Acute urinary retention

Background

• Urologic emergency characterized by sudden inability to pass urine
• Most common cause is BPH
• Rare in women

Clinical Manifestations

• Lower abdominal distention / pain
• Frequency, urgency, hesitancy, dribbling, decrease in voiding stream

DDX

1. Obstructive causes
   1. BPH
   2. Prostate cancer
   3. Blood clot
   4. Urethral Stricture
   5. Bladder Calculi
   6. Bladder neoplasm
   7. Foreign body, urethral or bladder
   8. Ovarian/uterine tumor
2. Neurogenic causes
   1. MS
   2. Parkinson's
   3. Brain tumors
   4. Cerebral vascular disease
   5. Cauda equina syndrome
   6. Metastatic spinal cord lesions
   7. Intervertebral disk herniation
   8. Neuropathy
   9. Nerve injury from pelvic surgery
   10. Postoperative retention
3. Trauma
   1. Urethral injury
   2. Bladder injury
   3. Spinal cord injury
4. Extraurinary causes
   1. Perirectal or pelvic abscesses
   2. Rectal or retroperitoneal masses
   3. Fecal impaction
   4. Abdominal Aortic Aneurysm
5. Psychogenic causes
   1. Psychosexual stress
   2. Acute anxiety
6. Infection
   1. Cystitis
   2. Prostatitis
   3. Herpes Simplex (genital)
   4. Herpes Zoster involving pelvic region
   5. Local Abscess
   6. PID
7. Meds
   1. Anticholinergics
   2. Antihistamines
   3. Cold meds
   4. Sympathomimetics
   5. TCA
   6. Muscle relaxants
   7. Narcotics

Work-Up

1. UA/Ucx
2. Chemistry
3. CBC (if suspect infection or massive hematuria)
4. Bedside US (to verify retention)
   1. Incomplete retention is PVR > 50 ml and > 100 ml in pts > 65 yoa
   2. Post-void residual of 150-200 cc is particularly concerning

Management

• Bladder Decompression
  • Urethral catheterization
    • Pass 14-18F Foley catheter (larger if blood clots)
      • If unable to pass Foley try Coude Catheter
    • If catheterization produces gross blood remove catheter and do not attempt reinsertion
      • Creation of false tract in penile soft tissue requires immediate urology consult
  • Suprapubic catheterization
    • Consider if urethral catheterization fails
    • US-guided results in low complication rate
      • Visualize the needle in the bladder before inserting the catheter
• Blood clot
  • Use 20-24F triple-lumen catheter to irrigate bladder until clear
• Voiding trial
• Alpha-blocker (outpt) - Tamslosin 0.4mg qday
  • Results in significant increase in voiding success
  • Possibility of hypotension with med use
• Bladder spasm
  • Oxybutinin 2.5mg TID
    • Note: Anticholinergic so can cause urinary retention
• Urology consult
  • Consider for precipitated retention (stricture, prostatitis, cancer)

Disposition

• Consider admission for:
  • 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

• Coude catheter

References

Tintinalli