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Acute urinary retention atila ppt

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Acute urinary retention atila ppt

  1. 1. PRESENTER :- ATINKUT D. MODERATOR: - Dr. Gersam 3/28/2014AUR seminar1 ACUTE URINARY RETENTION
  2. 2. Outline of presentation  Definition  Pathophysiology  Risk factors  Etiology  Urethral strictures  BPH  Urolithiasis  Clinical presentation  Management options  Summary  references 2
  3. 3. Acute Urinary Retention 3/28/2014AUR seminar3  Definition:- Painful inability to void, with relief of pain following drainage of the bladder by catheterization.
  4. 4. Pathophysiologic mechanism of AUR 3/28/2014AUR seminar4 1. BOO( bladder out flow obstruction)  Out flow obstruction by A) Mechanical :-  physical narrowing of the urethral channel  related to the volume of the prostate gland , other mass, or stricture. B) Dynamic obstruction:-  refers to the tension within and around the urethra.  When obstruction is caused by BPH,  dynamic obstruction is caused by the prostate capsular tone and smooth muscle tone within the prostate gland itself.  Medications and other factors also play a role in selected patients.
  5. 5. Pathophysiologic contnd….. 3/28/2014AUR seminar5  2) Neurologic impairment  Occur due to interruption of sensory or motor nerve supply to the detrusor muscle.  This is most commonly seen in spinal cord injuries, progressive neurologic diseases, diabetic neuropathy, and cerebrovascular accidents  Less common, but important, neurologic causes include epidural abscess and epidural metastasis, that can compress the spinal cord and thereby cause urinary retention as well as back pain and lower extremity neurologic impairments
  6. 6. Pathophysiologic contnd….. 3/28/2014AUR seminar6  3). Over distention  Acute urinary retention may result when a precipitating event results in an acute distended bladder in the setting of an inefficient detrusor muscle  This most often occurs in patients with obstructive urinary symptoms at baseline, who are then subjected to an insult to the lower urinary tract,  such as a fluid challenge (eg, alcohol, intravenous hydration), bladder distention during general anesthesia, or epidural analgesia without an indwelling Foley catheter.
  7. 7. 3/28/2014AUR seminar7  Medications — Multiple medications are implicated in the cause of urinary retention, principally involving anticholinergic and sympathomimetic drugs  Pharmacologic agents associated with urinary retention.docx
  8. 8. RISK FACTORS 3/28/2014AUR seminar8  Age — Age over 70 years  Symptom score — Use of the AUA symptom score (IPSS) permits quantitation of symptom severity and monitoring of symptom progression over time .  Prostate volume — Prostatic volumes greater than 30 mL as measured by trans rectal ultrasound have been associated with AUR  Urinary flow rate — Urinary flow rate of less than 12 mL/sec carries an RR of 3.9.
  9. 9. Etiology 3/28/2014AUR seminar9  BPH — 53 percent  Constipation — 7.5 percent  Prostate cancer — 7 percent  Urethral stricture — 3.5 percent  Postoperative — 5 percent  Neurologic disorder — 2 percent  Medications/drugs — 2 percent  Urinary tract infection — 2 percent  Urolithiasis — 2 percent  Miscellaneous — 16 percent
  10. 10. 3/28/2014AUR seminar10  AUR may also be related to a variety of other factors  Malignancy — bladder neoplasm, other tumors causing spinal cord compression  Phimosis or paraphimosis, which is prolonged foreskin retraction with swelling of the glans constricting the foreskin
  11. 11. 3/28/2014AUR seminar11  Pelvic masses  Genitourinary infections — acute prostatitis, urethritis, perianal abscess  Other — anorectal manipulation, acute sickle crisis, malpositioned indwelling urinary catheter.
  12. 12. Causes of AUR 3/28/2014AUR seminar12  1) Urethral Stricture  common in men with most patients acquiring the disease due to injury or infection  The most common etiology for stricture is iatrogenic injury due to urologic instrumentation (eg, oversized resect scope or the placement of indwelling catheters.
