Acute and chronic retention are very important aspect of emergency urology

1. Principles Of
Management of Acute
and Chronic Urinary
Retention
Dr Amit Mishra
M.Ch.Urology & Renal Transplant
DLU (IRCAD France),FACS
Assistant Professor, Urology

2. Cases
• It’s a typically busy morning in your community ED. The average wait time to be seen is 1 hour
when a 66-year-old man with hypertension and high cholesterol states that he has been unable to
urinate for a few days and now has suprapubic pain and constipation. He denies fever and chills.
He also notes that, in the past, he was diagnosed with benign prostatic hypertrophy and has
required Foley placement. It seems simple enough, and you anticipate he will be out as soon as the
Foley and leg bag are in place. You wonder if a rectal exam is needed and how fast his bladder can
be emptied...
• It’s 2:00 PM and you are about to finally grab some lunch, but in comes a 72-year-old man with a
history of large cell lymphoma for the past 15 years. He complains of dribbling urinary frequency,
which has worsened over 1 day after being prescribed an antibiotic by his doctor for a UTI. The
nurse asks him to walk to another stretcher, and as he gets up, he stumbles and catches himself
with his hands. As you prepare to do the bladder ultrasound, you wonder why he stumbled...
• It’s finally 6:30 PM, with just 30 minutes until relief arrives. You are spending the last half hour of
your shift tying up the loose ends with your current patients when a 46-year-old febrile woman with
a history of active intravenous drug abuse and HIV comes in. She is in excruciating discomfort and
tells you that she has not urinated in 2 days. You wonder if that is possible, and why...

3. Goals
• Review Anatomy: Urinary Tract
• Acute and Chronic Urinary Retention
• Pathophysiology
• Pathology
• Clinical Presentation
• Radiologic Work-up Modalities
• Management

5. ACUTE URINARY RETENTION
 Urinary retention is the accumulation of urine
in the bladder with associated inability of the
bladder to empty itself.
 Because urine production continues, retention
distends the bladder.

6. ACUTE URINARY RETENTION CONTD.
 The adult urinary bladder normally holds 250 to
450 ml of urine when the micturition reflex is
triggered.
 With urinary retention, some adult bladders may
distend to hold 2000 ml of urine.
 Precipitated
 Spontaneous

7. ACUTE URINARY RETENTION CONTD.
 Prolonged retention leads to stasis (a slowing of the flow of urine)
and stagnation of urine, which increase the possibility of a urinary
tract infection.
 Distention causes reduced blood flow to the bladder, which is
considered the major cause of urinary tract infections.

8. CLINICAL SIGNS OF AUR
 Discomfort/Pain in the suprapubic area
 Bladder distention
 Inability to void
 Increasing restlessness and need to void

9. Bladder Distention
 Retention is distinguished from oliguria or anuria by the bladder
distention.
 Bladder distention can be assessed by palpation and percussion
above the symphysis pubis.
 Percussion of the suprapubic area produces a “kettle-drum” or dull
sound when the bladder is full.

10. • Neuropathic etiologies
UMN Lesions- (eg, diabetic cystopathy) multiple sclerosis, trauma, Parkinson disease, stroke, and
neoplasms.
LMN lesions-causing bladder flaccidity with AUR include spinal cord tumors, epidural abscesses, and
trauma.
Infectious or inflammatory
urethritis from UTI), prostatitis, severe vulvovaginitis, or viral causes (eg, genital herpes involving the
sacral nerves)
Obstructive causes of AUR
Intrinsic causes (eg, prostatic enlargement, bladder stones), or extrinsic causes (eg, uterine or
gastrointestinal masses).
Obstructive causes in women often involve pelvic organ prolapse (eg, cystocele or rectocele) or
malignant pelvic masses. In patients during the postpartum period.

