Acute Urinary Retention J E Mensah Definitions ACUTE

Acute Urinary Retention J E Mensah

Definitions ACUTE RETENTION • Painful inability to void with relief of pain following drainage of the bladder by catheterization • Suprapubic pain +Suprapubic distension(full bladder 350500 mls)+failure to void CHRONIC RETENTION • Failure to empty bladder + Gross bladder distention(over 800 mls) + No Suprapubic pain. Can result in Post -renal failure ACUTE ON CHRONIC Failure to empty bladder + Gross bladder distention(over 800 mls)+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(S 2 -S 4) 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 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)

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.

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

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

Female genital mutilation(FGM)

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.

Retention caused by urethral stone

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

Initial management-Urethral catheterization • Explain the procedure to the patient • Aseptic techniqueone gloved hand is sterile, the other is ‘dirty’ • Adequate lubrication

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

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

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 8/10 fr • Antispasmodics. oxybutynin, 2. 5 mg tds

Stuck catheter • Faulty balloon mechanism. (test before use) • Obstruction of balloon channel by crystals (Na. Cl. 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 200300 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 •

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 (22 Fr 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

History of catheter