  13. 13. Etiology of urethral stricture 3/28/2014AUR seminar13 Location Anterior Urethra Meatus Instrumentation, iatrogenic, hypospadius, Pendulous urethra Instrumentation, iatrogenic, hypospadius, skin disorders (lichen sclerosus), sexually transmitted infections, crush injury Bulbar urethra Instrumentation, iatrogenic, skin disorders (lichen sclerosus), sexually transmitted infections, crush injury, straddle type injury Posterior Urethra Membranous urethra Instrumentation, pelvic fracture with urethral distraction defects Prostatic urethra Instrumentation, radiation therapy for prostate cancer (external beam radiation therapy, brachytherapy) Bladder neck Instrumentation, radiation therapy for prostate cancer (external beam radiation therapy,
  14. 14. Urethral Injury urethrography  Posterior urethra  Nearly always ass. With pelvic #  Crush, blunt, penetr. Or iatrogenic  Associated bladder inj.  Blood at meatus  Failure to void  Full bladder  Perineal swelling  Displaced prostate- DRE 3/28/2014AUR seminar14
  15. 15. Urethral… 3/28/2014AUR seminar15  Classes of injury  Complete or partial  Difficult to say which  Further classes based on radiograph  Management (Immediate)  Stretch - indwelling cath until able to void  Partial tear –careful! attempt - SPC then voiding CUG
  16. 16. Urethral… 3/28/2014AUR seminar16  Management…  Complete ?? - ?? immediate “indirect”/ endoscopic cath with SPC - SPC drainage, ante/retrograde eval’n later, complications - urethrotomy *stricture - open urethropasty *incontinence - endoscopic repair *impotence
  17. 17. Urethral… 3/28/2014AUR seminar17  Anterior urethra  Rare & isolated  Bulbar urethra >>  Stradle injury  Direct blow  Shaft # during activity  pelvic #  Penet. injury  blood at meatus  Unable to void  urethrograpy  Perin./penile echimosis
  18. 18. Urethral… 3/28/2014AUR seminar18  Initial managemnt  SPC diversion alone +/- debridement  Primary surgical repair  Definitive  Rethrograde & voiding - urethrotomy - anstomotic urethroplasty
  19. 19. Urethral stricture 3/28/2014AUR seminar19  Caused by:-  Inflammatory  Congenital  Traumatic  Instrumental , indwelling catheter and endoscopy  Post operative  Open prostectomy  Amputation of penis
  20. 20. complications 3/28/2014AUR seminar20  Retention of urine  Urethral diverticulum  Peri-urethral abscess  Urethral fistula  Rectal prolapse
  21. 21. 3/28/2014AUR seminar21  Diagnosis  Urethroscopy  Urethrography  Treatment  Dilation with elastic or metallic boogie Urethrotomy , internal visual incision of stricture  Urethroplasty, Excision and end to end anastomosis, patch urethroplasty
  22. 22. 3/28/2014AUR seminar22
  23. 23. BPH 3/28/2014AUR seminar23
  24. 24. BPH 3/28/2014AUR seminar24  BPH occurs in men over 50 years of age;  By the age of 60 years  50 per cent of men have histological evidence of BPH and  15 per cent have significant lower urinary tract symptoms
  25. 25. 3/28/2014AUR seminar25 Etiology  Unknown  Aging  Hormonal effects Androgen is important for both normal & abnormal growth of the prostate 90% of prostatic androgen is in form of DHT( from testicular androgen & 10% from adrenal androgen) Stromal – epithelial cells interaction produce growth factors (epidermal GF, insulin like GF,fibroblast GF) Increased estrogen increase the expression of AR in aging prostate & increase prostate size
  26. 26. Pathogenesis (Gland Enlargement) 3/28/2014AUR seminar26  Occurs as results of increased Number of epithelial & stromal cell ( increased cell proliferation)  Disruption of equilibrium between cell death & cell proliferation(decreased in cell death)  Androgen requiring during development, puberty,& aging  Castrated men or no androgen results no BPH
  27. 27. 3/28/2014AUR seminar27 Common symptoms (symtomatology)  Prostatism =LUTS  Classified in to irritative  obstructive frequency  Weak urine stream urgency  Difficulty starting urination urge incontinency  Dribbling enuresis  Needing to urinate several times  Straining  Sensation poor bladder emptying
