acute urinary retention j e mensah. definitions acute retention painful inability to void with...
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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 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
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
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 treatmentPrecipitating 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 syndrome-impaired
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 >150ml of urine should be palpable or percussible
Initial management-Urethral catheterization
• Explain the procedure to the patient
• Aseptic technique-one 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 (>200ml/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 FrWomen 14/16 FRChildren 8/10fr
• Antispasmodics . oxybutynin,2.5mg tds
Stuck catheter
• Faulty balloon mechanism .(test before use)
• Obstruction of balloon channel by crystals (NaCl.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 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
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
History of catheter