Acute urinary retention: Difference between revisions

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== Background ==
==Background==
[[File:Urinary system.png|thumb|'''(1) Human urinary system:''' (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra. <Br>'''Additional structures:''' (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.]]
[[File:2605 The Bladder.jpg|thumb|Anatomy of the male bladder, showing transitional epithelium and part of the wall in a histological cut-out.]]
*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
[[File:Urinary retention.jpg|thumb|Patient with acute urinary retention and dramatic bladder distention.]]
*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
{{DDX abdominal distention}}
##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
[[File:Ultrasound of trabeculated urinary bladder.jpg|thumb|Ultrasound of distended from urinary retention. Note trabeculated wall, which is a sign of urinary retention.]]
#Chemistry
[[File:Harnverhalt.jpg|thumb|Bladder distension from acute urinary retention seen on CT.]]
#CBC (if suspect infection or massive hematuria)
*[[UA]]/Urine cultures
#Bedside US (to verify retention)
*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<ref>Shenot PJ. Urinary Retention. Merck Manual. August 2014. http://www.merckmanuals.com/professional/genitourinary-disorders/voiding-disorders/urinary-retention</ref>
**Post-void residual of 150-200 cc is particularly concerning


== Management ==
==Management==
*Bladder Decompression
===Bladder Decompression===
**Urethral catheterization
*Urethral catheterization
***Pass 14-18F Foley catheter (larger if blood clots)
**Pass 14-18F Foley catheter (larger if blood clots)
****If unable to pass Foley try [[Coude Catheter]]
**Rate of decompression: rapid complete drainage
***If catheterization produces gross blood remove catheter and do not attempt reinsertion
***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>
****Creation of false tract in penile soft tissue requires immediate urology consult
*If unable to pass Foley, consider:
**Suprapubic catheterization
**[[Coude catheter]]
***Consider if urethral catheterization fails
**[[Suprapubic catheterization]]
***US-guided results in low complication rate
 
****Visualize the needle in the bladder before inserting the catheter
===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)
**Results in significant increase in voiding success
**Results in significant increase in voiding success
**Possibility of orthostatic hypotension
*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===
Admit for:
*[[Post-obstructive diuresis]] >200mL/hr for 2 hours or 3L over 24 hours (will need fluids and electrolyte monitoring/repletion)
*Elevated BUN/Cr ([[acute renal failure]])
*Significant [[hematuria]] or clot retention
*New neurologic cause (e.g. [[cord compression]])
 
===Discharge===
*Otherwise consider discharge with catheter placed to leg bag and urology follow up within 1 week


== Disposition ==
==See Also==
*Consider admission for:
*[[Coude catheter]]
**Postobstructive diuresis >200cc/hr
*[[Suprapubic catheter placement]]
**Elevated BUN/Cr
*[[Suprapubic bladder aspiration]]
**Clot retention
*[[Suprapubic catheter changing or replacement]]
**Hematuria
*[[Post-obstructive diuresis]]
**Neurologic cause
*Otherwise consider discharge w/ catheter and urology f/u in 1 week


== See Also ==
[[Category:Urology]]
*[[UTI]]
*[[Coude Catheter]]


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


==Source==
<references/>
Tintinalli

Latest revision as of 22:11, 15 November 2023

Background

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.
Anatomy of the male bladder, showing transitional epithelium and part of the wall in a histological cut-out.

Clinical Features

Patient with acute urinary retention and dramatic bladder distention.
  • Suprapubic abdominal distention and/or pain
  • Frequency, urgency, hesitancy, dribbling, decrease in voiding stream

Differential Diagnosis

Urinary retention

Abdominal distention

Evaluation

Ultrasound of distended from urinary retention. Note trabeculated wall, which is a sign of urinary retention.
Bladder distension from acute urinary retention seen on CT.
  • 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 Foley, consider:

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

Admit 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


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