Retention of Urine

Dr Prabha OmProfessor Surgery

SMS Medical College, JAIPUR

DefinitionUrinary retention is defined as the inability to completely or partially empty the bladder. It is a sudden painful inability to urinate inspite of a full bladderUrinary retention, also known as ischuria, is a lack of ability to urinate

Suffering from urinary retention means you may be unable to start urination, or if you are able to start, you can’t fully empty your bladder.

Normal micturition cycle:A. Filling: Impulses from the CNS to sympathetic and pudendal nerves relax the bladder and close the outlet.B. Voiding: Inhibition of sympathetic and pudendal impulses. Stimulation of parasympathetic (S2-4) leads to detrusor contraction →voiding in the absence of obstruction

Urinary retention is characterised by poor urinary stream with intermittent flow, straining, a sense of incomplete voiding and hesitancy (a delay between trying to urinate and the flow actually beginning). As the bladder remains full causes incontinence, nocturia (need to urinate at night) and high frequency. Acute retention is a medical emergency, as the bladder may distend (stretch) to enormous sizes and possibly tear if not dealt with quickly. If the bladder distends enough it will begin to become painful. The increase in pressure in the bladder can also prevent urine entering from the ureters or even cause urine to pass back up the ureters and get into the kidneys, causing hydronephrosis, and possibly pyonephrosis, kidney failure and sepsis. A person should go straight to an emergency department as soon as possible if unable to urinate when having a painfully full bladder.

Anuria means nonpassage of urine, in practice is defined as passage of less than 50 milliliters of urine in a day Anuria is complete absence of urine production by the kidney for 12 hours or more. Oliguria is decreased urine volume to less than 400 ml in a day.

. Anuria is often caused by failure in the function of kidneys. It may also occur because of some severe obstruction like kidney stones or tumours. It may occur with end stage renal disease. It is a more extreme reduction than oliguria, sometimes called anuresis.

CausesThere are two general types of urinary retention: obstructive and non-obstructive. If there is an obstruction (for example, kidney stone urine cannot flow freely through the urinary tract

. Non-obstructive causes include a weak bladder muscle and nerve problems that interfere with signals between the brain and the bladder. If the nerves aren’t working properly, the brain may not get the message

that the bladder is full.

Causes of non-obstructive urinary retention are:

•Stroke•Vaginal childbirth•Pelvic injury or trauma•Impaired muscle or nerve function due to medication or anesthesia•Accidents that injure the brain or spinal cord

Obstructive retention may result from:

•Cancer

•Kidney or bladder stones

•Enlarged prostate (BPH) in men

Causes:A. Mechanical or obstructive:1- Bladder:- Stone, bladder neck obstruction, cancer.2- Prostate:- BPH is the most common cause in men over 50 years.- Acute prostatitis and abscess.- Prostate cancer.

3- Urethra:-Stone, stricture, urethritis, rupture, phimosis,- posterior urethral valves.4- Clot retention in severe hematuria e.g. cancer, trauma.5- Women: pelvic masses, urethral stenosis and diverticulum, pelvic prolapse, hysterical.

C. Functional and neurogenic: 1. Postoperative AUR is common: Pain, limited mobility, drugs, bladder nerve injury e.g. hysterectomy & abdominal resection

Prevention is important by catheterization after surgery to bladder, prostate, urethra.

•vaginal childbirth•infections of the brain or spinal cord•diabetes•stroke•accidents that injure the brain or spinal cord•multiple sclerosis•heavy metal poisoning•pelvic injury or trauma ,• some children are born with nerve problems that can keep the bladder from releasing urine

2- Drugs:- Anesthetics- Anticholinergics- Sympathomimetics 3- Neurogenic:- Spinal cord injury.- Diabetic neuropathy.- Cauda equina lesions.- Intervertebral disc prolapse.- Neurotropic viruses: Herpes simplex or zoster.- Multiple sclerosis.- Transverse myelitis. Tabes dorsalis.

Symptoms of urinary retention may include:•Difficulty in starting to urinate•Difficulty in fully emptying the bladder•Weak dribble or stream of urine•Loss of small amounts of urine during the day•Inability to feel when bladder is full•Increased abdominal pressure•Lack of urge to urinate•Strained efforts to push urine out of the bladder•Frequent urination•Nocturia (waking up more than two times at night to urinate)

History:- Cause- related: A complication of BPH Drugs: Urethral trauma Stone disease- Suprapubic bursting pain, no urine, strong desire to urinate.- Acute urine retention should be differentiated from obstructive anuria.

Abdominal Examination: Midline globular tender suprapubic mass.Genital examination: Phimosis, severe urethral meatal stenosis.Digital Rectal Examination: BPH, Prostate cancer.