  28. 28. Symptomatology…… 3/28/2014AUR seminar28  Scoring system IPSS AUA  Used for assessment of symptom severity  Assess the response to therapy  Detect symptom progression ( in watchful waiting Rx)  Can not used to establish the DX of BPH(infections,tumor ,bladder disease will have a high ipss)  According to IPSS  0-9 mildly symptomatic  8-19 moderately symptomatic  20-35 severely symptomatic
  29. 29. Effects of BPH Initially bladder becomes hypertrophied Increase postvoidal residuals ,poor contractility LUTS & Boo Urinary retention Hematuria ,urinary infection Stone formation ,trabeculation Bladder irritability ,renal insufficiency 3/28/2014AUR seminar29
  30. 30. DDX of BOO 3/28/2014AUR seminar30  BPH  BNC  Bladder stone  Urethral stricture  Prostatic cancer  Neurogenic bladder
  31. 31. Diagnosis of BPH 3/28/2014AUR seminar31  To pathologist is microscopic Dx(cellular proliferation of stomal & epithelial elements)  To radiologist makes the Dx in presence of bladder neck elevation of cystogram phase of IVP or enlarged prostate  To urodynamist -elevated voiding pressure -low urinary rate  To practicing urologist is constellation of sign & symptom
  32. 32. Diagnosis…..  Hx  onset of the symptoms  Age  Hx of STD  Determine which symptoms are predominant( irritative or obstructive)  Determine severity of the symptoms by IPSS)  Hx of hematuria ,UTI,diabetis ,NS disease ,urinary retention, surgery ofLUT 3/28/2014AUR seminar32
  33. 33. Diagnosis….. 3/28/2014AUR seminar33  P/E  general assessment (chest,cvs,anemia,external genitalia)  Abdominal examination Bladder distention Dullness Tenderness
  34. 34. Diagnosis…. 3/28/2014AUR seminar34  DRE –prostate size,consistance,noduls -pelvic floor tone flactuance &pain - prostate size does not correlate with symptoms severity & degree of urodynamic obstruction & Rx outcome  Prostate is large,smooth,convex,elastic,firm,mucosa moves over the prostate  Ns examination (r/o cavaequina lesions)
  35. 35. Investigations 3/28/2014AUR seminar35 U/A –dipstick & /or via centrifuged sediment for blood,bact,prot,glucos … -cytology for severe irritable symptom -urine culture PSA to R/o prostatic Ca which can coexist with BPH  Large BPH may have slightly elevated PSA  PSA value >4ng/ml or DRE induration or nodularity needs transrectal us & multiple biopsy  PSA & DRE increase the detection rate of prostate Ca over DRE alone
  36. 36. Investigations…. 3/28/2014AUR seminar36 Serum creatinine to R/o renal insufficiency occurs in 13% of case  BPH with RI increase the risk of post.op. complication with RI 25% 17% without RI  Help to evaluate the pt.with occult & progressive renal damage secondary to silent prostatism Postvoidal residual urine -obtained after voiding of urine with a catheter transabdominal us NV= less than 5 ml (78%), less than 12ml(100%)
  37. 37. Investigations…. 3/28/2014AUR seminar37 Pressure flow studies -done to distinguish b/n low pressure flow rate secondary to Boo & decompensated bladder - Reliable if Boo not Dxed by flow rate, initial evaluation & PVR uroflometry - electrical recording of the urine flow rate -noninvasive urodynimic test -quantifies strength of urine stream -2 to 3 voids with voided volume 150 to 200ml in flow rate clinic
  38. 38. 3/28/2014AUR seminar38  Watchful waiting: In patients with mild symptoms.  Medical treatment 1. Alpha reductase inhibitor: affects the epithelial component of the prostate, resulting in reduction in the size of the gland and improvement in symptoms. 2. Alpha-adrenoceptor blacker: affect subtype alpha-1 adrenoreceptors. (dynamic component of obstruction). 3. Combination.  Surgical treatment: Minimally invasive or open. By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS TREATMENT
  39. 39. 3/28/2014AUR seminar39 A- Absolute indications:  Upper urinary tract affection.  Uremia  Recurrent attacks of acute retention.  Severe obstructive symptoms (high IPSS score). By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS Indications of surgical intervention B- Relative indications: • Moderate symptoms (moderate IPSS score). • Recurrent UTI. • Hematuria. • Stone bladder.
