Acute urinary retention

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.

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

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

• Obstructive causes
  • BPH
  • Prostate cancer
  • Blood clot
  • Urethral Stricture
  • Bladder Calculi
  • Bladder neoplasm
  • Foreign body, urethral or bladder
  • Ovarian/uterine tumor
  • Incarcerated uterus
• Neurogenic causes
  • Multiple sclerosis
  • Parkinson's
  • Brain tumor
  • Cerebral vascular disease
  • Cauda equina syndrome
  • Spinal cord compression (non-traumatic)
  • 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
  • Opioids

Abdominal distention

• Obesity
• Intestinal obstruction
• Pregnancy
• Ascites
  • Cirrhosis
  • Malignancy
  • Heart failure
  • Tuberculosis
• Spontaneous bacterial peritonitis
• Peritoneal dialysis-associated peritonitis
• Distended bladder / Acute urinary retention
• Constipation / fecal impaction
• Large tumor(s) (e.g. ovarian, lymphoma)
• Organomegaly

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
  • 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
• If unable to pass Foley, consider:
  • Coude catheter
  • Suprapubic catheterization

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
  • 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

See Also

• Coude catheter
• Suprapubic catheter placement
• Suprapubic bladder aspiration
• Suprapubic catheter changing or replacement
• Post-obstructive diuresis