2DefinitionAcute Urinary Retention refers to the inability to empty the bladderMost common in menIncreasing incidence with increasing age
3Case Study: History 1 67 yr old man PC 1) Unable to pass urine 2) Lower abdominal pain
4Case Study: History 2 HxPC 24 hours of inability to pass urine at will 4 yr Hx of prostatic symptoms.Patient c/o gradual worsening of prostatic symptoms over the past 2/12FrequencyNocturia x2-3 nightHesitancyPoor stream
5Case Study: History 3 12hrs of lower abdominal pain No dysuria Suprapubic painNo relieving/exacerbating factorsNo radiationNo dysuriaProstatic symptoms have been investigated over the past year last PSA was 1.9
6Case Study: History 4 PMHx Screen Nil else elicited Angina well controlled with medicationHTNOA kneesScreen Nil else elicited
13Differential Diagnosis Urinary retention can be secondary to a variety of causes:-BPHPrCaUTIProstatitisDrugs:AnticholinergicsAntidepressantsAnaestheticsIllicit drugs (particularly stimulants)EtOHConstipationPainCauda equina syndromeClot retention (2O to urinary tract malignancies or post-op)Urethral pathology
14DiscussionPoints in the history can give us clues as to the cause of the individuals retention………
15Discussion HxPC 24 hours of inability to pass urine at will 4 yr Hx of prostatic symptoms.Patient c/o gradual worsening of prostatic symptoms over the past 2/12FrequencyNocturia x2-3 nightHesitancyPoor streamIt is important to ask about prostatic symptoms as this could give you an indication as to whether the BPH or PrCa could be the cause of the retention.
16Ask about symptoms which might indicate a UTI as an underlying cause. Discussion12hrs of lower abdominal painSuprapubic painNo relieving/exacerbating factorsNo radiationO dysuriaProstatic symptoms have been investigated over the past year last PSA was 1.9Ask about symptoms which might indicate a UTI as an underlying cause.
17Discussion PMHx Screen Nil else elicited Angina well controlled with medicationHTNOA kneesScreen Nil else elicitedA detailed PMHx will help indicate whether there is any likelihood of other diseases contributing to the retention ie) any risk of cauda equina, autonomic neuropathies (more likely to be chronic retention), constipation, pain.
18Discussion DHx FHx Ramipril Aspirin Bendroflumethiazide GTN sublingual spray PRNParacetamol PRNNKDAFHxHx MI/Angina.The DHx is important as many drugs can cause urinary retention, particularly anticholinergics and antidepressants.
19Discussion SHx Ex smoker 20 pack year Hx, gave up 10 yrs ago EtOH Occasional, not in past weekIllicit Substances nilRetired office workerLives with wifeIndependentA good social history helps us to elicit whether EtOH consumption or drug abuse could have contributed to the development of retention. Be particularly aware of this in cases involving younger men with no other likely cause.
20Doing a DRE is essential, as it can identify:- DiscussionGIPalpable bladder to umbilicus, resonant to percussionSuprapubic tendernessNo organomegalyBS presentDRE: Smooth moderately enlarged prostate.Normal anal tone.Doing a DRE is essential, as it can identify:-BPH (enlarged, smooth), malignant prostate (craggy, hard) and can also help to identify other causes such as cauda equina syndrome (reduced anal tone, saddle anaesthesia).
21InvestigationsSome basic preliminary investigations may help narrow down the cause……
22Basic Investigations Bladder Scan Urine Dip + MSU This is done prior to catheterisation to identify the volume in the bladder to check that the patient is in fact in retention.Most individuals can hold up to 600mls before becoming significantly uncomfortableChronic retainers can hold much greater volumes, often up to 1l or more.Urine Dip + MSUTo identify infection and sensitivities
23Basic Investigations Bloods FBC:- an elevated white cell count might indicate underlying infectionU&E’s:- important to identify if there is any kidney damage from backpressure of urine due to the obstruction.PSA:- can be unreliable in the acute setting as will be raised by the very presence of retention as well as after DRE. However it is useful to identify the results from any previous PSA’s to aid in the differential diagnosis.
24TreatmentCatheterise using aseptic technique and appropriate Abx coverIM Gentamicin is the Abx of choice in this Trust.Record residual volume of urineMonitor for diuresis occurs due to:-Osmotic diuresis secondary to increased urea following retentionDiuresis of retained salt and H2OReduced concentration gradient in the Loop of Henlé after reduced flow rates in retention, which do not recover immediately after obstruction to the urinary tract is relieved.
25Further Investigations and Treatment Further treatment may include:-Abx for UTI’s and ProstitisTamsulosin 400 micrograms OD for BPHTWOC (trial without catheter) following underlying cause being treated.Further investigations may include:-Prostate biopsy (suspicion of malignancy)Renal Tract US (hydronephrosis)MRI L-S spine (cauda equina syndrome)Surgery (ie TURP for BPH/PrCa)
26Summary Acute retention is a common but easily treated condition There are a variety of common causes, most commonly BPH and UTI’s.It is important to fully investigate these causes and treat accordingly to prevent permanent damage to the urinary tract and prevent recurrence.