  40. 40. 3/28/2014AUR seminar40  Transurethral resection of the prostate.  Transurethral incision of the prostate  Transurethral needle abelation  Ballon dilatation.  Transurethral microwave treatment.  Intraprostatic stents. By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS Minimally-invasive surgery
  41. 41. 3/28/2014AUR seminar41 Transvesical Transurethral Retropubic perineal or perineal By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS Open Surgery (Prostatectomy)
  42. 42. Open prostatectomy…. 3/28/2014AUR seminar42 Contraindications  small fibrous gland  The presence of prostate cancer  Previous prostatectomy  Pelvic surgery that obliterate access to the prostate gland
  43. 43. Prostatectomy….. 3/28/2014AUR seminar43 Post-op Mx  Measure output input  Bladder irrigation  Effective pain mx  1st p.o.day fluid diet, ambulation ,deflate balloon(10ml↓) & irrigate residual clot  2nd p.o.day regular diet  3rd p.o.day remove retro pubic  4th p.o.day discharge with catheter  5- 7 pod day remove catheter
  44. 44. Prostatectomy….. 3/28/2014AUR seminar44 Complications Bleeding -urethral catheter traction with 50ml of saline to compress the bladder neck & prostatic fossa -bladder irrigation to prevent clot formation -the inflow through urethral catheter &out flow through the suprapubic tube -if the bleeding persist cystoscopic inspection of the prostatic fossa &bladder neck -if marked bleeding continue to persist →open re-exploration
  45. 45. Complications…… 3/28/2014AUR seminar45 Perforation of the bladder & prostatic capsule (IN TURP) Incontinency (if damaged external sphincter mechanism) Retrograde ejaculetion(80-90%) & impotence (3-6% due to damage of the nerves associated with erection) Bladder neck contracture Urethral stricture Sepsis Death(0.2 to 0.3%)
  46. 46. Complications…. 3/28/2014AUR seminar46 TUR-syndrome In 2% of all TURP Due to absorption irrigating fluid through cut open veins Characterized by (hyponatremia →↓Na+ ,HPT,nauesa& vomiting,bradicardia,visual disturbance,mental confusion) Risk factors (gland>45gm,↑resection time >90mnt & much fluid for irrigation RX diuretics &correct electrolytes
  47. 47. Nephrolithiasis / urolithiasis 3/28/2014AUR seminar47  Stone formation in the kidney  Affect about 4-15% of population  Males are more commonly affect  Multifactorial in etiology
  48. 48. Risk factors for stone formation 3/28/2014AUR seminar48
  49. 49. Pathopysiology 3/28/2014AUR seminar49  Randal’s plaque  Supersaturati on  Decreased inhibitors
  50. 50. Types of stones 3/28/2014AUR seminar50  Oxalate calculus (calcium oxalate)  Phosphate  Uric acid  Cystine  Xanthine
  51. 51. Clinical presentation 3/28/2014AUR seminar51  Asymptomatic  Flank pain  Hematuria  Flank mass( Hydronephrosis)  Hematuria  Ureteric colic  Passage of stone  Symptoms of UTI
  52. 52. 3/28/2014AUR seminar52
  53. 53. Investigation 3/28/2014AUR seminar53  KUB  U/S  U/A  IVU  CT scan(spiral with contrast)
  54. 54. Renal stone diseases 3/28/2014AUR seminar54
  55. 55. 3/28/2014AUR seminar55
  56. 56. management 3/28/2014AUR seminar56  Conservative  Adequate hydration  Dietary modification  Medical treatment of underlying conditions  follow up U/S  Surgical  Indications  Failed expectant treatment  Large stone size  Evidence of obstruction  Presence of infection  Non functioning kidney with pain and stone
  57. 57. Surgery cont’d 3/28/2014AUR seminar57  Minimally Invasive I. ESWL II. PNL( Percutaneous nephrolithotomy)  Open surgery I. Pyelolithotomy II. Extended pyelolithotomy III. Nephrolithotomy IV. Nephrectomy
