Urinary Retention


Overview (DDx)
Drugs Causes:
Antihistamines, anticholinergics, TCA, antispasmodic, alpha agonists
Dehydration CBC, CMP, IV Fluids
BPH Most common >50 yr
Tx: Flomax 0.4mg PO qd, Prazosin 1,2,5 mg PO bid
 
Infection Prostatitis Cipro, Bactrim, NSAIDs
UTI Cipro
Vaginitis Bacterial Flagyl 500mg PO bid x7d
Fungal Diflucan 150mg PO x1
Penile Obstruction Phimosis, Paraphimosis, Stenosis
Urethral Obstruction Tumor, Hematoma
Neurologic Causes: Diabetes, Syringomyelia, Spinal Cord Syndrome, Herpes Zoster, Multiple Sclerosis?,  stroke, Parkinson's, dementia,
 
Mechanical (+) Symptoms
@ night
Stress - w/ Cough
Tx:
Pseudoephedrine 15-50mg PO tid
Imipramine 10-25mg PO bid
HRT:
Kegel
Sling Procedure or Periurethertal bulking injection
 
(-) Symptoms
@ night
Urge Overactive Bladder
Tx:
Anti-cholinergic:
Enablex (darifenacin) 7.5-15 mg PO qd
Detrol  (tolterodine) 1-2 mg PO bid.
Anti-Spasm:
Ditropan (Oxybutin) 2.5-5 mg PO bid
Vesicare (solifenacin) 5-10 mg PO qd
 
Overflow/
Neurogenic Bladder
HypOactive Bladder
Tx:
Catheter
Cholinergic-Agonist: Bethanechol 10-50mg PO tid
 
Bypass Surgery


Causes Of Retention in both Sexes

Obstructive causes
  Urethral stricture
  Bladder calculi
  Bladder neoplasm
  Foreign body, urethral or bladder
Neurogenic causes
  Multiple sclerosis
  Parkinson's disease
  Shy-Drager syndrome
  Brain tumors
  Cerebral vascular disease
  Cauda equina syndrome
  Metastatic spinal cord lesions
  Intervertebral disk herniation
  Neuropathy, diabetes mellitus, and other causes
  Nerve injury from pelvic surgery
  Postoperative retention
Trauma
  Urethral injury
  Bladder injury
  Spinal cord injury
Extraurinary causes
  Perirectal or pelvic abscesses
  Rectal or retroperitoneal masses
  Fecal impaction
  Abdominal aortic aneurysm
Psychogenic causes
  Psychosexual stress
  Acute anxiety
Infection
  Cystitis
  Herpes simplex (genital)
  Herpes zoster involving pelvic region
  Local abscess
Operative
  Epidural anesthesia
Childhood
  Posterior urethral valves
  Rhabdomyosarcoma of the bladder
  Urethral atresia
Pharmacologic etiologies (see below
 

