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Acute Urinary Retention

Urinary retention is the inability to voluntarily void urine. This condition can be acute or chronic. Causes of urinary retention are numerous and can be classified as obstructive, infectious and inflammatory, pharmacologic, neurologic, or other.

Overview Acute urinary retention (AUR) is the inability to voluntarily pass urine. It is the most common urologic emergency. In men, AUR is most often secondary to benign prostatic hyperplasia. Acute urinary retention is rare in women.

Pathogenesis

  • Outflow obstruction Mechanical obstruction refers to a physical narrowing of the urethral channel
  • Neurological impairment AUR may develop secondary to the interruption of the sensory or motor nerve supply to the detrusor muscle
  • Inefficient detrusor muscle Inefficient detrusor muscle when a precipitating event results in an acute distended bladder
CLASSIFICATION OF URINARY RETENTION
Obstruction Benign prostatic hyperplasia (BPH). Other causes of outflow obstruction in men include constipation, cancer (prostate or bladder), urethral stricture, urolithiasis, phimosis, or paraphimosis
Neurological Disease Spinal cord injuries from trauma, infarct or demyelination, epidural abscess and epidural metastasis, Guillain-Barré syndrome, diabetic neuropathy, and stroke
Medications Anticholinergic and sympathomimetic drugs
Infections Infections may lead to AUR in the setting of inflammation that causes obstruction. For example, an acutely-inflamed prostate gland from acute prostatitis
Trauma Trauma to the pelvis, urethra, or penis

 

COMMON CAUSES OF ACUTE URINARY RETENTION BASED ON GENDER
Condition History Examination
MEN Prostate Cancer Weight loss, constitutional signs and symptoms DRE: enlarged nodular (hard) prostate
Benign Prostatic Hyperplasia Nocturia, frequency, polyuria, hestitency, double voiding DRE: enlarged firm, non-tender, non-nodular prostate
Acute Prosatitis Dysuria, Fever DRE: tender, boggy prostate
Phimosis, Paraphimosis Pain and swelling of foreskin or penis Oedema of penis with nonretractable foreskin
WOMEN   Vulvovaginititis Vaginal Discharge, itch, dysuria Vaginal discharge, inflamed genital area
Cystocele Feeling of pelvic heaviness or fullness, noticeable bulge from the vagina. Notable bulge on the anterior vaginal wall
Pelvic mass (fibroids, gynaecological malignancy) Feeling of pelvic heaviness or fullness, dysmenorrhea, menorrhagia Palpable uterine mass
BOTH GENDERs Urinary Tract Infection Dysuria, haematuria, groin/loin/back pain, genital rash Supracpubic tenderness, urethral discharge, genital rash
Bladder Tumour Painless haematuria with clots
Neurogenic Bladder Diagnosed neurological disease Other generalised or focal neurologic deficits

Approach

  • History
    • Presentin history
    • Medication (alcohol, antihistamine, anticholinergics, tricyclics)
Rememeber Faecal impaction in the elderly may be a cause of urinary retention
  • Examination
    • General observation
    • Bladder percussion
    • Bladder palpation
    • Flank palpation
    • PR examination
    • Spinal injury – neurological exam
Rememeber Digital rectal examination is mandatory in the patient with new retention
  • Investigation and Diagnosis
    • FBC
    • Urine MSU
    • EUC
    • Chest X-ray – pulmonary oedema (chronic kidney failure) and possible tumour
    • Bladder ultrasound
      • Confirm bladder size
      • Dilated upper urinary tract
      • Pregnant uterus
    • Urethrography
    • PSA
    • Cystoscopy
    • Urodynamics

Management Acute urinary retention should be managed by immediate and complete decompression of the bladder through catheterization

  • Pain Relief
  • Bladder examination
  • Urethral catheterization
  • Indwelling catheter
  • Clean intermittent catherization
  • Suprapubic catheter
Remember Catheterization Contraindications: urethral disruption, posteoperative urological patients, known stricture

Complication of decompression

  • Haematuria
  • Transient hypotension
  • Post-obstructive diuresis

More Info on Haematuria

acute urinary retention management

Acute urinary retention management

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