Retention of Urine Dr Prabha Om Professor SurgerySMS Medical College, JAIPUR
DefinitionUrinary retention is defined as the inability to completelyor partially empty the bladder.It is a sudden painful inability to urinate inspite of a fullbladderUrinary retention, also known as ischuria, is a lack of ability tourinateSuffering from urinary retention means you may be unable to start urination, or if you are able to start, you can’t fully empty yourbladder.
Normal micturition cycle:A. Filling: Impulses from the CNS tosympathetic and pudendal nervesrelax the bladder and close the outlet.B. Voiding: Inhibition of sympatheticand pudendal impulses.Stimulation of parasympathetic (S2-4)leads to detrusor contraction →voiding in the absence of obstruction
Urinary retention is characterised by poor urinary stream with intermittent flow, straining, a sense of incompletevoiding and hesitancy (a delay between trying to urinate and the flow actually beginning). As the bladder remains full causes incontinence, nocturia (need to urinate at night) and high frequency.Acute retention is a medical emergency, as the bladder may distend (stretch) to enormous sizes and possibly tear if not dealt with quickly. If the bladder distends enough it will begin to become painful. The increase in pressure in the bladder can also prevent urine entering from the ureters or even cause urine to pass back up the ureters andget into the kidneys, causing hydronephrosis, and possibly pyonephrosis, kidney failure and sepsis. A person should go straight to an emergency department as soon aspossible if unable to urinate when having a painfully full bladder.
Anuria means nonpassage of urine, in practice is defined as passage of less than 50 milliliters of urine in a dayAnuria is complete absence of urine production by the kidney for 12 hours or more.Oliguria is decreased urine volume to less than 400 ml in a day.. Anuria is often caused by failure in the function of kidneys. It may also occur because of some severe obstruction like kidney stones or tumours. It may occur with end stage renal disease. It is a more extreme reduction than oliguria, sometimes called anuresis.
CausesThere are two general types of urinary retention:obstructive and non-obstructive.If there is an obstruction (for example,kidney stone urine cannot flow freely through the urinary tract. Non-obstructive causes include a weak bladder muscle and nerve problems that interfere with signals between the brain and the bladder. If the nerves aren’t working properly, the brain may not get the message that the bladder is full.
Causes of non-obstructive urinary retention are:•Stroke•Vaginal childbirth•Pelvic injury or trauma•Impaired muscle or nerve function due to medication or anesthesia•Accidents that injure the brain or spinal cord
Obstructive retention may result from: •Cancer•Kidney or bladder stones•Enlarged prostate (BPH) in men
Causes:A. Mechanical or obstructive:1- Bladder:- Stone, bladder neck obstruction,cancer.2- Prostate:- BPH is the most common cause inmen over 50 years.- Acute prostatitis and abscess.- Prostate cancer.
3- Urethra:-Stone, stricture, urethritis,rupture, phimosis,- posterior urethral valves.4- Clot retention in severehematuria e.g. cancer, trauma.5- Women: pelvic masses, urethral stenosis and diverticulum,pelvic prolapse, hysterical.
C. Functional and neurogenic: 1. Postoperative AUR is common: Pain, limited mobility, drugs, bladder nerveinjury e.g. hysterectomy & abdominal resection Prevention is important by catheterization aftersurgery to bladder, prostate, urethra. •vaginal childbirth •infections of the brain or spinal cord •diabetes •stroke •accidents that injure the brain or spinal cord •multiple sclerosis •heavy metal poisoning •pelvic injury or trauma , • some children are born with nerve problems that can keep the bladder from releasing urine
Symptoms of urinary retention may include:•Difficulty in starting to urinate•Difficulty in fully emptying the bladder•Weak dribble or stream of urine•Loss of small amounts of urine during the day•Inability to feel when bladder is full•Increased abdominal pressure•Lack of urge to urinate•Strained efforts to push urine out of the bladder•Frequent urination•Nocturia (waking up more than two times at night to urinate)
History:- Cause- related: A complication of BPH Drugs: Urethral trauma Stone disease- Suprapubic bursting pain, no urine, strong desire tourinate.- Acute urine retention should be differentiated fromobstructive anuria.
Differential diagnosis of acute retention and obstructive / anuria• Acute retention obstuctive AnuriaDesire to urinate + - -Suprapubic pain + - -Renal pain - - +General exam. Good May be uremicAbdominal exam. Tender Full bladder Empty Loin bladder
Treatment:A) Conservative measures in non-obstructive causes: Patient is asked to go out of bed. Take hot bath. Parasympathomimetics. Failure → catheterization.
