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