CLINICAL SCIENCE

SESSION

ACUTE URINARY RETENTION

Preseptor : dr. Liza Nursanti, Sp.B, M.Kes., FInaCS

Rifa Fitriani Dewi - 12100118190

KELOMPOK 13 GEL.1

SMF BEDAH
RS AL ISLAM
DEFINITION
• Painful inability to void, with relief of pain
following drainage of the bladder by
catheterization.
RISK FACTORS
• Age - Age over 70 years
• Symptom score — Use of the AUA symptom score (IPSS)
permits quantitation of symptom severity and monitoring
of symptom progression over time.
• Prostate volume — Prostatic volumes greater than 30 mL
as measured by trans rectal ultrasound have been
associated with AUR
• Urinary flow rate — Urinary flow rate of less than 12
mL/sec carries an RR of 3.9.
ETIOLOGY
• BPH — 53 percent
• Constipation — 7.5 percent
• Prostate cancer — 7 percent
• Urethral stricture — 3.5 percent
• Postoperative — 5 percent
• Neurologic disorder — 2 percent
• Medications/drugs — 2 percent
• Urinary tract infection — 2 percent
• Urolithiasis — 2 percent
• Miscellaneous — 16 percent
• AUR may also be related to a variety of other
factors
• Malignancy — bladder neoplasm, other tumors
causing spinal cord compression
• Phimosis or paraphimosis, which is prolonged
foreskin retraction with swelling of the glans
constricting the foreskin
• Pelvic masses
• Genitourinary infections — acute prostatitis,
urethritis, perianal abscess
• Other — anorectal manipulation, acute sickle crisis,
malpositioned indwelling urinary catheter.
PATHOPHYSIOLOGIC MECHANISM OF
AUR
1. BOO (Bladder out flow obstruction)
• Out flow obstruction by:
A. Mechanical
• Physical narrowing of the urethral channel
• Related to the volume of the prostate gland , other mass, or
stricture

B. Dynamic obstruction
• Refers to the tension within and around the urethra.
• When obstruction is caused by BPH
• Dynamic obstruction is caused by the prostate capsular tone
and smooth muscle tone within the prostate gland itself.
• Medications and other factors also play a role in selected
patients.
2. Neurologic impairment

• Occur due to interruption of sensory or motor nerve

supply to the detrusor muscle.
• This is most commonly seen in spinal cord injuries,
progressive neurologic diseases, diabetic neuropathy, and
cerebrovascular accidents.
• Less common, but important, neurologic causes include
epidural abscess and epidural metastasis, that can
compress the spinal cord and thereby cause urinary
retention as well as back pain and lower extremity
neurologic impairments
• 3. Over Distention

• Acute urinary retention may result when a precipitating

event results in an acute distended bladder in the setting
of an inefficient detrusor muscle
• This most often occurs in patients with obstructive urinary
symptoms at baseline, who are then subjected to an insult
to the lower urinary tract,
• such as a fluid challenge (eg, alcohol, intravenous
hydration), bladder distention during general anesthesia,
or epidural analgesia without an indwelling Foley catheter
• Medications — Multiple medications are implicated in the
cause of urinary retention, principally involving
anticholinergic and sympathomimetic drugs
CAUSE OF AUR
1) Urethral Stricture

• common in men with most patients

acquiring the disease due to injury or
infection
• The most common etiology for stricture is
iatrogenic injury due to urologic
instrumentation (eg, oversized resect scope
or the placement of indwelling catheters)
Urethral Stricture
• Caused by:
• Inflammatory
• Congenital
• Traumatic
• Instrumental ,
indwelling catheter and
endoscopy
• Post operative
• Open prostectomy
• Amputation of penis
Etiology of urethral stricture
Urethral Injury
• Posterior Urethra

• Nearly always associated with pelvic fracture

• Crush, blunt, penetrated or iatrogenic
• Associated bladder injection
• Blood at meatus
• Failure to void
• Full bladder
• Perineal swelling
• Displaced prostate- DRE
• Classes of injury
• Complete or partial
• Difficult to say which
• Further classes based on radiograph