Urethral catheterization: Nelaton orFoleys:It is absolutely contraindicated inurethral injury.Proper Sterilization of parts. Adequate lubrication of urethra. Proper catheter size Children 6-12 F Adults 16 F
Clot retention:- Triway 22F urethral catheter with irrigation.- Evacuation of clots.-Cystoscopy - diagnostic and therapeutic Suprapubic cystocath: done in Urethral trauma Urethral stricture Failure of urethral catheterization
Treatment of the cause e.g. - TURP for BPH urethroplasty for urethral stricture. - Endoscopic crushing of vesical stone.
Chronic Retention of UrineCauses: Long standing incomplete obstructionA) Mechanical : BPH, prostate cancerB) Functional: Neuropathic flaccid bladder.- Large amounts of residual urine exist.- When the vesical pressure exceeds the urethralresistance, the patient can pass some urine ordribble continuously. This is called false oroverflow incontinence.
Differentiation between acute and chronic urine retention Acute retention Chronic retentionUrination No urine Overflow incontinencePain Severe, suprapubic, Painless burstingObstruction Complete Partial Suprapubic + +/-tenderness
Emergency measures – Urethral catheter or Suprapubic catheter if urethral trauma or injury are expected - Ureteric catheter Or DJ stent if Failure - PCN
Causes according to siteIn the bladder⇒ Detrusor sphincter dyssynergia⇒ Neurogenic bladder (commonly pelvic splanchic nerve damage, cauda equina syndrome, descending cortical fibers lesion, pontine micturation or storage center lesions, demyelinating diseases or Parkinsons disease)⇒ Iatrogenic scarring of the bladder neck (commonly from removal of indwelling catheters or cystoscopy operations)⇒ Damage to the bladderIn the prostate⇒ Benign prostatic hyperplasia⇒ Prostate cancer and other pelvic malignancies⇒ Prostatitis.
Penile urethra⇒ Congenital urethral valves⇒ Phimosis or pinhole meatus⇒ Circumcision⇒ Obstruction in the urethra, for example a metastasis or a precipitated pseudogout crystal in the urine⇒ STD lesions (gonorrhoea causes numerous strictures, leading to a rosary bead appearance, whereas chlamydia usually causes a single stricture)Other⇒ Paruresis ( shy bladder syndrome )-, urinary retention can result⇒ Consumption of some psychoactive substances, mainly stimulants, such as MDMA and amphetamine.⇒ Use of NSAIDs or drugs with anticholinergic properties.⇒ Stones or metastases can theoretically appear anywhere alongthe urinary tract, but vary in frequency depending on anatomyParuresis, inability to urinate in the presence of others (such as in a public restroom), may also be classified as a type of urinary retention, although it is psychologicalrather than biological.
InvestigationsHistory of complaints and physical examinationUltrasonography for any calculi, growth, post voiding residual urine, condition of Kidney any injuryXray KUB for calculiBlood Urea , Creatinine levelsCT Scan for any pathologyUrine examination for infectionPSA for Prostate CancerUrodynamic Test for CystoceleCystoscopy for status of bladderMRI Lumber spine for spinal pathology
Dysuria refers to painful urination.It is one of a constellation of irritative bladder symptoms, which includes urinary frequency and haematuria.Differential diagnosisThis is typically described to be a burning or stinging sensation. It is most often a result of a urinary tract infection It may also be due to an STD, bladder stones, bladder tumours, and virtually any condition of the prostate. It can also occur as a side effect of anticholinergic medication used for Parkinsons disease.
Polyuria is a condition usually defined as excessive orabnormally large production and/or passage of urine .Polyuria often appears in conjunction with polydipsia(increased thirst), though it is possible to have onewithout the other, and the latter may be a cause or aneffect. Psychogenic polydipsia may lead to polyuria.Polyuria is physiologically normal in somecircumstances, such as cold diuresis, altitude diuresis,and after drinking large amounts of fluids
The most common cause of polyuria in both adults andchildren is uncontrolled diabetes mellitus, causing anosmotic diuresis. Primary polydipsia (excessive fluid drinking), diabetes insipidus hypercalcemia) or various chemical substances (diuretics, caffeine, alcohol).after supraventricular tachycardias, during an onset ofatrial fibrillation, childbirth, and the removal of anobstruction within the urinary tract.Cold diuresis is the occurrence of increased urineproduction on exposure to cold, which also partiallyexplains immersion diuresis.Substances that increase diuresis are called diuretics.