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Acute Urinary Retention Laura Oakley FY1 Urology.

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Presentation on theme: "Acute Urinary Retention Laura Oakley FY1 Urology."— Presentation transcript:

1 Acute Urinary Retention Laura Oakley FY1 Urology

2 Definition Acute Urinary Retention refers to the inability to empty the bladder Most common in men Increasing incidence with increasing age

3 Case Study: History 1 67 yr old man PC 1) Unable to pass urine 2) Lower abdominal pain

4 Case 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 2/12  Frequency Nocturia  x2-3 night Hesitancy Poor stream

5 Case Study: History 3 12hrs of lower abdominal pain Suprapubic pain No relieving/exacerbating factors No radiation No dysuria Prostatic symptoms have been investigated over the past year  last PSA was 1.9

6 Case Study: History 4 PMHx Angina  well controlled with medication HTN OA knees Screen  Nil else elicited

7 Case Study: History 5 DHx Ramipril Aspirin Bendroflumethiazide GTN sublingual spray PRN Paracetamol PRN NKDA FHx Hx MI/Angina.

8 Case Study: History 6 SHx Ex smoker  20 pack year Hx, gave up 10 yrs ago EtOH  Occasional, not in past week Illicit Substances  nil Retired office worker Lives with wife Independent

9 Case Study: Examination Observation Patient uncomfortable, but alert and orientated. HR = 86 regular T = 36.4 BP = 138/74 RR = 18

10 Case Study: Examination CVS HS I + II + 0 JVP  Ankles = some mild ankle oedema Resp Chest clear Air entry good and equal bilaterally No added sounds

11 Case Study: Examination GI Palpable bladder to umbilicus, resonant to percussion Suprapubic tenderness No organomegaly BS present DRE: Smooth moderately enlarged prostate. Normal anal tone.

12 Case Study: Examination Neuro Power 5/5 Sensation N, perineal sensation normal Reflexes N Tone N Bladder scan ~ 750 mls

13 Differential Diagnosis Urinary retention can be secondary to a variety of causes:- BPH PrCa UTI Prostatitis Drugs: Anticholinergics Antidepressants Anaesthetics Illicit drugs (particularly stimulants) EtOH Constipation Pain Cauda equina syndrome Clot retention (2 O to urinary tract malignancies or post-op) Urethral pathology

14 Discussion Points in the history can give us clues as to the cause of the individuals retention………

15 Discussion 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 2/12  Frequency Nocturia  x2-3 night Hesitancy Poor stream It 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.

16 Discussion 12hrs of lower abdominal pain Suprapubic pain No relieving/exacerbating factors No radiation O dysuria Prostatic symptoms have been investigated over the past year  last PSA was 1.9 Ask about symptoms which might indicate a UTI as an underlying cause.

17 Discussion PMHx Angina  well controlled with medication HTN OA knees Screen  Nil else elicited A 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.

18 Discussion DHx Ramipril Aspirin Bendroflumethiazide GTN sublingual spray PRN Paracetamol PRN NKDA FHx Hx MI/Angina. The DHx is important as many drugs can cause urinary retention, particularly anticholinergics and antidepressants.

19 Discussion SHx Ex smoker  20 pack year Hx, gave up 10 yrs ago EtOH  Occasional, not in past week Illicit Substances  nil Retired office worker Lives with wife Independent A 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.

20 Discussion GI Palpable bladder to umbilicus, resonant to percussion Suprapubic tenderness No organomegaly BS present DRE: 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).

21 Investigations Some basic preliminary investigations may help narrow down the cause……

22 Basic Investigations Bladder Scan 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 uncomfortable Chronic retainers can hold much greater volumes, often up to 1l or more. Urine Dip + MSU To identify infection and sensitivities

23 Basic Investigations Bloods  FBC:- an elevated white cell count might indicate underlying infection U&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.

24 Treatment Catheterise using aseptic technique and appropriate Abx cover IM Gentamicin is the Abx of choice in this Trust. Record residual volume of urine Monitor for diuresis  occurs due to:- Osmotic diuresis secondary to increased urea following retention Diuresis of retained salt and H 2 O Reduced 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.

25 Further Investigations and Treatment Further treatment may include:- Abx for UTI’s and Prostitis Tamsulosin 400 micrograms OD for BPH TWOC (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)

26 Summary 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.


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