Approach to Acute Urinary Retention

Pathophysiology
1. Outflow obstruction
2. Disruption of sensory or motor nerve supply to detrusor muscle
3. Overdistension in the setting of inefficient detrusor
4. Medications

Causes
Mechanical
Extraluminal Intramural Intraluminal
 BPH  Bladder neck ca (TCC)  Stones
 Prostate ca  Urethritis  Strictures
 Faecal impaction  Urethral stricture (from prev. STD,  Blood clot
 Constipation Instrumentation)  FB
 Pelvic/GI/Retroperitoneal masses
 Pregnancy
 UV Prolapse/POP

Non-mechanical
Neurologic Drugs Others
 Diabetic peripheral neuropathy  Sympathomimetics  Acute prostatitis
 Radical pelvic surgery  Anticholinergics: TCA (e. coli, proteus)
 Spinal cord trauma  Prolonged immobility
 PD/MS/Normal pressure  Post-op complication
hydrocephalus/Shy Drager Syndrome

History
1. Presenting complaint – inability to void, suprapubic pain (severe ARU); note if painless inability to void, this suggests chronic retention instead
2. Any fever???
3. Current episode
4. Previous episodes
5. Previous UTI/STD/Stones
6. Precipitating event – recent surgery, new meds started, pelvic trauma, immobilisation, alcohol consumption, GU instrumentation
7. Obstructive sx – terminal dribbling, incomplete emptying, poor stream, straining to pass, hesitancy
8. Irritative sx – frequency, urgency, nocturia, haematuria, fever, dysuria
9. Med HX
10. Constitutional sx / Gross painless haematuria
11. Red glags - Back pain/trauma/LL weakness/numbness/ bowel incontinence/spinal dx

Physical
1. General appearance – any signs of uraemia (sallow appearance, scratch marks, pedal edema)
2. Abdomen – tenderness on deep suprapubic palpation, percussible bladder
3. Any other pelvic masses on palpation – fibroids, gravid uterus, ovarian cyst (female!!)
4. DRE – saddle anesthesia, anal tone, prostate enlargement (firm and smooth or hard and boggy), faecal impaction
5. Neuro exam – LL

Management
1. Rapid and complete decompression of bladder with 14F Foley catheter
2. If cannot pass past bladder neck, use thicker catheter (20F) which is stiffer to bypass enlarged prostate
3. If cannot pass but more proximally, use 10F cathter to pass by urethral strictures
4. If urethal catheterisation fails, do suprapubic catheterisation which requires LA 2fb above pubic symphysis then trocar-type suprapubic tube is
inserted into incision
- SP catheterisation is good for long-term drainage to prevent bladder neck and urethral dilatation (which predisposes to urinary
incontinence, stricture formation)
- Also better for prostatitis patients p/w fever, chills, tender prostate
5. Urinary obstruction + Fever = Urological emergency  Admit