11. CAUSES
MALE: Bladder outlet obstruction
Urethral stricture
Postoperative
Acute prostatitis
Severe phimosis
FEMALE: Retroverted Gravid Uterus
Multiple Sclerosis

12. CONTD…
• BOTH: Clot Retention
Urethral calculus
Rupture Urethra
Spinal Anesthesia
Faecal Impaction
Medications

15. 14
Acute Obstruction and Anuria
Patients may die from acute
renal failure with
oliguria/anuria
Requires prompt
recognition and
possible surgical
intervention
CT examination: Postcontrast axial scan: The retroperitoneal giant tumor mass compresses the
right ureter and causes hydronephrosis (arrows).
http://www.szote.u-szeged.hu/radio/panc/alep8c.htm
Acute complete, bilateral obstruction
= Medical Emergency

16. Management of Urinary Tract Obstruction
Obstructive lesions of the urinary tract that cause hydronephrosis from Robbins & Cotran, 7th Ed, Chap 20, p 1013
Surgery
Nephrectomy
Partial Nephrectomy
Resect extrinsic masses
Foley Catheter
Prostate resection/TURP/PVP
Cystoscopy
TURB
Ureteral Stents
Percutaneous Nephrostomy Tube
Emergency Drainage
Intraureteral Stone removal
Extracorporeal Shock Wave Lithotripsy
Laser Lithotripsy
Percutaneous Ultrasonic Lithotripsy

17. Diagnosis
17
Early diagnosis and decompression is
critical to prevent renal failure
Continue to Radiologic work-up

18. Ultrasonography
18
Test of Choice for Suspected Urinary Tract Obstruction
Screening test
Indications: Renal failure of unknown origin/Hematuria/Signs of UTO/Urolithiasis
Sensitivity for detection of chronic obstruction: 90%
Sensitivity for detection of acute obstruction: 60%
Advantages:
No allergic/toxic complications of radiocontrast media
Fast, inexpensive
Diagnose other causes of renal disease in patient with renal insufficiency of
unknown origin
Polycystic Kidney Disease
Disadvantages
Nonspecific
Rarely identifies cause
False positive rate: < 25% with minimal criteria (operator dependent)
Any visualization of collecting systems
False negative with acute obstruction, dehydration, sepsis
Bowel Gas decreases sensitivity

19. Ultrasound – Obstructive Uropathy
19
Compressed
renal fat,
hyperechoic
Renal
parenchyma,
hypoechoic
Dilated collecting
duct, hypoechoic
(fluid)
Pt. AK, PACS, Courtesy of Dr. AC Kim

20. 19
Abdominal CT & Plain Film
1. CT
***Noncontrast***
Urolithiasis  test of choice in ED
Size
Location
Identify masses/Inflammation causing
extrinsic obstruction
Identify obstructive atrophy
Quick
Post Trauma
2. Plain Film
Enlarged renal shadows
Heavy metal densities  renal stones
Tumor metastases to bones of
spine/pelvis
Osteoblastic? Likely prostate
metastases
CT/Plain film + ultrasound will make the
diagnosis of ureteral obstruction in ~90% cases
Limitations of Plain Film and CT
• Obstruction due to radiolucent
stones (indinavir), sloughing of
renal papillae, small blood clot
• Radiation doses
• Need Fat to see soft tissue
Contraindications to Contrast
• Pregnancy, children, nursing
moms
• Renal failure/insufficiency
• Allergy
• Multiple Myeloma
• CHF
• Gout

21. 51
Radiologic Work-up for Urinary Tract
Obstruction: Rationale
Is there
hydronephrosis?
What is renal
function?
Final Diagnosis
Management:
Decompression
Urology Consult
Cystoscopy
Yes/Equivocal with
High Clinical
Suspicion
Is there mechanical
obstruction?
Ultrasound CT
Plain Film
Answer
Where is it?
IVU/CTU/MRU
Renal scan/Nephrogram
No:
Alternate
Work-up
Obstructive
Symptoms
Flank pain
Hematuria
Renal failure
Dysuria/Frequency
Urgency

23. URETHRAL CATHETERIZATION
• INDICATIONS:
1. DIAGNOSTIC:
a) COLLECTION OF URINE FOR CULTURE IN FEMALE.
b) MEASUREMENT OF P.V.R URINE.
c) INSTILLATION OF CONTRAST FOR CYSTOURETHROGRAPHY.
2. THERAPEUTIC:
a) FOR BLADDER OUTLET OBSTRUCTION
b) FOR MONITORING URINE OUTPUT.
c) C.I.S.C IN NEUROGENIC BLADDER PATIENTS.
d) STENTS AFTER URETHRAL SURGERY.

