No dysuria
Suprapubic pain
No relieving/exacerbating factors
No radiation
No dysuria
Prostatic symptoms have been investigated over the past year last PSA was 1.9

6. Case Study: History 4 PMHx Screen  Nil else elicited
Angina  well controlled with medication
HTN
OA knees
Screen  Nil else elicited

7. Case Study: History 5 DHx FHx Ramipril Aspirin Bendroflumethiazide
GTN sublingual spray PRN
Paracetamol PRN
NKDA
FHx
Hx MI/Angina.

8. Case Study: History 6 SHx
Ex smoker  20 pack year Hx, gave up 10 yrs ago
EtOH  Occasional, not in past week
Illicit Substances  nil
Retired office worker
Lives with wife
Independent

9. Case Study: Examination
Observation
Patient uncomfortable, but alert and orientated.
HR = 86 regular
T = 36.4
BP = 138/74
RR = 18

10. Case Study: Examination
CVS
HS I + II + 0
JVP 
Ankles = some mild ankle oedema
Resp
Chest clear
Air entry good and equal bilaterally
No added sounds

11. Case Study: ExaminationGI
Palpable bladder to umbilicus, resonant to percussion
Suprapubic tenderness
No organomegaly
BS present
DRE: Smooth moderately enlarged prostate.
Normal anal tone.

12. Case Study: Examination
Neuro
Power 5/5
Sensation N, perineal sensation normal
Reflexes N
Tone N
Bladder scan ~ 750 mls

13. Differential Diagnosis
Urinary retention can be secondary to a variety of causes:-
BPH
PrCa
UTI
Prostatitis
Drugs:
Anticholinergics
Antidepressants
Anaesthetics
Illicit drugs (particularly stimulants)
EtOH
Constipation
Pain
Cauda equina syndrome
Clot retention (2O to urinary tract malignancies or post-op)
Urethral pathology

14. Discussion
Points in the history can give us clues as to the cause of the individuals retention………

15. Discussion HxPC 24 hours of inability to pass urine at will
4 yr Hx of prostatic symptoms.
Patient c/o gradual worsening of prostatic symptoms over the past 2/12
Frequency
Nocturia  x2-3 night
Hesitancy
Poor stream
It is important to ask about prostatic symptoms as this could give you an indication as to whether the BPH or PrCa could be the cause of the retention.

16. Ask about symptoms which might indicate a UTI as an underlying cause.
Discussion
12hrs of lower abdominal pain
Suprapubic pain
No relieving/exacerbating factors
No radiation
O dysuria
Prostatic symptoms have been investigated over the past year last PSA was 1.9
Ask about symptoms which might indicate a UTI as an underlying cause.

17. Discussion PMHx Screen  Nil else elicited
Angina  well controlled with medication
HTN
OA knees
Screen  Nil else elicited
A detailed PMHx will help indicate whether there is any likelihood of other diseases contributing to the retention ie) any risk of cauda equina, autonomic neuropathies (more likely to be chronic retention), constipation, pain.

18. Discussion DHx FHx Ramipril Aspirin Bendroflumethiazide
GTN sublingual spray PRN
Paracetamol PRN
NKDA
FHx
Hx MI/Angina.
The DHx is important as many drugs can cause urinary retention, particularly anticholinergics and antidepressants.

19. Discussion SHx Ex smoker  20 pack year Hx, gave up 10 yrs ago
EtOH  Occasional, not in past week
Illicit Substances  nil
Retired office worker
Lives with wife
Independent
A good social history helps us to elicit whether EtOH consumption or drug abuse could have contributed to the development of retention. Be particularly aware of this in cases involving younger men with no other likely cause.

20. Doing a DRE is essential, as it can identify:-
Discussion GI
Palpable bladder to umbilicus, resonant to percussion
Suprapubic tenderness
No organomegaly
BS present
DRE: Smooth moderately enlarged prostate.
Normal anal tone.
Doing a DRE is essential, as it can identify:-
BPH (enlarged, smooth), malignant prostate (craggy, hard) and can also help to identify other causes such as cauda equina syndrome (reduced anal tone, saddle anaesthesia).

21. Investigations
Some basic preliminary investigations may help narrow down the cause……

22. Basic Investigations Bladder Scan Urine Dip + MSU
This is done prior to catheterisation to identify the volume in the bladder to check that the patient is in fact in retention.
Most individuals can hold up to 600mls before becoming significantly uncomfortable
Chronic retainers can hold much greater volumes, often up to 1l or more.
Urine Dip + MSU
To identify infection and sensitivities

23. Basic Investigations Bloods 
FBC:- an elevated white cell count might indicate underlying infection
U&E’s:- important to identify if there is any kidney damage from backpressure of urine due to the obstruction.
PSA:- can be unreliable in the acute setting as will be raised by the very presence of retention as well as after DRE. However it is useful to identify the results from any previous PSA’s to aid in the differential diagnosis.

24. Treatment
Catheterise using aseptic technique and appropriate Abx cover
IM Gentamicin is the Abx of choice in this Trust.
Record residual volume of urine
Monitor for diuresis  occurs due to:-
Osmotic diuresis secondary to increased urea following retention
Diuresis of retained salt and H2O
Reduced concentration gradient in the Loop of Henlé after reduced flow rates in retention, which do not recover immediately after obstruction to the urinary tract is relieved.

25. Further Investigations and Treatment
Further treatment may include:-
Abx for UTI’s and Prostitis
Tamsulosin 400 micrograms OD for BPH
TWOC (trial without catheter) following underlying cause being treated.
Further investigations may include:-
Prostate biopsy (suspicion of malignancy)
Renal Tract US (hydronephrosis)
MRI L-S spine (cauda equina syndrome)
Surgery (ie TURP for BPH/PrCa)

26. Summary Acute retention is a common but easily treated condition
There are a variety of common causes, most commonly BPH and UTI’s.
It is important to fully investigate these causes and treat accordingly to prevent permanent damage to the urinary tract and prevent recurrence.