Acute urinary retention: Difference between revisions

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== Background ==
==Background==
*Urologic emergency characterized by sudden inability to pass urine
*Urologic emergency characterized by sudden inability to pass urine
*Most common cause is BPH
*Most common cause is benign prostatic hyperplasia (BPH)
*Rare in women
*Rare in women


==Clinical Manifestations==
==Clinical Features==
*Lower abdominal distention / pain
*Suprapubic abdominal distention and/or pain
*Frequency, urgency, hesitancy, dribbling, decrease in voiding stream
*Frequency, urgency, hesitancy, dribbling, decrease in voiding stream


==DDX==
==Differential Diagnosis==
#Obstructive causes
{{Urinary retention DDX}}
##BPH
##Prostate cancer
##Blood clot
##Urethral Stricture
##[[Bladder Calculi]]
##Bladder neoplasm
##Foreign body, urethral or bladder
##Ovarian/uterine tumor
#Neurogenic causes
##MS
##Parkinson's
##Brain tumors
##Cerebral vascular disease
##Cauda equina syndrome
##Metastatic spinal cord lesions
##Intervertebral disk herniation
##Neuropathy
##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]]
##[[Prostatitis]]
##Herpes Simplex (genital)
##[[Herpes Zoster]] involving pelvic region
##Local [[Abscess]]
##[[PID]]
#Meds
##Anticholinergics
##Antihistamines
##Cold meds
##Sympathomimetics
##[[TCA]]
##Muscle relaxants
##Narcotics


== Work-Up ==
==Evaluation==
#UA/Ucx
*[[UA]]/Urine cultures
#Chemistry
*Chemistry
#CBC (if suspect infection or massive hematuria)
*CBC (if suspect infection or massive hematuria)
#Bedside US (to verify retention)
*Bedside [[ultrasound]] (to verify retention)
##Post-void residual of 150-200cc is abnormal
**Incomplete retention is PVR > 50ml and > 100ml in patients > 65 years of age<ref>Shenot PJ. Urinary Retention. Merck Manual. August 2014. http://www.merckmanuals.com/professional/genitourinary-disorders/voiding-disorders/urinary-retention</ref>
== Management ==
**Post-void residual of 150-200 cc is particularly concerning
*Bladder Decompression
 
**Urethral catheterization
==Management==
***Pass 14-18F Foley catheter (larger if blood clots)
===Bladder Decompression===
****If unable to pass Foley try [[Coude Catheter]]
*Urethral catheterization
***If catheterization produces gross blood remove catheter and do not attempt reinsertion
**Pass 14-18F Foley catheter (larger if blood clots)
****Creation of false tract in penile soft tissue requires immediate urology consult
**Rate of decompression: rapid complete drainage
**Suprapubic catheterization
***At one time, rapid complete bladder decompression was thought to increase the rate of potential complications, however partial drainage and clamping does not reduce these complications and may increase risk for [[UTI]]<ref>Management of urinary retention: rapid versus gradual decompression and risk of complications</ref>
***Consider if urethral catheterization fails
*If unable to pass Foleyconsider:
***US-guided results in low complication rate
**[[Coude catheter]]
****Visualize the needle in the bladder before inserting the catheter
**[[Suprapubic catheterization]]
 
===Other Considerations===
*Blood clot
*Blood clot
**Use 20-24F triple-lumen catheter to irrigate bladder until clear
**Use 20-24F triple-lumen catheter to irrigate bladder until clear
*Voiding trial
*Consider α-blocker as outpatient if concern for BPH (e.g. [[tamsulosin]] 0.4mg QHS)
*Alpha-blocker (outpt) - Tamslosin 0.4mg qday
**Results in significant increase in voiding success
**Results in significant increase in voiding success
**Possibility of hypotension with med use
**Possibility of orthostatic hypotension  
*Bladder spasm
**Oxybutinin 2.5mg TID
***Note: Anticholinergic so can cause urinary retention
*Urology consult
*Urology consult
**Consider for precipitated retention (stricture, prostatitis, cancer)
**Consider for precipitated retention (e.g. stricture, prostatitis, cancer) or need for [[suprapubic catheterization]]
 
==Disposition==
===Admission===
Consider for:
*[[Post-obstructive diuresis]] >200mL/hr for 2 hours or 3L over 24 hours
*Elevated BUN/Cr ([[acute renal failure]])
*Significant [[hematuria]] or clot retention
*New neurologic cause (e.g. [[cord compression]])


== Disposition ==
===Discharge===
*Consider admission for:
*Otherwise consider discharge with catheter placed to leg bag and urology follow up within 1 week
**Postobstructive diuresis >200cc/hr
**Elevated BUN/Cr
**Clot retention
**Hematuria
**Neurologic cause
*Otherwise consider discharge w/ catheter and urology f/u in 1 week


== See Also ==
==See Also==
*[[Coude catheter]]
*[[Coude catheter]]
*[[Suprapubic catheter placement]]
*[[Suprapubic bladder aspiration]]
*[[Suprapubic catheter changing or replacement]]
*[[Post-obstructive diuresis]]
[[Category:Urology]]


[[Category:GU]]
==References==
<references/>


==Source==
<references/>
Tintinalli

Revision as of 16:52, 8 December 2018

Background

  • Urologic emergency characterized by sudden inability to pass urine
  • Most common cause is benign prostatic hyperplasia (BPH)
  • Rare in women

Clinical Features

  • Suprapubic abdominal distention and/or pain
  • Frequency, urgency, hesitancy, dribbling, decrease in voiding stream

Differential Diagnosis

Urinary retention

Evaluation

  • UA/Urine cultures
  • Chemistry
  • CBC (if suspect infection or massive hematuria)
  • Bedside ultrasound (to verify retention)
    • Incomplete retention is PVR > 50ml and > 100ml in patients > 65 years of age[1]
    • Post-void residual of 150-200 cc is particularly concerning

Management

Bladder Decompression

  • Urethral catheterization
    • Pass 14-18F Foley catheter (larger if blood clots)
    • Rate of decompression: rapid complete drainage
      • At one time, rapid complete bladder decompression was thought to increase the rate of potential complications, however partial drainage and clamping does not reduce these complications and may increase risk for UTI[2]
  • If unable to pass Foleyconsider:

Other Considerations

  • Blood clot
    • Use 20-24F triple-lumen catheter to irrigate bladder until clear
  • Consider α-blocker as outpatient if concern for BPH (e.g. tamsulosin 0.4mg QHS)
    • Results in significant increase in voiding success
    • Possibility of orthostatic hypotension
  • Urology consult

Disposition

Admission

Consider for:

Discharge

  • Otherwise consider discharge with catheter placed to leg bag and urology follow up within 1 week

See Also

References

  1. Shenot PJ. Urinary Retention. Merck Manual. August 2014. http://www.merckmanuals.com/professional/genitourinary-disorders/voiding-disorders/urinary-retention
  2. Management of urinary retention: rapid versus gradual decompression and risk of complications