1. Acute Urinary Retention J E Mensah

2. Definitions ACUTE RETENTION 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

3. 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

4. Mechanisms of urinary retention Increased Anatomic urethral resistance ie bladder outlet obstruction(BOO) Low bladder pressure (impaired detrusor muscle contractility) Interruption of sensory or motor innervation of bladder Failure of co-ordination of bladder contraction with sphincter relaxation(DSD)

5. Retention in males Benign Prostatic Hyperplasia (BPH) Carcinoma of the Prostate Urethral Stricture Bladder neck contracture (late complication of prostate surgery) Trauma to urethra or bladder neck Phimosis and Paraphimosis in children and uncircumcised men Posterior Urethral Valves in children.

6. Spontaneous or precipitated retention Precipitated-retention is less likely to recur Spontaneous-more likely to recur and therefore requires definitive treatment Precipitating events Drugs-sympathomimetics (Ephedrine in cough syrups), anticholinergics,anesthetic drugs Constipation Pain Abdominal or pelvic surgery

7. Retention in women Extrinsic compression of bladder neck or proximal urethra eg fibroid,cystocoel Infections Foreign body Meatal stenosis Fowlers syndrome- impaired relaxation of the external sphincter, associated with polycystic ovaries

8. Female genital mutilation(FGM)

9. Other causes Haematuria leading to clot retention Drugs Stones Diabetic cystopathy(sensory and motor dysfunction) Detrusor sphincter – sphincter dyssynergia (DSD),Sacral and suprasacral spinal cord injury with loss of coordination of external sphincter relaxation with detrusor contraction.

10. Retention caused by urethral stone

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

12. Initial management-Urethral catheterization Explain the procedure to the patient Aseptic technique- one gloved hand is sterile, the other is ‘dirty’ Adequate lubrication

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

14. Post catheterization problems Excessive diuresis (>200ml/hr) Bleeding. (bladder mucosal disruption) hypotension (vasovagal response ) Urine leakage around catheter Stuck catheter

15. 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

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 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

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. History of catheter