  58. 58. Clinical manifestations of AUR 3/28/2014AUR seminar58  AUR presents as the abrupt inability to pass urine.  lower abdominal and/or suprapubic discomfort  patients are often restless, and may appear in considerable distress  AUR is superimposed upon chronic urinary retention  Chronic urinary retention is most often painless  presence of hematuria, dysuria, fever, low back pain, neurologic symptoms, or rash.  Younger patient age, a history of cancer or intravenous drug abuse, and the presence of back pain or neurologic symptoms suggest the possibility of spinal cord compression.  Finally, a complete list of prescribed and over the counter medications should be obtained.
  59. 59. Physical examination 3/28/2014AUR seminar59  previous history of retention, prostate cancer, surgery, radiation, or pelvic trauma.  Lower abdominal palpation — The urinary bladder may be palpable, either on abdominal or rectal examination. Deep suprapubic palpation will provoke discomfort.  Rectal examination — A rectal examination should be done in both men and women, to evaluate for masses, fecal impaction, perineal sensation, and rectal sphincter tone. A normal prostate examination does not preclude BPH as a cause of obstruction.  Pelvic examination — Women with urinary retention should have a pelvic examination.  Neurologic evaluation — The neurologic examination should include assessment of strength, sensation, reflexes, and muscle tone.
  60. 60. Investigations 3/28/2014AUR seminar60  Urine analysis  CBC  Serum electrolytes  RFT and LFT  Ultrasound if pelvic mass suspected  cystoscopy
  61. 61. ACUTE MANAGEMENT Initial management of AUR 3/28/2014AUR seminar61  management of acute urinary retention (AUR) involves prompt bladder decompression  accomplished with urethral or suprapubic catheterization  Patients who have had recent urologic surgery (eg, radical prostatectomy or urethral reconstruction) and develop acute retention should not have urethral catheterization
  62. 62. Management contnd… 3/28/2014AUR seminar62  Emergency drainage  Emergency drainage of the bladder in acute retention may be undertaken by:  Urethral catheterization  Suprapubic puncture ???  Suprapubic cystostomy.  Urethral catheterization or bladder puncture is usually adequate, but  cystostomy may become necessary for the removal of a bladder stone or foreign body, or for more prolonged drainage, for example after rupture of the posterior urethra or if there is a urethral stricture with complications
  63. 63.  SUPRAPUBIC PUNCTURE Bladder puncture may become necessary if urethral catheterization fails. It is essential that the bladder is palpable if a suprapubic puncture is to be performed 3/28/2014AUR seminar63
  64. 64. SUPRAPUBIC PUNCTURE 3/28/2014AUR seminar64
  65. 65. SUPRAPUBIC CYSTOSTOMY 3/28/2014AUR seminar65  The purpose of supra pubic cystostomy is  To expose and, if necessary, allow exploration of the bladder  To permit insertion of a large drainage tube, usually a self-retaining catheter  To allow supra pubic drainage of a non-palpable bladder Infiltrate using local anesthesia .5% 1% lidocaine with adrenaline layer by layer and supra pubic midline incision 2cm above SP Openrectussheathusingscissors
  66. 66. supra pubic (SP) catheter 3/28/2014AUR seminar66  necessary in patients with urethral stricture disease, severe BPH.  abnormalities that preclude Foley catheter placement per urethra  Ultrasound guidance may be indicated when adhesions are possible from prior abdominal surgery.