24. CONTD..
• CATHETER SIZE: BY FRENCH SCALE
I FR. =.33mm.IN DIAMETER.
DENOTES OUTER DIAMETER.
• CATHETER MATERIAL:
SILICON
LATEX
POLYURETHANE
RUBBER

25. CONTD..
• TECHNIQUE:
INFORM PATIENT
PAINT AND DRAP
IN MALES- RETROGRADE INJECTION
OF XYLOCAINE JELLY 2%.
APPLY CLAMP FOR 5-10 MTS.
STRETCH PENIS PERP. TO BODY
CATHETERIZE (16-18 FR.)
REPOSITION PREPUCE.
IN FEMALES- PRELIMINARY PREPARATION
SPREAD LABIA WITH MIDDLE AND INDEX FING.
JELLY CAN BE PLACED DIRECTLY OVER CATH.
CATHETERIZE. (14-16 FR.)

26. CONTD..
• COMPLICATIONS
IMMEDIATE
URETHRAL
TRAUMA
IMPROPER
PLACEMENT
BLADD. SPASM
PARAPHIMOSIS
INFECTION
ALLERGIC
REACTION
DELAYED
PERICATH. LEAK
INFECTION
PRESSURE
NECROSIS
PERIURETH.
ABSCESS
POOR DRAINAGE
STUCK CATH.
STRICTURE
MALIGNANCY

27. Suprapubic Cystotomy

28. Indications for suprapubic catheterization include: (1) AUR in a patient who has contraindications for
urethral catheterization, (2) major urethral trauma when no urologist is available, and (3) failure of
Foley and Coude catheterization in an AUR patient without contraindications.1

29. Bilateral ureteral obstruction
• Management
• Bilateral DJ stenting
• Bilateral Percutaneous Nephrostomy

30. Chronic urinary retention

31. Definition
• A painless bladder distention with consistently “high” PVR. No consensus on value of PVR: 200-500 many
values have been suggested in different texts .
• high-pressure chronic retention (HPCR) and low-pressure chronic retention (LPCR) .
• The terms high and low refer to the detrusor pressure at the end of micturition (ie, at the start of the next
filling phase) .
• Bladder outlet obstruction usually exists in HPCR, and the voiding detrusor pressure is high but is associated
with poor urinary flow rates.
• The constantly raised bladder pressure in HPCR during both the storage and voiding phases of micturition
creates a backward pressure on the upper-tract drainage and results in bilateral hydro-nephrosis.
• Other patients may have large-volume retention in a very compliant bladder with no hydronephrosis or renal
failure, and they are said to have LPCR.
• UDS in these patients show low detrusor pressures, low flow rates, and very large residual volumes.
• Lower urinary tract symptoms (LUTS), however, are usually mild in CUR,certainly in the early stages, until
the onset of nocturnal enuresis, which results from the drop in urethral resistance during sleep.
• In nocturnal enuresis, urethral resistance is overcome by the maintained high bladder pressure, which
causes incontinence (sometimes inappropriately called overflow incontinence).

32. Difference with acute retention
• Chronic retention is usually relatively painless
• High intravesical pressure can cause hydronephrosis and renal
impairment
• Can present as late-onset enuresis/ overflow or paradoxical
incontinence/ HT
• Need to exclude neurogenic causes
• Patients with chronic retention and renal impairment need urgent
urological assessment

33. Etiology
• At Bladder: myogenic weakness
• At bladder outlet(BOO)
Prostate( BPH/CAP)
Urethra (USD/ PUV/ DSD)

34. Pathophysiology
• Effect on bladder:
Stage of Compensation
- Trabeculations: coarsely
interwoven appearance of bladder
mucosa/ prominent IU bar/
trigonal hypertrophy
-Cellules and saccules : pockets of
mucosa pushed b/w supl. muscle
bundles.
-Diverticula: cellules forcing their
way through whole muscle.
--trigonal hypertrophy and High
residual urine
Stage of Decompensation
- Decompensation of Detrusor
leading to high PVR
• Effect on Upper Tracts
On Ureter
-resistance to flow across terminal
ureter
On Kidney
- PCS dilatation and hydronephrosis
- Parenchymal atrophy

