1. Acute Urinary Retention
J E Mensah

2. 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

3. 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 bladder mls)+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

4. 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

5. 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)

6. Retention in males Benign Prostatic Hyperplasia (BPH)
Carcinoma of the Prostate
Urethral Stricture
Trauma to urethra or bladder neck

7. Retention in women
Extrinsic compression of bladder neck or proximal urethra eg fibroid,cystocoel
Infections
Meatal stenosis

8. Female genital mutilation(FGM)

9. Other causes
Haematuria leading to clot retention
Drugs
Stones

10. Retention caused by urethral stone

11. Physical exam
Palpable suprapubic mass: A bladder with >150ml of urine should be palpable or percussible
USG in obese patients

12. 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

13. After catheterization
Write operation notes(indication, volume drained, nature of urine
Urine bag for continuous drainage.
Adequate hydration

14. Urethral catheterization problems
Urine leakage around catheter
Stuck catheter
Failure

15. Urine leakage around catheter
Usually caused by bladder spasm NOT blockage or small catheter size.
Adult males 16/18 Fr
Women /16 FR
Children 8/10fr
Antispasmodics . oxybutynin,2.5mg tds
Solefenacin 5 mg daily
Tolterodine 2mg daily

16. Stuck catheter Faulty balloon mechanism .(test before use)
Obstruction of balloon channel by crystals (NaCl.mannitol).use sterile water to inflate balloon.
Encrustations

17. 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

18. Failure of urethral catherization
Spasm of external sphincter
Huge middle lobe
Urethral Stricture or bladder neck contracture

19. Suprapubic tap/catherization
Insertion requires at least cc 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

20. 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

21. DEFINATIVE MANAGEMENT OF ACUTE RETENTION FROM BPH
TRIAL WITHOUT CATHETER
PROSTATE SHRINKING AND RELAXING DRUGS FOLLOWED BY TWOC
SURGERY
LONG TERM CATHERIZATION

22. 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: )
Precipitating events
Drugs-sympathomimetics (Ephedrine in cough syrups), anticholinergics,anesthetic drugs
Constipation
Pain
Abdominal or pelvic surgery
Timing of TWOC???-no evidence based guideline

23. 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:
5 α reductase inhibitors-reduce prostate size. eg Finasteride (Proscar)

24. SURGICAL MANAGEMENT Transurethral resection of the prostate(TURP)
Open prostatectomy

25. 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: doi: /bmj (Published 8 November 2007
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

26. Management of AROU in 907AD