Acute urinary retention atila ppt

PRESENTER :- ATINKUT D.
MODERATOR: - Dr. Gersam
3/28/2014AUR seminar1
ACUTE URINARY RETENTION

Outline of presentation
 Definition
 Pathophysiology
 Risk factors
 Etiology
 Urethral strictures
 BPH
 Urolithiasis
 Clinical presentation
 Management options
 Summary
 references
2

Acute Urinary Retention
 Definition:- Painful inability to void, with relief of
pain following drainage of the bladder by
catheterization.

Pathophysiologic mechanism of AUR
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.

Pathophysiologic contnd…..
 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

Pathophysiologic contnd…..
 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.

 Medications — Multiple medications are
implicated in the cause of urinary retention,
principally involving anticholinergic and
sympathomimetic drugs
 Pharmacologic agents associated with urinary
retention.docx

RISK FACTORS
 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.

Etiology
 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

 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

 Pelvic masses
 Genitourinary infections — acute prostatitis,
urethritis, perianal abscess
 Other — anorectal manipulation, acute sickle
crisis, malpositioned indwelling urinary catheter.

Causes of AUR
 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.

Etiology of urethral stricture
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,

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

Urethral…
 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

Urethral…
 Management…
 Complete ??
- ?? immediate “indirect”/ endoscopic cath
with SPC
- SPC drainage, ante/retrograde eval’n
later, complications
- urethrotomy *stricture
- open urethropasty *incontinence
- endoscopic repair *impotence

Urethral…
 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

Urethral…
 Initial managemnt
 SPC diversion alone +/- debridement
 Primary surgical repair
 Definitive
 Rethrograde & voiding
- urethrotomy
- anstomotic urethroplasty

Urethral stricture
 Caused by:-
 Inflammatory
 Congenital
 Traumatic
 Instrumental , indwelling catheter and
endoscopy
 Post operative
 Open prostectomy
 Amputation of penis

complications
 Retention of urine
 Urethral diverticulum
 Peri-urethral abscess
 Urethral fistula
 Rectal prolapse

 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

BPH
 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

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

Pathogenesis
(Gland Enlargement)
 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

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

Symptomatology……
 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

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

DDX of BOO
 BPH
 BNC
 Bladder stone
 Urethral stricture
 Prostatic cancer
 Neurogenic bladder

Diagnosis of BPH
 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

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

Diagnosis…..
 P/E
 general assessment (chest,cvs,anemia,external
genitalia)
 Abdominal examination
Bladder distention
Dullness
Tenderness

Diagnosis….
 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)

Investigations
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

Investigations….
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%)

Investigations….
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

 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

A- Absolute indications:
 Upper urinary tract
affection.
 Uremia
 Recurrent attacks of acute
retention.
 Severe obstructive
symptoms (high IPSS
score).
Indications of surgical intervention
B- Relative indications:
• Moderate symptoms (moderate
IPSS score).
• Recurrent UTI.
• Hematuria.
• Stone bladder.

 Transurethral resection of the prostate.
 Transurethral incision of the prostate
 Transurethral needle abelation
 Ballon dilatation.
 Transurethral microwave treatment.
 Intraprostatic stents.
Minimally-invasive surgery

Transvesical
Transurethral
Retropubic
perineal
or
perineal
Open Surgery (Prostatectomy)

Open prostatectomy….
Contraindications
 small fibrous gland
 The presence of prostate cancer
 Previous prostatectomy
 Pelvic surgery that obliterate access to the prostate
gland

Prostatectomy…..
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

Prostatectomy…..
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

Complications……
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%)

Complications….
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

Nephrolithiasis / urolithiasis
 Stone formation in the
kidney
 Affect about 4-15% of
population
 Males are more
commonly affect
 Multifactorial in etiology

Risk factors for stone formation

Pathopysiology
 Randal’s
plaque
 Supersaturati
on
 Decreased
inhibitors

Types of stones
 Oxalate calculus (calcium oxalate)
 Phosphate
 Uric acid
 Cystine
 Xanthine

Clinical presentation
 Asymptomatic
 Flank pain
 Hematuria
 Flank mass( Hydronephrosis)
 Hematuria
 Ureteric colic
 Passage of stone
 Symptoms of UTI

Investigation
 KUB
 U/S
 U/A
 IVU
 CT scan(spiral with contrast)

Renal stone diseases

management
 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

Surgery cont’d
 Minimally Invasive
I. ESWL
II. PNL( Percutaneous
nephrolithotomy)
 Open surgery
I. Pyelolithotomy
II. Extended
pyelolithotomy
III. Nephrolithotomy
IV. Nephrectomy

Clinical manifestations of AUR
 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.

Physical examination
 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.

Investigations
 Urine analysis
 CBC
 Serum electrolytes
 RFT and LFT
 Ultrasound if pelvic mass suspected
 cystoscopy

ACUTE MANAGEMENT
Initial management of AUR
 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

Management contnd…
 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

 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

SUPRAPUBIC PUNCTURE

SUPRAPUBIC CYSTOSTOMY
 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

supra pubic (SP) catheter
 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.

contnd…
 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.

contnd…
 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

 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

Trial without catheter(TWOC)
 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,

SURGICAL THERAPY
 definitive treatment of AUR.
 symptomatic patients with BPH, transurethral
resection of the prostate (TURP)
 Transurethral resection of the prostate remains
the gold standard

SUMMARY AND RECOMMENDATIONS
 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.


SUMMARY AND RECOMMENDATIONS
 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.


References
Campbell's – walsh Urology 9th edition
Schwartz's Principles of surgery 9th edit
Mannipal urology
Upto date 19.2 ed.

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