Acute Urinary Retention. Laura Oakley FY1 Urology. Definition. Acute Urinary Retention refers to the inability to empty the bladder Most common in men Increasing incidence with increasing age. Case Study: History 1. 67 yr old man PC 1) Unable to pass urine 2) Lower abdominal pain .
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Acute Urinary Retention Laura Oakley FY1 Urology
Definition • Acute Urinary Retention refers to the inability to empty the bladder • Most common in men • Increasing incidence with increasing age
Case Study: History 1 • 67 yr old man • PC • 1) Unable to pass urine • 2) Lower abdominal pain
Case Study: History 2 • HxPC • 24 hours of inability to pass urine at will • 4 yr Hx of prostatic symptoms. • Patient c/o gradual worsening of prostatic symptoms over the past 2/12 • Frequency • Nocturia x2-3 night • Hesitancy • Poor stream
Case Study: History 3 • 12hrs of lower abdominal pain • Suprapubic pain • No relieving/exacerbating factors • No radiation • No dysuria • Prostatic symptoms have been investigated over the past year last PSA was 1.9
Case Study: History 4 • PMHx • Angina well controlled with medication • HTN • OA knees • Screen Nil else elicited
Case Study: History 5 • DHx • Ramipril • Aspirin • Bendroflumethiazide • GTN sublingual spray PRN • Paracetamol PRN • NKDA • FHx • Hx MI/Angina.
Case Study: History 6 • SHx • Ex smoker 20 pack year Hx, gave up 10 yrs ago • EtOH Occasional, not in past week • Illicit Substances nil • Retired office worker • Lives with wife • Independent
Case Study: Examination • Observation Patient uncomfortable, but alert and orientated. HR = 86 regular T = 36.4 BP = 138/74 RR = 18
Case Study: Examination • CVS HS I + II + 0 JVP Ankles = some mild ankle oedema • Resp Chest clear Air entry good and equal bilaterally No added sounds
Case Study: Examination • GI Palpable bladder to umbilicus, resonant to percussion Suprapubic tenderness No organomegaly BS present DRE: Smooth moderately enlarged prostate. Normal anal tone.
Case Study: Examination • Neuro Power 5/5 Sensation N, perineal sensation normal Reflexes N Tone N • Bladder scan~ 750 mls
Differential Diagnosis • Urinary retention can be secondary to a variety of causes:- • BPH • PrCa • UTI • Prostatitis • Drugs: • Anticholinergics • Antidepressants • Anaesthetics • Illicit drugs (particularly stimulants) • EtOH • Constipation • Pain • Cauda equina syndrome • Clot retention (2O to urinary tract malignancies or post-op) • Urethral pathology
Discussion • Points in the history can give us clues as to the cause of the individuals retention………
Discussion • HxPC • 24 hours of inability to pass urine at will • 4 yr Hx of prostatic symptoms. • Patient c/o gradual worsening of prostatic symptoms over the past 2/12 • Frequency • Nocturia x2-3 night • Hesitancy • Poor stream It is important to ask about prostatic symptoms as this could give you an indication as to whether the BPH or PrCa could be the cause of the retention.
Discussion • 12hrs of lower abdominal pain • Suprapubic pain • No relieving/exacerbating factors • No radiation • O dysuria • Prostatic symptoms have been investigated over the past year last PSA was 1.9 Ask about symptoms which might indicate a UTI as an underlying cause.
Discussion • PMHx • Angina well controlled with medication • HTN • OA knees • Screen Nil else elicited A detailed PMHx will help indicate whether there is any likelihood of other diseases contributing to the retention ie) any risk of cauda equina, autonomic neuropathies (more likely to be chronic retention), constipation, pain.
Discussion • DHx • Ramipril • Aspirin • Bendroflumethiazide • GTN sublingual spray PRN • Paracetamol PRN • NKDA • FHx • Hx MI/Angina. The DHx is important as many drugs can cause urinary retention, particularly anticholinergics and antidepressants.
Discussion • SHx • Ex smoker 20 pack year Hx, gave up 10 yrs ago • EtOH Occasional, not in past week • Illicit Substances nil • Retired office worker • Lives with wife • Independent A good social history helps us to elicit whether EtOH consumption or drug abuse could have contributed to the development of retention. Be particularly aware of this in cases involving younger men with no other likely cause.
Discussion • GI Palpable bladder to umbilicus, resonant to percussion Suprapubic tenderness No organomegaly BS present DRE: Smooth moderately enlarged prostate. Normal anal tone. Doing a DRE is essential, as it can identify:- BPH (enlarged, smooth), malignant prostate (craggy, hard) and can also help to identify other causes such as cauda equina syndrome (reduced anal tone, saddle anaesthesia).
Investigations • Some basic preliminary investigations may help narrow down the cause……
Basic Investigations • Bladder Scan • This is done prior to catheterisation to identify the volume in the bladder to check that the patient is in fact in retention. • Most individuals can hold up to 600mls before becoming significantly uncomfortable • Chronic retainers can hold much greater volumes, often up to 1l or more. • Urine Dip + MSU • To identify infection and sensitivities
Basic Investigations • Bloods • FBC:- an elevated white cell count might indicate underlying infection • U&E’s:- important to identify if there is any kidney damage from backpressure of urine due to the obstruction. • PSA:- can be unreliable in the acute setting as will be raised by the very presence of retention as well as after DRE. However it is useful to identify the results from any previous PSA’s to aid in the differential diagnosis.
Treatment • Catheterise using aseptic technique and appropriate Abx cover • IM Gentamicin is the Abx of choice in this Trust. • Record residual volume of urine • Monitor for diuresis occurs due to:- • Osmotic diuresis secondary to increased urea following retention • Diuresis of retained salt and H2O • Reduced concentration gradient in the Loop of Henlé after reduced flow rates in retention, which do not recover immediately after obstruction to the urinary tract is relieved.
Further treatment may include:- Abx for UTI’s and Prostitis Tamsulosin 400 micrograms OD for BPH TWOC (trial without catheter) following underlying cause being treated. Further investigations may include:- Prostate biopsy (suspicion of malignancy) Renal Tract US (hydronephrosis) MRI L-S spine (cauda equina syndrome) Surgery (ie TURP for BPH/PrCa) Further Investigations and Treatment
Summary • Acute retention is a common but easily treated condition • There are a variety of common causes, most commonly BPH and UTI’s. • It is important to fully investigate these causes and treat accordingly to prevent permanent damage to the urinary tract and prevent recurrence.