• Management (Immediate)
• Stretch - indwelling cath until able to void
• Partial tear –careful! attempt - SPC then voiding CUG
• Management • Complications
• Complete • Stricture
• immediate “indirect”/ • Incontinence
endoscopic cath with SPC • impotence
• SPC drainage,
ante/retrograde eval’n

• Later
• Urethrotomy
• open urethropasty
• endoscopic repair
Anterior urethra

• Rare & isolated • Initial managemnt

• Bulbar urethra >> • SPC diversion alone +/-
• Stradle injury
debridement
• Primary surgical repair
• Direct blow
• Shaft fracture during
activity • Definitive
• Pelvic fracture • Rethrograde & voiding
• Penet. injury • urethrotomy
• blood at meatus • anstomotic urethroplasty
• Unable to void
• Urethrograpy
• Perin./penile echimosis
Diagnosis
• Urethroscopy
• Urethrography
Treatment
• Dilation with elastic or
metallic boogie
Urethrotomy , internal
visual incision of
stricture
• Urethroplasty, Excision
and end to end
anastomosis, patch
urethroplasty
Complication
• Retention of urine
• Urethral diverticulum
• Peri-urethral abscess
• Urethral fistula
• Rectal prolapse
2. Benign Prostatic Hyperplasia
• BPH occurs in men over 50 years of age;
• By the age of 60 years
• 50 per cent of men have histological evidence of BPH
and
• 15 per cent have significant lower urinary tract
symptoms
ETIOLOGY
• Unknown
• Aging
• Hormonal effects
• Androgen is important for both normal & abnormal growth of the
prostate
• 90% of prostatic androgen is in form of DHT( from testicular
androgen & 10% from adrenal androgen)
• Stromal – epithelial cells interaction produce growth factors
(epidermal GF, insulin like GF,fibroblast GF)
• Increased estrogen increase the expression of AR in aging prostate
& increase prostate size
Pathogenesis (Gland Enlargement)
• Occurs as results of increased Number of epithelial &
stromal cell ( increased cell proliferation)
• Disruption of equilibrium between cell death & cell
proliferation(decreased in cell death)
• Androgen requiring during development, puberty,& aging
• Castrated men or no androgen results no BPH
Common Symptoms
• Prostatism = LUTS • Irritative
• Frequency
• Classified in to:
• Urgency
• obstructive • Urge incontinency
• Weak urine stream • enuresis
• Difficulty starting urination
• Dribbling
• Needing to urinate several
times
• Straining
• Sensation poor bladder
emptying
• Scoring system IPSS (international prostate symptom score )
AUA
• Used for assessment of symptom severity
• Assess the response to therapy
• Detect symptom progression ( in watchful waiting Rx)

