Acute urinary retention

Background

• Urologic emergency characterized by sudden inability to pass urine
• Most common cause is benign prostatic hyperplasia (BPH)
• Rare in women

Clinical Features

• Lower abdominal distention / pain
• Frequency, urgency, hesitancy, dribbling, decrease in voiding stream

Differential Diagnosis

• Obstructive causes
  • BPH
  • Prostate cancer
  • Blood clot
  • Urethral Stricture
  • Bladder Calculi
  • Bladder neoplasm
  • Foreign body, urethral or bladder
  • Ovarian/uterine tumor
• Neurogenic causes
  • Multiple sclerosis
  • Parkinson's
  • Brain tumor
  • Cerebral vascular disease
  • Cauda equina syndrome
  • Metastatic spinal cord lesions
  • Intervertebral disk herniation
  • Neuropathy
  • Nerve injury from pelvic surgery
  • Postoperative retention
• Trauma
  • Urethral injury
  • Bladder injury
  • Spinal cord injury
• Extraurinary causes
  • Perirectal or pelvic abscesses
  • Rectal or retroperitoneal masses
  • Fecal impaction
  • Abdominal Aortic Aneurysm
• Psychogenic causes
  • Psychosexual stress
  • Acute anxiety
• Infection
  • Cystitis
  • Prostatitis
  • Herpes Simplex (genital)
  • Herpes Zoster involving pelvic region
  • Local Abscess
  • PID
• Meds
  • Anticholinergics
  • Antihistamines
  • Cold meds
  • Sympathomimetics
  • TCA
  • Muscle relaxants
  • Opioids

Evaluation

• UA/Urine cultures
• Chemistry
• CBC (if suspect infection or massive hematuria)
• Bedside US (to verify retention)
  • Incomplete retention is PVR > 50ml and > 100ml in patients > 65 years of age
  • Post-void residual of 150-200 cc is particularly concerning

Management

• Bladder Decompression
  • Urethral catheterization
    • Pass 14-18F Foley catheter (larger if blood clots)
      • If unable to pass Foley try Coude Catheter
    • If catheterization produces gross blood remove catheter and do not attempt reinsertion
      • Creation of false tract in penile soft tissue requires immediate urology consult
  • Suprapubic catheterization
    • Consider if urethral catheterization fails
    • US-guided results in low complication rate
      • Visualize the needle in the bladder before inserting the catheter
• Blood clot
  • Use 20-24F triple-lumen catheter to irrigate bladder until clear
• Voiding trial
• Alpha-blocker (outpatient) - Tamsulosin 0.4mg qday
  • Results in significant increase in voiding success
  • Possibility of hypotension with med use
• Bladder spasm
  • Oxybutinin 2.5mg TID
    • Note: Anticholinergic so can cause urinary retention
• Urology consult
  • Consider for precipitated retention (stricture, prostatitis, cancer)

Disposition

• Consider admission for:
  • Postobstructive diuresis >200cc/hr
  • Elevated BUN/Cr
  • Clot retention
  • Hematuria
  • Neurologic cause
• Otherwise consider discharge with catheter and urology follow up in 1 week

See Also

• Coude catheter