This document discusses the definitions, causes, evaluation, and management of urinary retention and anuria. It defines urinary retention as the inability to pass urine despite an urge to void, while anuria is the lack of urine production or passage. The causes of retention are discussed for different age groups and include conditions like urethral stricture, enlarged prostate, neurogenic bladder, bladder stones, and drugs. Evaluation involves history, examination, urinalysis, renal function tests, ultrasound, and urodynamics. Management depends on whether it is acute or chronic retention and may include catheterization, treating underlying causes, and surgery in some cases. Anuria is evaluated and managed based on whether its cause is pre-renal

1. LUTS RETENTION OF URINE, ANURIA DR AHMED REHMAN FCPS (URO) Assistant Professor of Urology

2. Learning Objectives To understand the definitions & Know causes of Be able to take elaborate history And conduct a relevant clinical exam Be able to suggest relevant investigations

3. LUTS - OBSTRUCTIVE Static Obstruction (Mass related Increase in Urethral resistance). Poor flow / thin stream Hesitancy Intermittency of stream Sense of incomplete evacuation of bladder Terminal dribbling Retention of urine Acute / chronic

4. LUTS - I RRITATIVE Dynamic Obstruction (Increased adrenergic tone in prostate) Urgency Frequency Day time / Night time (nocturia) Urge incontinence

5. Dysurea Pain associated with act of micturation Burninng, scalding

6. Causes of Frequency – Dysuria Infections & inflammations nonspecific - Acute Cystitis, urethritis, prostatitis specific - TB, schistosomiasis, Intersitial cystitis Abacterial cystitis /urethritis ( mycoplasma, herpes, chemical) Cystitis cystca and Alkaline encrustin cystitis BOO +/- sec. infection Phemosis / fused synichae, Ext. meatal stenosis Urethral Stone / foreign body impaction, Enlarged prostate--------- benign / malignant / inflammatory/abscess bladder neck stenosis, Post urethral,valve Urethral stricture neoplasm of bladder, urethra, prostate and penis vesical calculus, foreign body Neurogenic Detrusor sphincter dyssynergia , neurogenic bladder ,spine trauma, multiple seclerosis.DM Stones , vesical , urethral, ureteric Inncomplete bladder evacuation VUR, and vesical diverticulum Cystocele / UV prolapse decompensation of bladder / bladder atonia BOO Malignancy CIS UB, bladder & prostatic CA Miscellaneous Drugs . Anticholinergic, frequency – dysuria syndrome Atrophic urethritis (senile) Distal urethral syndrome Pregnancy, diabetes, LVF, CCF, diuretics, polyuria

7. 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. No urine in bladder on USG, Even on correct catheterization, no urine is drained.. <100 cc urine / 24hrs Extravasion Leakage of urine into tissues / body cavity (peritoneum Bladder rupture / perforation

8. Oligurea <300 ml urine / 24 hrs Renal failure When kidneys no longer able to maintain renal functions Acute: sudden, potentiality reversible Sudden rise of S creatinine by 1 Chronic: insidious, progressive. nonreversible

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. Causes of retention - boys Phemosis 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

11. Causes of retention - girls Synechia vulvae Urethritis uncommon Urethral stricture / trauma Vesical / urethral calculus Blader neck stenosis Neurogenic bladder Constipation Drugs

12. Causes of retention – young males Meatal ulcer / stenosis Urethral stricture / stone / abscess / trauma Bladder stone Drugs / anesthesia Spinal shock / neurogenic bladder / DSD Prostatitis / prostatic abscess utrethritis # penis Para phemosis / phemosis

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

14. Causes of retention – elderly males BPH, CaP, abscess Stone, Ca UB, clot retention Stricture/stone/abscess /rupture –urethra Meatal stenosis, Phemosis, para-phemosis 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

15. 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

16. Work up

17. ASSESSMENT - Essential information from patient LUTS (including QoL Score) Other Urinary symptoms (eg hematuria) Previous pelvic surgery (eg Ant Resection) Neuropathy (eg Parkinsonis, MS,CVA) Cardiac Problems Diabetes Mellitus Fluid Intake & out put chart.

