This is about retention of urine in general and BPH in particular

1. Urinary Retention
Professor Dr. Manzoor Ali
FRCS

2. Definition
 Inability to pass urine voluntarily
 There are multiple causes for urinary retention

3. Acute Retention
 Acute urinary retention (AUR) is the sudden inability to
pass urine. It is usually painful.

4. Chronic Retention
 Non painful bladder that remains palpable after voiding
 Inability to completely empty the bladder despite
maintaining an ability to urinate, which results in
elevated postvoidal residual urine (PVR) urine volumes

5. Causes of Urinary Retention
 Obstructive
 Inflammatory and Infectious
 Drug Induced
 Nuerological
 Other Causes

6. Obstructive Causes Common
to Males
 Benign Prostatic Hyperplasia
 Meatal Stenosis
 Paraphomosis
 Penile Constricting Bands
 Phimosis
 Prostratic Cancer

7. Obstructive Causes Common
to Females
 Organ Prolapse (cystocele, rectocele, uterine collapse)
 Pelvic mass (gynecologic malignancy, uterine fibroid,
ovarian cyst)
 Retroverted gravid uterus

8. Obstructive Causes Common
to Both Genders
 Bladder calculi
 Bladder neoplasm
 Fecal impaction
 Uretheral strictures
 Foreign bodies
 Stone in urethra
 G.I. malignancy
 Others

9. Inflammatory and Infectious
Men
 Balanitis
 Prostatitis
 Prostatic abcess
Women
 Acute Vulvovaginitis
 Vaginal lichen planus
 Vaginal lichen sclerosis
 Vaginal pemphigus

10. Inflammatory and Infectious
(both genders)
 Cystitis
 Echinococcosis
 Gullain-Barre Syndrome
 Herpes Simplex Virus
 Lyme Disease
 Periurethral Abcess
 Transverse Myelitis
 Tubercular Cystitis
 Urethritis
 Varicella-zoster virus
 Schistosomiasis

11. Drug-Induced (both acute and
chronic retention) 10% AUR
 Antichlolinergics (eg
antipsychotic, anti
depressants, etc)
 Opioids and anaesthetics
 Alpha-adrenoceptor
agonists
 Benzodiazepines
 NSAID’s
 Detrusor Relaxants
 Calcium-channel blockers
 Antihistamines
 Alcohol

12. Neurological
 Autonomic or peripheral nerve
 Autonomic neuropathy, diabetes mellitus, GB syndrome, pernicious
anemia, polio, radical pelvic surgery, spinal cord trauma, tabes dorsalis
 Brain
 MS, neoplasm, normal pressure hydrocephalus, Parkinson's disease
 Spinal Cord
 Intervertrebral disc disease, meningomyelocele, MS, spina bifida occulta,
spinal cord hematoma or abcess, spinal cord trauma, spinal stenosis,
transverse myelitis, tumor, cauda equina

13. Other Causes
 In Men – Penile trauma, fracture or laceration
 In women- Porpartum labor complications (prolonged
labor & C section urethral sphincter dysfunction) (Fowler
Syndrome)
 In both- Pelvic Trauma, iatrogenic, psychogenic

14. Features of Acute Retention
 Pain in Abdomen
 History of inability to pass urine
 Distended bladder on palpation

15. BPH (common cause of urine
retention)
 Symptoms Include:
 Frequency, urgency, nocturia, straining to void, weak
urinary stream, hesitancy, sensation of incomplete
bladder emptying and stopping and strating of urinary
stream (LUTS)

16. BPH
 Usually causes chronic retention but patient may come
with acute on chronic retention
 Some patients may be unaware of LUTS due to BPH

17. History Taking (Pay Attention to)
 Onset & Progression
 Fever
 Any previous episode of retention
 LUTS?
 Past medical history, neurological disease, medical
conditions
 Drug History
 Alcohol, constipation, long travel
 Low fluid intake & high fluid intake

18. Examination
 Fever
 Palpate abdomen for full bladder
 Look for phimosis, paraphimosis, meatal stenosis and
infection
 In females- look for cystocele, rectocele, UV prolapse,
Gravid Uterus
 Do a vaginal examination for pelvic mass
 Do DRE/PR in males to look for enlarged prostrate
 Neurological examination to detect neurogenic bladder

19. Lab Investigations
 FBC
 Urea & Electrolytes (U&E)
 Serum Creatinine
 Blood Glucose
 Prostrate Specific Antigen (PSA) this can be raised in AUR
although this is specific for prostatic cancer

20. Imaging Studies
 Ultrasound Scan for kidneys, ureter, bladder, prostrate
size, PVR and any mass
 CT Scan (abdominal and brain)
 MRI of the spine for neurological causes
 Cystoscopy
 Retrograde Cystourethrography
 Urodynamic Studies

21. Management
 AUR should be managed immediately
 Decompress distended bladder by a suitable catheter
 If urethral catheter fails, then pass suprapubic catheter
 In BPH keep the catheter for 2 weeks, and start alpha
blocker like Tamsulosin
 If prostrate is enlarged on DRE then start finasteride
 In neurogenic bladder train the patient on clean
intermittent self catheterization

22. Important Tips
(American Association of Family Physicians)
 Start alphablocker at the time of catheterization in AUR
 Give atleast one chance of TWOC before surgical intervention
 For TWOC patient should be able to pass urine in 4-6 hours after
taking plenty of fluids and should have less than 150ml of urine left
behind in urinary bladder (USS) to be allowed to go home
 Five alpha reductase inhibitors is used reduce the size of prostrate
 Use silicone coated catheters to avoid infection
 Give trial without catheter after 14 days of catheterization
 Catheterization should be done under complete aseptic conditions by
a doctor or a urology nurse who is fully trained for doing so.
 Supra pubic catheters should always be passed by a senior doctor

23. Types of Catheters
Latex Foley’s Catheter Silicone Foley’s Catheter

24. Contra Indications for
Catheterization
 Urethral Trauma
 Pelvic Fractures
 Blood at meatal tip
 High riding prostrate on DRE
 Scrota heamatoma

25. Surgery
 Prostrate
 Transurethral Resection of Prostrate (TURP)
 Transurethral Incision of Prostrate (TUIP)
 Microwave therapy
 Laser ablation
 Heat wave therapy
 Prostatic stent
 Transvesical Prostatectomy (TVP)
 Supra Pubic Prostatectomy (Millon’s)
 Perineal Prostatectomy (Obsolete now)

26. Surgery
 Treat phimosis, paraphimosis, urethral stricture
 Deal with stones in bladder and urethra
 Treat tumors accordingly
 In females- repair anterior/posterior vaginal wall in case
of cystocele and rectocele
 Carry out vaginal hysterectomy in case of UV prolapse
 Remove masses

27. Thank You