35. Clinical Presentation
• LUTS may/may not be +nt
If +nt ..usually long history
• Overflow incontinence/ Nocturnal eneuresis
• With complications:
-UTI/Renal Insufficiency/ HT/ Acute on
chronic retention
• Examination: relatively painless distended bladder

36. Evaluation
• Immediate evaluation to rule out renal insufficiency and presence of
B/L hydro-nephrosis
• Further evaluation for cause and other complications

38. Management
• Immediate drainage of bladder required if obstructive uropathy or infection +nt
• Observation for and Mx of post obstructive diuresis. Early catheterisation is
indicated if renal dysfunction or upper tract dilatation is present. Patients must
be monitored for postobstructive diuresis and may pass many litres of urine in
the first few days following catheterisation.
• The diuresis can result from
• off- loading of retained salt and water(retained in the weeks prior to the
episode of retention);
• loss of the corticomedullary concentration gradient, caused by reduced urinary
flow through the chronically obstructed kidney; or
• a high urea level that results in osmotic diuresis.
• Patient can be managed on elective basis or conservatively if upper tract changes
ruled out

39. Implications of Chronic Urinary Retention on
BPH Management
• Conservative management of BPH is possible only in a selected
patients after ruling out obst.uropathy & detrusor failure and very
strict FU protocol is reqd. to avoid progress. (Bates et al; Is conservative Mx if BPH in
CUR ever justified?; BJUI 2003, 92,581-583)
• After TURP the chances of failed cath free trial are more d/t detrusor
failure. Better selection can be done after putting patients on CISC for
6 wks prior to TURP(reestablishing filling-emptying cycle) and then
reassesing detrusor function urodynamically ( Ghaliyani et al; prospective
randomised trial comparing TURP and CISC in men with CUR; 2005 BJUI, 96,93-97)

40. • In the case of the 66-year-old man with hypertension and high cholesterol, after you performed a
thorough head-to-toe examination and a complete history, you performed a rectal examination,
which showed good rectal tone with an enlarged, smooth prostate. You used bedside ultrasound to
evaluate the bladder and saw a full, distended bladder with an approximate volume of 1100 mL.
Urgent bedside complete bladder decompression was performed with a 16F dual-lumen Foley
catheter, and urine was sent for urinalysis and culture. The patient’s symptoms improved, his vital
signs remained stable, and the urinalysis returned as normal. You arranged a urology follow-up
appointment in 3 days, had the Foley bag changed to a hip bag, and gave the patient care and
changing instructions. You prescribed him a 2-week course of doxazosin and discharged him home
with return instructions if his condition worsened .
• In your second case, the 72-year-old man, a quick physical examination revealed only a distended
bladder. A urethral catheter was placed, and 700 mL of urine was obtained, with much relief for the
patient. Not forgetting the patient’s presentation and his stumble while changing stretchers, you
decided to perform a thorough neurological examination, and you found nearly absent rectal tone
and absence of sensation and vibration below T11. Urgent MRI confirmed your diagnosis of spinal
cord compression. You consulted neurosurgery, and the patient was admitted for decompressive
laminectomy and eventual chemotherapy.

41. • In the third case, the 46-year-old febrile woman with HIV, after taking her history and giving her a
thorough physical examination, you performed a rectal examination, which showed good rectal tone
and no evidence of obstruction. You then performed a pelvic examination (with a chaperone
present), and it showed vesicular lesions suggestive of herpes. Adequate pain control was
achieved. Ultrasound showed a fully distended bladder. You gave the patient acetaminophen, IV
acyclovir, and IV fluids, and you started cardiorespiratory monitoring. You performed complete
bladder decompression using a 16F Foley and sent the urine for urinalysis and culture. The
urinalysis returned positive for white blood cells, so you gave her IV ceftriaxone and admitted her to
medicine for IV antibiotics, IV fluids, and antivirals.

44. THANK YOU