18. History Duration of retention Painfull? Precipitating factors Preceding LUTS Other urinary complaints Differential diagnosis Stage of disease Medical illnesses - co-morbidity

19. History Catheterization Easy Caliber Urine quantity / color Where / by whom TWOC

20. EVALUATION BPH symptom scoring AUA scoring (scoring chart)

21. AUA SOURCE Urinary Symptoms (Symptom Score Criteria) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost Always 1. Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0 1 2 3 4 5 2. Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0 1 2 3 4 5 3. Intermittency Over the past month, how often have you found you stopped and started again several times when you urinate? 0 1 2 3 4 5 4. Urgency Over the past month, how often have you found it difficult to postpone urination? 0 1 2 3 4 5

22. AUA SCORE Urinary Symptoms (Symptom Score Criteria) Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost Always 5. Weak Stream Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5 6. Straining Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5 None 1 time 2 times 3 times 4 times 5 or more times 7. Nocturia Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got in the morning? 0 1 2 3 4 5

23. AUA Symptom Score QUALITY OF LIFE DUE TO URINARY PROBLEMS Delighted Pleased Mostly Satisfied Mixed-about equally satisfied and un-satisfied Mostly dis-satisfied Unhappy Terrible If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? 0 1 2 3 4 5 6

24. ASSESMENT CLINICAL Per abdominal examination and DRE NORMAL DISTENDED BLADDER SIGNS OF RENAL FAILURE ALWAYS EXAMINE EXTERNAL URINARY MEATUS EPIDYDIMES FOR EPIDYDIMITIS DRE Prostate (size/symmetry/consistency), Anal Tone,Rectal masses

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

26. ASSESSMENT Lab & Other tests URINALYSIS / CS CBE BLOOD UREA & SERUM CREATININE U.S.G. RENAL TRACT (POST VOID URINE) CXR, ECG, RBS.

27. PSA ? Role of IVU ? Role of Urodynamics UROFLOWMETRY,PRESSURE FLOW STUDIES.

28. Investigations Cystoscopy

29. Retention 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

30. 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

31. 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

32. 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 Retract prepuse back Documentation of procedure Exam abdomen

33. Closed drainage system Antibiotecs Size of cath Leakage blocked / spasm

34. 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

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

36. 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

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

38. RENAL FAILURE PRE-RENAL (hypotention) Hypovolumia, hemmorhage,sepsis, cardiogenic shock, aneasthesia, hypoxiaa RENAL Drugs, poisons, contrast media, eclampsia, myoglobinuria, incompatible blood transfusion, DIC POST RENAL

39. Causes of post renal anuria Bilateral PUJ obstruction by stone Unilateral PUJ obstruction by stone with contralateral ureteric obstruction BILATERAL Ureteric Obstruction Extramural Tumors of cervix, ovary, uterous, vagina, urinary bladder, prostate, rectum, colon, caecum & lymphomas Idiopathic retroperitoneal fibrosis Retrocaval ureter Pararenal cysts Aberent vessels LIGATURES Intraluminal Calculus, sloughed papilla, clot, ureteric malignancy, CRYSTALURIA Intramural Congenital PUJ obstruction or stenosis Ureterocele and congenital small ureteric orifice Strictures ( stone, repair, tuberculosis, schistosomiasis) Ureteric / vecsical malignanncy Kenks & adhesions ( sec to VUR) Unilateral PUJ or ureteric obstruction in case of Contralateral nephrectomy Already obstructed or nonfunctional Congenitally absent

40. History taking Urge to void Duration Pain, hemaaturia, stone passage Symptoms of uremia Any precipitating event

41. Clinical exam Bladder not palpable Confirmed by cath Signs of uremia

42. Workup Urine usually not available for testing If ==urine osmolality, Na Urea, critinine Serum ellectrolite Arterial Blood gases Hb Xray and ultrasound KUB IUV usually contraindicated Retrograde Urography CT scan (contrast ???????) RENAL SCAN

43. Management SUPPORTIVE Renal support - dialysis Infection control Nutritional support Nursinng care Fluid balance BYPASS PROCEDURES Ureteric catheterization / stenting Nephrostomy PCN – percutaneous nephrostomy Open DEFINATIVE PROCEDURESSS

44. Dialysis Diffusion across semipermiable memb Dialyysis fluids Peritonneal Hemodialysis Indications A acidosis I intoxication O overload (fluid) U uremia P pericarditis P polyneuroathy