management of various types of acute urine retention

1. MANAGEMENT OF URINE
RETENTION
Dr Winston Makanga, M.B.Ch.B., M.Med. (Surg)
Consultant General and Laparoscopic Surgeon

2. Objectives of the lecture
• Definition
• Classification
• Causes
• History and examination
• Investigations
• Management – acute and definitive

3. Definitions
• Acute retention: Sudden (hours) inability to pass urine – accompanied
with suprapubic pain and suprapubic swelling.
• Chronic retention: Insidious, progressive enlargement (filling up)of the
bladder associated with voiding lower urinary tract symptoms (LUTS)
with little or no pain

5. Etiology
General Nervous system – Cord compression, spinal tumors, multiple sclerosis, tabes
Post-operative pain (perianal or other major surgery)
Medications – Anticholinergics, TCAs, antihistamines, antihypertensives
Local Bladder Urethra
Intramural Clots
Bladder neck tumor
Stone
Clots
Polyp
Stone
Posterior urethral valves
Extramural Acute Prostatitis
BPE
Ca Prostate
Phimosis
Paraphimosis
Mural Bladder neck stricture Urethral stricture
Acute Urethritis
Meatal stenosis
Others Retroverted uterus*, fecal impaction, spinal anesthesia, urethral rupture

6. Clinical evaluation
• History
• Lower urinary tract symptoms (LUTS)
• Overflow incontinence
• Medications
• Perineal trauma
• Stroke, back pain, limb weakness
• Examination
• Systemic features of renal dysfunction
• Abdomen for distended bladder
• Perineum – urethra, sensation
• DRE: anal tone and reflexes, prostate characteristics

7. Investigation
• Urinalysis
• Complete blood count
• Urea, Creatinine, Electrolytes
• PSA*
• Ultrasound
• Urethrogram: retrograde and micturating cystourethrogram (MCU)
• CT scan abdomen
• MRI Spine
* May be spuriously elevated in acute retention

8. Classical features of an obstructed bladder
• Thick wall
• Trabeculations
• Diverticulae
• Significant retained volume
• Vesicoureteric reflux + hydronephrosis

9. Management
• Acute care
• Per urethral catheter
• Nelaton (in and out)
• Foley (rubber/silicon vs introducer vs Coude tip)
• Suprapubic puncture
• Suprapubic cystostomy
• Treat UTI and pain
• Definitive care
• Directed at primary cause

10. Management
Primary pathology Management
PUV Valve ablation
Bladder neck stricture TU bladder neck incision
Bladder neck tumor TURBT
BPE TURP, Open prostatectomy
Prostatic cancer Radical prostatectomy
Chemotherapy + ADT
Radiotherapy
Palliative orchidectomy
Urethral stricture Dilatation
DVIU
Meatal stenosis Meatotomy, estrogen
Urethroplasty
Phimosis, Paraphimosis Dorsal slit
Circumcision
Cord compression (CES) Spinal surgical decompression

11. Review
• Definition
• Classification
• Causes
• History and examination
• Investigations
• Management

12. Thank you