Pharmacologic Etiologies

Pharmacologic etiologies (Table 95-3) 
β-Adrenergic agents (selected) Hormonal agents
  Ephedrine sulfate   Progesterone
  Phenylephrine HCl   Estrogen
  Phenylpropanolamine HCl   Testosterone
  Pseudoephedrine HCl Antipsychotics (selected)
β-Adrenergic agents   Haloperidol
  Isoproterenol   Thiothixene
  Metaproterenol   Thioridazine
  Terbutaline   Chlorpromazine
Antidepressants (selected)   Fluphenazine
  Imipramine   Prochlorperazine
  Nortriptyline   Clozapine
  Amitriptyline   Risperidone
  Doxepin   Ziprasidone
  Amoxapine Antihistamines (selected)
  Maprotiline   Diphenhydramine HCl
  Reboxetine   Promethazine
  Selective serotonin reuptake inhibitors with other psychotropic drugs   Chlorpheniramine
  Brompheniramine
Antiarrhythmics (selected)   Cyproheptadine
  Disopyramide   Hydroxyzine
  Flecainide Antihypertensives (selected)
  Quinidine   Calcium channel blockers
  Procainamide   Hydralazine
Anticholinergics/antispasmodics (selected)   Trimethaphan
  Atropine Analgesic drugs (selected)
  Scopolamine hydrobromide   Morphine sulfate and other opiates
  Belladonna
  Homatropine methylbromide   NSAIDs
  Hyoscyamine Muscle relaxants (selected)
  Clidinium bromide   Diazepam and other benzodiazepines
  Glycopyrrolate
  Mepenzolate bromide   Baclofen
  Methantheline bromide   Cyclobenzaprine
  Oxyphenonium bromide Miscellaneous (selected)
  Propantheline bromide   Indomethacin
  Dicyclomine HCl   Carbamazepine
  Oxybutynin   Amphetamines
  Flavoxate HCl   Dopamine
  Tolterodine   Vincristine
Operative Ecstasy (3, 4 methylenedioxymethamphetamine)
  Anesthesia agents
Antiparkinsonian agents (selected)    
  Trihexyphenidyl HCl    
  Benztropine mesylate    
  Biperiden    
  Amantadine HCl    
  Levodopa  
  Bromocriptine mesylate  
 

Gender Specific Causes

Men Women
Obstructive Obstructive
  Benign prostatic hypertrophy*   Cystocele
  Prostate cancer   Ovarian tumor
  Phimosis   Uterine tumor
  Paraphimosis Operative
  Meatal stenosis   Incontinence surgery
  Urethral strangulation Infection
Infection   Pelvic inflammatory disease
  Prostatitis  
 


Diagnosis

History

  • Straining to void w/decr or absent urine output
  • Lower abd discomfort, overflow incontinence

Evaluation

  • Obtain post void residual; abnormal if >100cc
  • Check renal functions & lytes
  • U/A & urine culture
 

Treatment

Steps in Evaluation and Management of Acute Urinary Retention
Recognition Recognize a patient with possible acute urinary retention.
Initial assessment Obtain complete history and physical examination to identify underlying diseases and precipitating factors: obstructive, infectious, pharmacologic, neurogenic, traumatic, childhood, or psychogenic causes. Assess bladder volume with bedside US.
Initial stabilization Place a urethral or suprapubic catheter.
Risk assessment Assess for risk of recurrence, need for surgical intervention, and morbidity: age, severity of clinical presentation, causes, comorbidity, prostate size, postvoid residual, maximum urine flow rate.
Need for inpatient care Admit for treatment of significant underlying medical illness or precipitating factors. Consider malignancy, spinal cord compression or injury, unresolved hematuria, urinary tract infection with possible sepsis.
Need for urologic consultation Discuss with urology consultant in the event of precipitated acute urinary retention, urethral stricture, meatal stenosis, urethral injury, suspected prostate cancer, acute prostatitis, or urologic postoperative complications.
Outpatient management Spontaneous acute urinary retention without significant and/or acutely symptomatic comorbidities and without evidence of complications, such as bleeding, infection, or renal function impairment:
- Discharge with Foley catheter, leg bag, α-adrenergic receptor blocker, (i.e., alfuzosin, 10 milligrams daily, or tamsulosin, 0.4 milligram daily) and follow up with urology in 3–7 days.
 
  1. Once the condition of urinary retention is considered, immediate decompression of the bladder by catheterization is the primary method of treatment and is used as an aid in the diagnosis of the cause. Urethral or suprapubic catheterization can be done
  2. Remove retained urine from bladder
  3. Defer if post trauma w/possible pelvic fracture/urethral injury
  4. First try insertion of Foley cath (16 or 18F)
    • Avoid if < 1wk post-prostatectomy or recent urethral surgery; consult urology
    • Clot retention: use large Foley, may need urology
  5. If unsuccessful, try coude catheter
  6. If again unsuccessful consider filiforms to navigate strictures
  7. May require suprapubic catheterization
  8. Only treats symptoms, not underlying problem
    • Tamsulosin (Flomax) 0.4mg PO QAM may be considered when obstruction due to prostatic hypertrophy
  9. Decompress bladder slowly to avoid mucosal hemorrhage

