2. What is acute
urinary retention?
Acute urinary retention (AUR) is the sudden
inability to pass urine. It is usually painful
and requires emergency treatment with a
urinary catheter.
3. Aetiology
In men - benign prostatic
hyperplasia (BPH), meatal
stenosis, paraphimosis, penile
constricting bands, phimosis,
prostate cancer.
In women - prolapse (cystocele,
rectocele, uterine), pelvic mass
(gynaecological malignancy,
uterine fibroid, ovarian cyst),
retroverted gravid uterus.
In both - bladder calculi, bladder
cancer, faecal impaction,
gastrointestinal or retroperitoneal
malignancy, urethral strictures,
foreign bodies, stones.
4. Infectious and
inflammatory
In men - balanitis, prostatitis and prostatic
abscess.
In women - acute vulvovaginitis, vaginal
lichen planus and lichen sclerosis, vaginal
pemphigus.
In both - bilharzia, cystitis, herpes simplex
virus (particularly primary infection), peri-
urethral abscess, varicella-zoster virus.
7. In men - penile trauma, fracture or laceration.
In women - postpartum complications (increased risk with instrumental
delivery, prolonged labour and caesarean section); urethral sphincter
dysfunction (Fowler's syndrome).
In both - pelvic trauma, iatrogenic, psychogenic.
BPH is by far the most common cause of urinary retention.
8. Acute urinary
retention is often
encountered
postoperatively
and the reasons
for this are
multifactorial:
Pain.
Traumatic instrumentation.
Bladder overdistension.
Drugs (particularly opioids).
Iatrogenic - for example:
Suburethral sling procedures for stress
incontinence[3].
Posterior colporrhaphy.
Decreased mobility and increased bed rest.
9. Urinary retention symptoms :
History :
Nature and duration of
current symptoms - eg,
anuria, pain.
Any other associated
symptoms - eg, fever, weight
loss, sensory loss,
weakness.
Enquire regarding previous
episodes of retention and
history of lower urinary tract
symptoms (LUTS).
Consider precipitants - eg,
alcohol consumption, recent
surgery, urinary tract
infection (UTI), constipation,
large fluid intake, cold
exposure or prolonged
travel.
Past medical history - eg,
neurological conditions.
Check medication (both
prescribed and over-the-
counter) for agents known to
cause urinary retention.
10. Examination : General - look for fever and signs of infection and
systemic illness.
Abdominal - a tender enlarged bladder with dullness to
percussion well above the symphysis pubis, often
almost to the level of the umbilicus.
Genitourinary:
In men, look for phimosis or meatal stenosis, as well as
urethral discharge and genital vesicles.
11. In women, look for evidence of:
Vulval or vaginal inflammation or infection.
Cystocele, rectocele or uterine prolapse.
Pelvic mass (eg, retroverted gravid uterus,
uterine fibroid, gynaecological malignancy).
Per rectum (PR) - check anal tone, prostatic size,
nodules, tenderness, etc and exclude faecal
impaction[6].
Neurological - look for evidence of prolapsed disc
or cord compression by checking lower limb
power and reflexes as well as perineal sensation.
12. Investigations
Urinalysis - check for infection, haematuria, proteinuria, glucosuria.
MSU.
Blood tests:
FBC.
U&E, creatinine, estimated glomerular filtration rate (eGFR).
Blood glucose.
Prostate-specific antigen (PSA). NB: this is elevated in the setting of AUR so is of
limited use at this stage[6].
.
13. Imaging studies:
Ultrasound - commonly used,
as it can provide a measure
of post-void residual urine as
well as looking for
hydronephrosis and other
structural abnormalities of the
renal system.
CT scan - used to look for
pelvic, abdominal or
retroperitoneal mass causing
extrinsic bladder neck
compression.
MRI/CT brain scan - used to
look for intracranial lesions
(eg, tumour, stroke, MS).
MRI scan of the spine - used
to look for disc prolapse,
cauda equina syndrome,
spinal tumours, spinal cord
compression, MS.
Investigations such as
cystoscopy, retrograde
cystourethrography or
urodynamic studies may also
be undertaken depending on
the suspected cause of
retention
14. Urinary
retention
treatment and
management :
Immediate and complete bladder decompression.
The National Institute for Health and Care
Excellence (NICE) recommends that men with
acute urinary retention should be immediately
catheterised. An alpha-blocker should be offered
before removal of the catheter.
15. Complications :
UTIs. Acute kidney injury. Post-obstructive diuresis
(marked natriuresis and diuresis
with electrolyte disturbance,
including hypokalaemia,
hyponatraemia, hypernatraemia
and hypomagnesaemia).
Post-retention haematuria.
16. SUPRA PUBIC CATHETER :
Suprapubic catheters are often placed for a short time following certain surgical
procedures as they can contribute to patients’ improved recovery times, compared
with urethral catheterization.
They can provide stable bladder drainage before and after complex urethral
reconstructions. In patients undergoing bladder, prostate or urethral surgery,
these tubes can be a valuable tool to maintain adequate urinary drainage.
Also, they may be combined with a urethral catheter to provide a means for
continuous irrigation. Irrigation inflow can be instilled through a SPC and outflow
by way of the urethral catheter, or vice versa.
19. PROCEDURE :
A small incision will be made in your lower abdomen, just above the pubic hairline.
A special inserted trocar allows insertion of the suprapubic catheter. In patients
with small bladders.
The incision often needs to be larger so that the bladder can be seen clearly to
allow the catheter to be inserted.
Correct positioning within the bladder is checked throughout the procedure
utilizing the cystoscope.
20. INDICATIONS :
Acute and chronic urinary retention in a patient with contraindications to or complications from a transurethral catheter.
Patients with spinal cord injury who have failed intermittent catheterization and need long-term bladder management, SPC preferred
over IUC.
Failed urethral catheterization
Inability to catheterize urethra (e.g. obesity/body hiatus with a large abdominal girth, obstruction, stricture, trauma, abnormal urethral
anatomy).
Lack of urethral or perineal sensation where the risk of urethral injury or skin breakdown is increased (e, g, spinal cord injury).
While undergoing pelvic radiation
Postoperative bladder drainage following: GU or colon surgery (e.g. female stress UI, colorectal surgery, prostate surgery), post pelvic
trauma or injury.
Men with diagnosis of bladder outlet obstruction and transurethral resection is contraindicated.
To decrease risk of contamination from fecal material (e.g. patient with fecal incontinence).
Palliative use - where the use of an SPC may simplify patient care and increase patient comfort
21. CONTRA INDICATIONS :
Pregnancy
Known or suspected carcinoma of the bladder.
Absolutely contraindicated is the absence of an easily palpable or ultrasonographically
localized distended urinary bladder.
Previous lower abdominal surgery.
Coagulopathy.
Presence of ascites, hernia mesh or other prosthetic devices in lower abdomen.
Presence of ovarian cyst
Neuropathic disorders causing frequent urethral catheter expulsion.