• Can not used to establish the DX of BPH (infections,tumor, bladder

disease will have a high ipss)
• According to IPSS
• 0-9 mildly symptomatic
• 8-19 moderately symptomatic
• 20-35 severely symptomatic
Effects of BPH
• Initially bladder becomes hypertrophied
• Increase postvoidal residuals ,poor contractility
• LUTS & Boo
• Urinary retention
• Hematuria, urinary infection
• Stone formation, trabeculation
• Bladder irritability, renal insufficiency
Diagnosis of BPH
• To pathologist is microscopic Dx (cellular proliferation of
stomal & epithelial elements)
• To radiologist makes the Dx in presence of bladder neck
elevation of cystogram phase of IVP or enlarged prostate
• To urodynamist -elevated voiding pressure -low urinary
rate
• To practicing urologist is constellation of sign & symptom
• History
• onset of the symptoms
• Age
• History of STD
• Determine which symptoms are predominant (irritative or
obstructive)
• Determine severity of the symptoms by IPSS)
• History of hematuria, UTI, diabetis, NS disease, urinary
retention, surgery of LUT
• P/E
• general assessment (chest,cvs,anemia,external
genitalia)
• Abdominal examination
• Bladder distention
• Dullness
• Tenderness
• DRE
- prostate size, consistance, noduls
- pelvic floor tone flactuance & pain
- prostate size does not correlate with symptoms
severity & degree of urodynamic obstruction & Rx outcome
• Prostate is large, smooth, convex, elastic, firm, mucosa
moves over the prostate
• Ns examination (r/o cavaequina lesions)
• U/A–dipstick & /or via centrifuged sediment for
blood,bact,prot,glucos
• cytology for severe irritable symptom
• urine culture
• PSA to R/o prostatic Ca which can coexist with
BPH
• Large BPH may have slightly elevated PSA
• PSA value >4ng/ml or DRE induration or nodularity
needs transrectal us & multiple biopsy
• PSA & DRE increase the detection rate of prostate Ca
over DRE alone
• Serum creatinine to R/o Renal insufficiency occurs in 13%
of case
• BPH with Renal Insufficiency increase the risk of post.op.
complication with RI 25%, 17% without RI
• Help to evaluate the pt.with occult & progressive renal
damage secondary to silent prostatism
• Postvoidal residual urine
• obtained after voiding of urine with a catheter transabdominal us
• NV= less than 5 ml (78%), less than 12ml(100%)
• Pressure flow studies
• done to distinguish b/n low pressure flow rate secondary to Boo &
decompensated bladder
• Reliable if Boo not Dxed by flow rate, initial evaluation & PVR

• uroflometry
• electrical recording of the urine flow rate -noninvasive urodynimic
test
• quantifies strength of urine stream
• 2 to 3 voids with voided volume 150 to 200ml in flow rate clinic
Treatment
• Watchful waiting: In patients with mild symptoms.

• Medical treatment
• 1. Alpha reductase inhibitor: affects the epithelial
component of the prostate, resulting in reduction in the
size of the gland and improvement in symptoms.
• 2. Alpha-adrenoceptor blocker: affect subtype alpha-1
adrenoreceptors. (dynamic component of obstruction).
• 3. Combination.

• Surgical treatment: Minimally invasive or open.

Indications of Surgical Intervention
• A- Absolute • B- Relative indications:
indications: • Moderate symptoms
• Upper urinary tract (moderate IPSS score).
affection. • Recurrent UTI.
• Uremia • Hematuria.
• Recurrent attacks of • Stone bladder.
acute retention.
• Severe obstructive
symptoms (high IPSS
score).
Minimally – Invasive Surgery
• Transurethral resection of the prostate.
• Transurethral incision of the prostate
• Transurethral needle abelation
• Ballon dilatation.
• Transurethral microwave treatment.
• Intraprostatic stents.
Open Surgery (Prostatectomy)
• Transvesical • Contraindication
• Transurethral • Small fibrous gland
• The presence of prostate
• Retropubic
cancer
• Perineal
• Previous prostatectomy
• Pelvic surgery that
obliterate access to the
prostate gland
Complications
• Bleeding
• urethral catheter traction with 50ml of saline to
compress the bladder neck & prostatic fossa
• bladder irrigation to prevent clot formation
• the inflow through urethral catheter &out flow through
the suprapubic tube
• if the bleeding persist cystoscopic inspection of the
prostatic fossa &bladder neck
• if marked bleeding continue to persist →open re-
exploration
• Perforation of the bladder & prostatic capsule (IN TURP)
• Incontinency (if damaged external sphincter mechanism)
• Retrograde ejaculetion (80-90%) & impotence (3-6% due
to damage of the nerves associated with erection)
• Bladder neck contracture
• Urethral stricture
• Sepsis
• Death (0.2 to 0.3%)
• TUR-syndrome
• In 2% of all TURP
• Due to absorption irrigating fluid through cut open veins
• Characterized by (hyponatremia →↓Na+ ,HPT,nauesa&
vomiting,bradicardia,visual disturbance,mental
confusion)
• Risk factors (gland>45gm,↑resection time >90mnt &
much fluid for irrigation RX diuretics &correct
electrolytes
3. Nephrolithiasis / urolithiasis
• Stone formation in the kidney
• Affect about 4-15% of population
• Males are more commonly affect
• Multifactorial in etiology
Risk factors for stone formation
• Low urine volume
• Hypercalciuria
• Hyperoxaluria
• Hyperuricosuria
• Dietary factors
• Low fluid intake
• Types of fluid intake – sodas, apple juice, grapefruit juice
• High sodium chloride intake
• High pritein intake
• Low calcium intake
• History of prior nephrolithiasis
• Hyperoxaluria (enteric hyperoxaluria, short bowel syndrome)
• Type I renal tubular acidosis
Pathophysiology
• Randal’s plaque
• Supersaturation
• Decreased inhibitors
Types of stones
Clinical Presentation
• Asymptomatic
• Flank pain
• Hematuria
• Flank mass (Hydronephrosis)
• Hematuria
• Ureteric colic
• Passage of stone
• Symptoms of UTI
• Ureteric colic
• There is a pattern of severe exacerbation on a
background of continuing pain
• Radiates to the groin, penis, scrotum or labium as the
stone progresses down the ureter
• The severity of pain is not related to the size of the
stone
• The pain is almost invariably associated with
haematuria
• There may be few physical sign
Management
• Conservative
• Adequate hydration
• Dietary modification
• Medical treatment of underlying conditions
• follow up U/S

