undergraduate, Anuria & acute retention2

1. Urology Department
Under-graduate courses
Anuria and Acute Urinary
Retention
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

2. For our Lectures and Scientific resources
visit our web sites,
Uroainshams.blogspot.com
Uronotes2012.blogspot.com
©

3. Anuria and Acute renal failure (ARF)
Definition
• no urine output or less than 200 ml/24 hours (while bladder
is empty).
Differential diagnosis:
 Urinary retention (bladder is full)
Causes
• Pre renal (functional)
• Renal-intrinsic (structural)
• Post renal (obstruction)
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

4. CAUSES OF ARF

5. Causes of Pre-renal ARF
Decreased renal perfusion due to:
• hypovolaemia,
• hypotension,
• impaired cardiac function
• Advanced liver disease
• renal vascular disease.
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

6. Causes of renal (Intrinsic) ARF
• Acute tubular necrosis (ATN)
– Ischaemia
– Toxin (e.g., aminoglycoside, antibiotics, contrast media)
– Tubular factors
• Acute interstitial Necrosis (AIN)
– Inflammation
– Oedema
– Drugs (sulfa drugs, penicillin, furosemide, hydrochlorothiazide)
• Glomerulonephritis (GN)
– Damage to filtering mechanisms
– Multiple causes
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

7. Causes of Post-renal ARF
• Post renal obstruction due to
– Prostatic hypertrophy
– Blocked catheter
– Malignancy (obstructing both ureters):
 Bladder cancer.
 Prostatic cancer
 Retroperitoneal tumors or pathology
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

8. Evaluation of ARF
Pre-renal
• Evaluate Circulatory System & Check Volume Status
• Urinalysis is typically unremarkable.
• Evaluate Renal Vasculature: by renal scan
Renal (Intrinsic)
• Urinalysis: tubular cell casts during the early ATN. Urine
specific gravity is fixed at 1010 and the urinary sodium
concentration > 30 mEq/L. Proteinuria in glomerular
disease.
• History of Nephrotoxins (ATN) or drugs (interstitial
nephritis)
©

9. Evaluation of ARF
Post-renal
• Bladder Outlet obstruction: Place a Foley
catheter or irrigate pre-fixed catheter.
• Upper Tracts: Abdominal Ultrasound.
©

10. Management of ARF
Supportive treatment
• Support with dialysis may be needed
• Restrict sodium, potassium, and fluid intake.
• Treat hyperkalemia and acidosis
Pre-renal
• restore volume, support blood pressure, and
treat sepsis or cardiac failure.
©

11. Evaluation of ARF
Post-renal - RELIEF THE OBSTRUCTION
• Bladder Outlet obstruction: Place a Foley
catheter.
• Upper Tracts: JJ stent or nephrostomy tube then
definite surgery later.
Renal (Intrinsic)
• stop any nephrotoxic drugs (i.e., change
antibiotics as needed, discontinue NSAIDs).
©

12. Indications for acute dialysis
• Acidosis (metabolic)
• Electrolytes (hyperkalemia)
• Ingestion of drugs/Ischemia
• Overload (fluid)
• Uremia
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

13. Urinary retention
Definition
• Inability to empty the bladder
Types of Retention
Acute urinary retention Complete and painful inability to
empty the bladder and < 800 ml of urine is drained
Chronic urinary retention inability to completely empty
bladder and leave large amount of post-void volume.
Acute-on-chronic urinary retention Complete and painful
inability to empty the bladder and >800 ml of urine is
drained
©
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

14. Urinary retention
Causes of urinary retention
– Benign prostatic hyperplasia (BPH)
– Prostatic carcinoma
– Urethral stricture
– Pelvic mass (especially in women)
– Urinary tract infection
– Constipation
– Neurological
– Postoperative pain or immobility
Types of Retention
can be acute or chronic or acute-on-chronic
©
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

15. Acute Urinary retention (AUR)
• Acute retention is characterized by an acute
onset of suprapubic discomfort associated
with the desire, but inability to urinate.
• It is typically seen in men, when the cause is
usually obstructive: for example, benign
prostatic hyperplasia, prostate cancer or
urethral stricture.
• It can occur in women, due to pelvic mass or
neurogenic bladder.
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

16. Acute Urinary retention (AUR)
• AUR may be associated with previous LUTS:
obstructive and irritative.
• Typically, patients have increasing preceding
LUTS till reaches complete retention.
• Usually those patients have acute-on-chronic
retention.
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

17. Acute Urinary retention (AUR)
• AUR can be precipitated by:
 Medications e.g. anticholinergic or sympathomimetic
agents (cough and cold remedies).
 Urinary infection.
 Excessive fluid intake.
 Consequences of surgery (postoperative pain, effects
of anesthesia or analgesia and loss of mobility).
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

18. AUR- Initial Management
• Urethral catheterization is straightforward and will relieve
the patient’s symptoms instantly.
• Suprapubic catheterization is used in patients with a
history of urethral stricture or previous traumatic
catheterisations,
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

19. AUR- Further management
Acute retention
A trial of catheter removal after alpha blocker is justified.
Acute –on-chronic retention (residual urine > 800cc)
• they should probably proceed to (TURP)
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

20. Clot retention
• Retention due to obstruction of urine
pathway by blood clots filling the
bladder.
• occur as a result of bleeding from a
renal or bladder tumor or,
commonly, following TURP.
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

21. Clot retention- investigations
Lab
• measuring baseline haemoglobin, platelets
and blood clotting.
Radiology
• IVU is the traditional investigation for
hematuria.
• Pelvi-abdominal U/S for masses or prostatic
enlargment.
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

22. Clot retention- management
• Resuscitation by a wide bore IV line,
monitoring vital data and blood transfusion.
• Triple-way catheter (22 or 24 Ch) to
evacuate clot and irrigate the bladder
• Anticoagulant and antiplatelet drugs
should be stopped, if feasible.
• cystoscopy after the bleeding has
settled down and the catheter has been
removed, to identify and treat the cause.
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS

23. Thank You
By Younan Ramsees, MBBcH Revised by M.A.Wadood , MD, MRCS