acute urinary retention j e mensah. definitions acute retention painful inability to void with...
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Acute Urinary Retention
J E Mensah
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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 voidCHRONIC RETENTION• Failure to empty bladder + Gross bladder distention(over 800mls)
+ No Suprapubic pain.Can result in Post -renal renal failureACUTE ON CHRONICFailure to empty bladder + Gross bladder distention(over 800mls)
+Suprapubic pain
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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
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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)
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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.
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Spontaneous or precipitated retention
• Precipitated-retention is less likely to recur • Spontaneous-more likely to recur and therefore
requires definitive treatmentPrecipitating events• Drugs-sympathomimetics (Ephedrine in cough
syrups), anticholinergics,anesthetic drugs• Constipation• Pain• Abdominal or pelvic surgery
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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
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Female genital mutilation(FGM)
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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.
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Retention caused by urethral stone
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Physical exam
• Palpable suprapubic mass: A bladder with >150ml of urine should be palpable or percussible
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Initial management-Urethral catheterization
• Explain the procedure to the patient
• Aseptic technique-one gloved hand is sterile, the other is ‘dirty’
• Adequate lubrication
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After catheterization
• Write operation notes(indication, volume drained, nature of urine
• Urine bag for continuous drainage.• Adequate hydration• Antibiotics?
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Post catheterization problems
• Excessive diuresis (>200ml/hr) • Bleeding. (bladder mucosal disruption)• hypotension (vasovagal response )• Urine leakage around catheter• Stuck catheter
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Urine leakage around catheter
• Usually caused by bladder spasm NOT blockage or small catheter size.
Adult males 16/18 FrWomen 14/16 FRChildren 8/10fr
• Antispasmodics . oxybutynin,2.5mg tds
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Stuck catheter
• Faulty balloon mechanism .(test before use)
• Obstruction of balloon channel by crystals (NaCl.mannitol).use sterile water to inflate balloon.
• Encrustations
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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
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Failure of urethral catherization
• Spasm of external sphincter
• Huge middle lobe• Urethral Stricture or
bladder neck contracture
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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
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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
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History of catheter