Urethral Catheterization

  • Urethral catheterization is the primary treatment method due to its commonality and lower complication rate compared to suprapubic catheterization.
  • The retrograde injection of 10 to 15 mL of water-soluble anesthetic lubricant (e.g., 2% lidocaine jelly) 5 to 10 minutes before and in combination with the urethral catheter can alleviate the uncomfortable sensation typical of catheter passage.
  • The catheter is in place when urine is freely draining.
  • Inflate the catheter balloon, and apply gentle traction to make sure the catheter is well seated in the bladder. All the while, make sure that urine continues to easily drain.
  • If the catheter is in the urethra and not the bladder, urine will not drain freely, and balloon inflation will cause extreme pain.
  • If attempts at passage of a straight 14F to 18F Foley catheter fail, use of a firm angulated Coude catheter with the tip pointing anteriorly may be successful.
  • Difficult catheterization in male patients can result from variable causes, including
    • Urethral stricture
    • Prostatic enlargement, and
    • Postsurgical bladder neck contractures.
  • If catheterization produces gross blood, deflate the balloon, remove the catheter, and do not attempt reinsertion because a false passage (through the penile soft tissue instead of the urethra) may have been produced.
  • Management may require urology consultation for the use of a guidewire, flexible filiforms, and dilation followers for progressive dilation of the urethra to place a catheter.
  • CONSULT UROLOGY:
    • If the patient recently underwent urologic surgery (e.g., radical prostatectomy or complex urethral reconstruction), consult the urologist before attempts at catheter placement.
    • If one suspects the creation of a false passage by traumatic urethral catheterization, consult the urologist for endoscopic catheter placement into the urethra.

Suprapubic Catheterization

  • Suprapubic catheterization can be performed in patients after failure of several attempts of urethral catheterization and as long as there is no obvious pelvic trauma or abnormal anatomy in the lower abdomen.
  • This may be the only option to decompress an extremely painful, distended bladder when urethral catheterization is not possible.
  • US-guided suprapubic catheterization has a low complication rate.
  • Prepare the suprapubic area with Betadine and local anesthesia.
  • Visualize the distended bladder with US.
  • While monitoring with US, advance a 22-gauge spinal needle with 10-mL syringe posteriorly and caudally at a 30-degree angle from the true vertical and 60 degrees from the horizontal plane of the abdomen, 3 to 4 cm above the pubic symphysis in the midline.
  • Advance the needle while withdrawing on the syringe.
  • US visualization of the needle in the bladder and urine return indicates correct placement.
  • Use the depth and position of this attempt to direct the placement of the obturator.
  • Make a small skin incision in the midline at the point of prior needle removal.
  • The cystostomy catheter and obturator assembly is then placed in similar manner as the spinal needle, again aspirating for urine.

Special Considerations

Females with Urinary Retention

  • Urinary retention in women is relatively uncommon. Due to its low incidence, few articles describe the common causes. The obstructive causes of urinary retention in women are usually related to gynecologic problems, but neurogenic causes can develop in both men and women. One study surveying 91 women with abnormal urethral sphincter electromyography and urine retention found that 40 (44%) of those with urinary retention were initially misdiagnosed as psychogenic. A detailed history and physical examination, urine analysis, culture, and pelvic US should help identify causes. Urodynamic studies can distinguish detrusor failure and outlet obstruction.
  • The management of urinary retention in females involves catheterization and attending to any treatable cause. The ideal selection of catheterization method, including in and out catheterization, short-term indwelling urethral catheter followed by a trial of voiding, or clean intermittent self-catheterization, depends on the clinical assessment of precipitating factors and underlying conditions. α-Blockers do not appear to be helpful in women with urinary retention. If there is no apparent cause, refer to a gynecologic urologist for urodynamic studies.