Differential diagnosis of acute retention and obstructive / anuria

• Acute retention obstuctive AnuriaDesire to urinate + - -Suprapubic pain + - -Renal pain - - +General exam. Good May be uremicAbdominal exam. Tender Full bladder Empty Loin bladder

Treatment:A) Conservative measures in non-obstructive causes: Patient is asked to go out of bed. Take hot bath. Parasympathomimetics.

Failure → catheterization.

Urethral catheterization: Nelaton or Foley's: It is absolutely contraindicated in urethral injury. Proper Sterilization of parts. Adequate lubrication of urethra. Proper catheter size Children 6-12 F Adults 16 F

Clot retention:- Triway 22F urethral catheter with irrigation.- Evacuation of clots.-Cystoscopy - diagnostic and therapeutic

Suprapubic cystocath: done in Urethral trauma Urethral stricture Failure of urethral catheterization

Treatment of the cause e.g.

- TURP for BPH

urethroplasty for urethral stricture. - Endoscopic crushing of vesical stone.

Chronic Retention of Urine

Causes: Long standing incomplete obstruction

A) Mechanical : BPH, prostate cancer

B) Functional: Neuropathic flaccid bladder.- Large amounts of residual urine exist.- When the vesical pressure exceeds the urethral resistance, the patient can pass some urine or dribble continuously. This is called false or overflow incontinence.

Differentiation between acute and chronic urine retention

Acute retention Chronic retentionUrination No urine Overflow incontinencePain Severe, suprapubic, Painless bursting

Obstruction Complete Partial

Suprapubic + +/-tenderness

Emergency measures – Urethral catheter or Suprapubic catheter if urethral trauma or injury are expected - Ureteric catheter Or DJ stent if Failure - PCN

Causes according to siteIn the bladder⇒ Detrusor sphincter dyssynergia⇒ Neurogenic bladder (commonly pelvic splanchic nerve damage, cauda equina syndrome, descending cortical fibers lesion, pontine micturation or storage center lesions, demyelinating diseases or Parkinson's disease)⇒ Iatrogenic scarring of the bladder neck (commonly from removal of indwelling catheters or cystoscopy operations)⇒ Damage to the bladder

In the prostate⇒ Benign prostatic hyperplasia⇒ Prostate cancer and other pelvic malignancies⇒ Prostatitis.

Penile urethra⇒ Congenital urethral valves⇒ Phimosis or pinhole meatus⇒ Circumcision⇒ Obstruction in the urethra, for example a metastasis or a precipitated pseudogout crystal in the urine⇒ STD lesions (gonorrhoea causes numerous strictures, leading to a rosary bead appearance, whereas chlamydia usually causes a single stricture)Other⇒ Paruresis ( shy bladder syndrome )-, urinary retention can result⇒ Consumption of some psychoactive substances, mainly stimulants, such as MDMA and amphetamine.⇒ Use of NSAIDs or drugs with anticholinergic properties.⇒ Stones or metastases can theoretically appear anywhere along the urinary tract, but vary in frequency depending on anatomyParuresis, inability to urinate in the presence of others (such as in a public restroom), may also be classified as a type of urinary retention, although it is psychological rather than biological.

Investigations History of complaints and physical examination Ultrasonography for any calculi, growth, post voiding residual urine, condition of Kidney any injury Xray KUB for calculi Blood Urea , Creatinine levels CT Scan for any pathology Urine examination for infection PSA for Prostate Cancer Urodynamic Test for Cystocele Cystoscopy for status of bladder MRI Lumber spine for spinal pathology

Dysuria refers to painful urination.It is one of a constellation of irritative bladder symptoms, which includes urinary frequency and haematuria.Differential diagnosisThis is typically described to be a burning or stinging sensation. It is most often a result of a urinary tract infection It may also be due to an STD, bladder stones, bladder tumours, and virtually any condition of the prostate. It can also occur as a side effect of anticholinergic medication used for Parkinson's disease.

Polyuria is a condition usually defined as excessive or abnormally large production and/or passage of urine .

Polyuria often appears in conjunction with polydipsia (increased thirst), though it is possible to have one without the other, and the latter may be a cause or an effect. Psychogenic polydipsia may lead to polyuria.Polyuria is physiologically normal in some circumstances, such as cold diuresis, altitude diuresis, and after drinking large amounts of fluids

The most common cause of polyuria in both adults and children is uncontrolled diabetes mellitus, causing an osmotic diuresis. Primary polydipsia (excessive fluid drinking), diabetes insipidus hypercalcemia) or various chemical substances (diuretics, caffeine, alcohol). after supraventricular tachycardias, during an onset of atrial fibrillation, childbirth, and the removal of an obstruction within the urinary tract. Cold diuresis is the occurrence of increased urine production on exposure to cold, which also partially explains immersion diuresis.Substances that increase diuresis are called diuretics.

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