  67. 67. supra pubic (SP) catheter contnd… 3/28/2014AUR seminar67  Suprapubic catheterization is performed under local anesthesia.  with steady aspiration until urine is retrieved.  A trocar-type suprapubic tube is then passed through a one centimeter skin incision and  the catheter advanced over the trocar and sutured in place.  The patients undergoing SP catheterization had fewer urinary tract infections and were less uncomfortable than those who were treated with urethral catheters.
  68. 68. supra pubic (SP) catheter contnd… 3/28/2014AUR seminar68  They Allow assessment of the patient's ability to void before removing the catheter.  The risk of complications associated with placement, including bowel perforation and wound infection is high in SP  females, who are expected to require long-term bladder drainage. SP catheters prevent bladder neck and urethral dilatation and therefore prevent urinary incontinence due to sphincter dysfunction.  They avoid the risk of subsequent urethral stricture, a common complication in men requiring long-term urethral catheterization
  69. 69. 3/28/2014AUR seminar69  Duration of catheterization — The optimal duration of catheter management prior to a trial of voiding has been evaluated, with some contradictory findings  A subsequent observational study from France of 2600 men with AUR found that men who were catheterized for three days or less had greater success with spontaneous voiding than men catheterized for more than three days
  70. 70. Trial without catheter(TWOC) 3/28/2014AUR seminar70  involves catheter removal (usually in two to three days) and determination if the patient can successfully void.  success rates for initial TWOC have ranged from 20 to 40%.  Factors that favor successful trial of void includes  age less than 65 years,  detrusor pressure greater than 35 cmH2O,  a drained volume of less than one liter at catheterization,
  71. 71. SURGICAL THERAPY 3/28/2014AUR seminar71  definitive treatment of AUR.  symptomatic patients with BPH, transurethral resection of the prostate (TURP)  Transurethral resection of the prostate remains the gold standard
  72. 72. SUMMARY AND RECOMMENDATIONS 3/28/2014AUR seminar72  Acute urinary retention (AUR) is the most common urologic emergency, affecting 1 in 10 men age 70 and older. Benign prostate hyperplasia (BPH) is the most common underlying condition, but multiple etiologies may cause AUR. Medications are frequently implicated  Initial management of AUR involves prompt bladder decompression. We suggest initial treatment with a Foley urethral catheter, rather than a suprapubic catheter  A suprapubic catheter may be indicated when obstruction precludes a urethral catheter, and may be preferred in patients who are expected to require longer term decompression. 
  73. 73. SUMMARY AND RECOMMENDATIONS 3/28/2014AUR seminar73  Hospitalization is indicated for patients who are uro septic, or who have obstruction related to malignancy or spinal cord compression.  Emergency surgery for relief of prostatic obstruction is rarely indicated, and carries an increased risk over elective surgery. The majority of patients can be managed as outpatients once bladder decompression is accomplished.  Removal of the catheter after a period of time ("trial without catheter" or TWOC) results in successful spontaneous micturition in up to 40 percent of patients with AUR, though recurrent AUR is common.  We suggest a trial of catheter removal in one to two weeks  The majority of men who have BPH and AUR will ultimately require definitive intervention for their BPH. 
  74. 74. References 3/28/2014AUR seminar74 Campbell's – walsh Urology 9th edition Schwartz's Principles of surgery 9th edit Mannipal urology Upto date 19.2 ed.

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