Lecture notes for medical students

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2. Inability to Pass Urine

3. Inability to Pass Urine
• Retention of Urine
• When patient, despite an urge to void, is unable to push urine
out of bladder due to either infravesical obstruction or inability
to generate effective detrusor contractions. Correct
catheterization yields urine relieving symptoms.
• Anuria
• A condition when either urine is not being produced ( pre-renal
& renal) or is not reaching urinary bladder (post-renal /
obstructive). No urge to void. Even on correct catheterization,
no urine is drained.
• Extravasion
• Leakage of urine into tissues / body cavity (peritoneum)

4. Physiology of bladder

5. Physiology of bladder
• Low pressure reservoir (compliance /
distensibility) 400-550 cc at around 5cm water (<15cm)
• Sensations of fullness ( 250cc +)
• Initiation and maintenance of Contractions till its
complete evacuation

6. Micturition Reflex

7. Micturition Reflex
• Afferants from bladder activate sacral spinal cord
centre which through their efferants cause
Contraction of detrusor and relaxation of
sphincters
• Higher Centre facilitate or inhibit
pons / mid brain
– Medial pontine nuclei Micturation
– Lateral pontine nuclei inhibition

8. Types of Retention

9. Types of Retention
• Acute Retention
– Agonizing painful condition with intense urge
– Well defined palpable & tender bladder
• Chronic Retention
– Painless condition of incomplete bladder
evacuation / high residual urine, (>250cc)
– Bladder percussible but not well
palpable/tender

10. Differentiation between acute and
chronic urine retention

11. Differentiation between acute and
chronic urine retention
Acute retention Chronic
retention
Urination No urine Overflow
incontinence
Pain Severe, suprapubic, Painless
bursting
Obstruction Complete Partial
Suprapubic + +/-
tenderness

12. Causes of retention - boys

13. Causes of retention - boys
• Phimosis
• Scab – meatal ulcer
• External meatal stenosis
• Urethritis
• Urethral stricture
• Urethral trauma
• Post. & ant. Urethral valves
• Vesical / urethral calculus
• Blader neck stenosis
• Neurogenic bladder
• Constipation
• Drugs

14. Causes of retention – young females

15. Causes of retention – young females
• Hysterical conversion reaction
• Drugs /anesthesia
• Pain ( parturition, epi-, vaginal surgery)
• Retroverted gravid uterus
• MS
• Cystocele / bladder stone
• Neurogenic bladder

16. Causes of retention – elderly males

17. Causes of retention – elderly males
• BPH, CaP, abscess
• Stone, Ca UB, clot retention
• Stricture/stone/abscess /rupture –urethra
• Meatal stenosis, Phimosis, para-phimosis
• Drugs / anesthesia,
• Disc prolapse / cauda equina syndrome
• spinal shock , neurogenic bladder
• Ca penis
• Bladder neck stenosis / hypertrophy
• Diabetic sensory neuropathy
• Pelvic surgery, anal fissure, hemorrhoids
• Obstructed hernia

18. Causes of retention – elderly females

19. Causes of retention – elderly females
• Atrophic urethritis
• Meatal stenosis
• Ca UB, clot retention
• Neurogenic blader,
• Carancle
• Stricture / stone/rupture –
urethra
• Cystocele/ prolapse
• Drugs / anesthesia,
• Disc prolapse / cauda equina
syndrome
spinal shock
Bladder neck stenosis /
hypertrophy
Diabetic sensory
neuropathy
Pelvic surgery, anal
fissure, hemorrhoids
Obstructed hernia
Urethral diverticulum

20. Causes according to site
In 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 Parkinson's disease)
⇒ Iatrogenic scarring of the bladder neck
(commonly from removal of indwelling catheters
or cystoscopy operations)
⇒ Damage to the bladder
In the prostate
⇒ Benign prostatic hyperplasia
⇒ Prostate cancer and other pelvic malignancies
⇒ Prostatitis
.

21. 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 along
the urinary tract, but vary in frequency depending on anatomy
Paruresis, 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 psychological
rather than biological.

22. History

23. History
• Duration
• Painfull?
• Precipitating factors
• Preceding LUTS
• Other urinary complaints
• Differential diagnosis
• Medical illnesses - D/D, co-morbidity

24. History
• Catheterization
– Easy
– Caliber
– Urine quantity / color
– Where / by whom
– TWOC

25. Examination

26. Examination
• Per abdomen
• Meatus
• Urethra
• Bladder Ac / Ch
• DRE
• Hernia
• Neurological ex
• Higer mental functions
• Cranial nerves
• Lower limb
• perineum - sensations

27. Abdominal Examination:
Midline globular tender suprapubic mass.
Genital examination: Phimosis,
severe urethral meatal stenosis.
Digital Rectal Examination:
BPH, Prostate cancer.

28. Investigations

29. Investigations
• Urine RE/ CS
• Renal Function Tests
• US
• X ray KUB
• Urodynamics
• Cystoscopy

30. Treatment

31. Treatment
• Urethral catheterization
– Technique
• Explain / consent ( need / discomfort)
• Keep Items ready
• Theatre / dressing room / bed
• Supine posture legs separated
• Female – knee bent & separated, feet together
• Gloves

32. Urethral catheterization
Technique

33. Urethral catheterization
Technique
• Cleaning = aniseptics
• Females – separate labia – clean from before backwards, hold
till cath complete
• Prepuse – retract & clean
• Drape
• instill gel – hold 2 min / clamp
• Hold penis with non-dominent hand glans towards head end
== Curve “S” --- “U”
• Use dominant hand for cath
• Gently push cath - non touch technique
• Deep / slow breathing

34. Urethral catheterization
Technique
• Relax ---------- valium
• Push whole length in – till bifercation
• Don’t inflate till clear urine drained
– gel, misplaced, anuria, extravasion
– Inflate while full length inside / pull afterwards
– Use water = not saline
– Don’t inflate = blood, not sure of position
• Note color amount of urine
• C/S
• Post cath heamaturia - slow/ intermitant / high

35. Urethral catheterization
Technique
• Resistance -- look for help
– refer
– Suprapubic puncture abscess
– Marryfield introducer
– coude tip cath
– trocar cath == ingram / bard
– Open s/p
– urethral instrumentation = bougies / optical

36. • Closed drainage system
• Antibiotics
• Size of cath
• Leakage blocked / spasm

37. Chronic Retention

38. Chronic Retention
• High residual volume urine , >250cc
• Longstanding, painless, not precisely
palpable, dull to percussion
• High / low pressure ch. Retention
• Upper tract dilatation / deterioration
• Causes
– Long standing BOO
– LMNL

39. Chronic Retention
• Treatment
CATHETERIZATION
– CATH IS NOT A RISK FOR INFECTION, IT
RATHER CURES INFECTION
– CURE OF PYO-CYSTITIS IS DAINAGE
LIKE I/D FOR ABSCESS

40. Chronic Retention
• Complications
– Hematuria
• slow decompression
– clamp / non-gravity dependant / elevate
– Crit >200 mmole = post obst diuresis
• Concentration ability
• Fluid overload / backlog
• Osmotic diuresis
– Dehydration / ellectrolyte disturbances
• Replacement of fluid / Na
– ml to ml replacement on hourly basis
– Later -- one litre less then prvious days output
– oral / intravenous saline.
– Potassium only if low ---- renal failure
• Infection

41. RETENTION WITH OVERFLOW /
PARADOXICAL INCONTENANCE

42. RETENTION WITH OVERFLOW /
PARADOXICAL INCONTENANCE
• Incontinence associated with a full bladder
• Almost same as ch. retention

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