• Surgical
• Indications
• Failed expectant treatment
• Large stone size
• Evidence of obstruction
• Presence of infection
• Non functioning kidney with pain and stone
• Minimally Invasive
• I. ESWL
• II. PNL (Percutaneous nephrolithotomy)

• Open surgery
• I. Pyelolithotomy
• II. Extended pyelolithotomy
• III. Nephrolithotomy
• IV. Nephrectomy
Clinical Manifestations of AUR
• AUR presents as the abrupt inability to pass urine.
• lower abdominal and/or suprapubic discomfort
• patients are often restless, and may appear in considerable
distress
• AUR is superimposed upon chronic urinary retention
• Chronic urinary retention is most often painless
• presence of hematuria, dysuria, fever, low back pain,
neurologic symptoms, or rash.
• Younger patient age, a history of cancer or intravenous drug
abuse, and the presence of back pain or neurologic symptoms
suggest the possibility of spinal cord compression.
• Finally, a complete list of prescribed and over the counter
medications should be obtained.
Physical Examinations
• Previous history of retention, prostate cancer, surgery,
radiation, or pelvic trauma.
• Lower abdominal palpation — The urinary bladder may be
palpable, either on abdominal or rectal examination. Deep
suprapubic palpation will provoke discomfort.
• Rectal examination —A rectal examination should be done in
both men and women, to evaluate for masses, fecal impaction,
perineal sensation, and rectal sphincter tone. A normal prostate
examination does not preclude BPH as a cause of obstruction.
• Pelvic examination — Women with urinary retention should
have a pelvic examination.
• Neurologic evaluation — The neurologic examination should
include assessment of strength, sensation, reflexes, and
muscle tone.
Investigations
• Urine analysis
• CBC
• Serum electrolytes
• RFT and LFT
• Ultrasound if pelvic mass suspected
• cystoscopy
Acute Management – Initial Management of
AUR
• Management of acute urinary retention (AUR) involves prompt
bladder decompression
• accomplished with urethral or suprapubic catheterization
• Patients who have had recent urologic surgery (eg, radical
prostatectomy or urethral reconstruction) and develop acute
retention should not have urethral catheterization
• Emergency drainage : Emergency drainage of the bladder in
acute retention may be undertaken by:
• Urethral catheterization
• Suprapubic puncture
• Suprapubic cystostomy.
• Urethral catheterization or bladder puncture is usually adequate,
but
• cystostomy may become necessary for the removal of a bladder stone
or foreign body, or for more prolonged drainage, for example after
rupture of the posterior urethra or if there is a urethral stricture with
complications
Surgical Therapy
Definitive treatment of AUR.
symptomatic patients with BPH, transurethral resection of
the prostate (TURP)
Transurethral resection of the prostate remains the gold
standard
ALHAMDULILLAH
Terima kasih 