Gross Hematuria and Clot Retention

  • Gross hematuria can lead to clot retention, resulting in pain and hypertension and tachycardia from acute bladder distention.
  • Management of gross hematuria is placement of a 20F to 24F triple-lumen catheter (one port for urine drainage, one port for balloon inflation, one port for bladder irrigation) and irrigation with saline until clear to evacuate clots.
  • Patients with clot retention are generally admitted, as clot retention may reoccur and may require cystoscopic clot removal.
  • Patients with gross hematuria from coagulopathy (i.e., warfarin) should have clotting parameters corrected as appropriate and be admitted.
  • Consideration: Leave Foley in and follow up with Urology.

Spontaneous VS Precipitated Urinary Retention

  • Spontaneous urinary retention denotes no evidence of precipitating factors other than BPH, whereas "precipitated" urinary retention is defined by clinical factors (in addition to BPH) that could possibly have precipitated the episode.
  • Factors considered as precipitating urinary retention include preceding surgery; a common medical event, such as anesthesia, stroke, or urinary tract infection; or ingestion of α-sympathomimetics, cold medications, antihistamines, or anticholinergics. The importance of such differentiation becomes clear when evaluating outcomes.
  • Patients with spontaneous urinary retention have a higher rate of a recurrent spontaneous episode (15% vs. 9%) and undergoing surgery (75% vs. 26%) than those with precipitated urinary retention.
  • A trial of voiding is deserved in all patients with BPH-related urinary retention, whether or not precipitating factors exist.
  • Treat precipitated urinary retention with bladder drainage and then catheter removal and a voiding trial in the ED.
  • Discontinue medications that may be associated with urinary retention.

Disposition and Follow-Up

  • Some authorities recommend admitting all acute urinary tract obstructions
    • Pts. should be monitored min of 4-6hrs post decompression
    • May develop postobstructive diuresis (watch for hypovolemia)
    • May have chronic obstruction & require maintenance of catheter
    • Monitor for signs of renal failure
    • Patients with clot retention, hematuria and coagulopathy, sepsis, possible neurologic cause of urinary retention, or other significant comorbidities should be admitted
       
  • Approximately 90% of patients with urinary retention are discharged home with a catheter after initial ED management and wait for further surgical intervention after the urology clinic visit. Patients should be educated in Foley catheter care and given a list of alarm symptoms that should prompt return to the ED.
    • These include fever, return of symptoms, repeated vomiting, abdominal pain, catheter blockage, or penile pain.
    • Penile pain suggests migration of the balloon into the proximal urethra.
    • Feelings of urgency or bladder spasm can be treated with oxybutynin (Ditropan®), 2.5 mg PO two or three times a day.
    • Oxybutynin has anticholinergic properties and can cause the same adverse effects as any anticholinergic agent.
    • There is no satisfactory treatment for urinary leakage around the catheter.
    • Placement of a larger catheter is not typically effective.
       
  • Patients with spontaneous urinary retention and without evidence of complications, such as bleeding, infection, or renal function impairment after Foley catheterization, can be discharged home with the urinary catheter left in place and attached to a urinary leg bag collecting system.
  • If pt. D/C'd, f/u should occur in 1-2 days
    • Catheter should remain in place w/outpatient drainage bag attached
    • Pt. should return immediately if catheter output decreases, pain, fever, or bleeding
    • Instruct the patient or family members in the technique for emptying the leg bag.
    • α-Blockers or oxybutynin can be prescribed as needed.
    • Recommend urology follow-up within 3 to 7 days.
    • A longer period of Foley drainage is encouraged in patients with retention volumes >1.3 L to improve chances of successful voiding.
    • The serum PSA assay and long-term usage of 5 α-reductase inhibitor could be evaluated at urology follow-up.
    • For precipitated urinary retention, remove the catheter in the ED and allow a voiding trial. Discontinue offending medications.
       

 

Ref: Tintinalli EM 7th ed