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Editors
Urinary Retention
Essentials
- Acute symptomatic urinary retention must be treated immediately at the health care setting where the patient is first encountered.
- Considerable retention (above 1 000 ml) should be treated by cystostomy, indwelling catheter, or repeated catheterization.
- Consider the patient's medication as a potential cause of retention (anticholinergic and sympathomimetic drugs).
Symptoms and signs
- Lower abdominal pain (often absent in slowly developing retention)
- Overflow incontinence or increased urinary frequency
- Enlarged palpable bladder
- Enlarged bladder by percussion
Aetiology
- Benign prostatic hyperplasia Benign Prostatic Hyperplasia (BPH; suggested by age and DRE finding)
- Postoperative retention
- Urethral stricture
- Urethral mucosal prolapse, uterine prolapse or myoma in women
- Neurogenic causes (spinal cord injury, intervertebral disc herniation, multiple sclerosis, diabetes, neuropathy caused by alcohol or toxic substances)
- Functional causes (pain, tension, exposure to cold)
- Drugs
- Anticholinergic drugs
- Sympathomimetics, oral decongestants (pseudoephedrine) used mainly for rhinitis
- Tricyclic antidepressants
Treatment
- Before commencing treatment, ultrasonography (video Residual Urine Volume (Ultrasonography)) should be performed first to assess the volume of retention if it seems not to be considerably large and the examination can be performed without delay Determining the Volume of Residual Urine by Ultrasonography.
- Perform single catheterization if
- the bladder seems not to be tense
- in postoperative retention more than 6 hours have elapsed since last voiding and the patient is unable to void despite encouragement and analgesics.
- Suprapubic cystostomy is recommended as the first procedure if
- the retention is large (above 1000 ml according to ultrasonography or the bladder reaches the navel)
- the patient has a complicated urethral stricture
- a large prostate has caused difficulties in catheterization earlier
- or if recurrent retention occurs after treatment with single catheterization.
- The cystostomy catheter can be removed when voiding is repeatedly successful and the residual urine is less than 200 ml. The patient should be given clear instructions on bladder training by regular closing of the catheter.
- A large retention without anatomical catheterization problems can be treated with an indwelling silicone catheter Catheterization of the Urinary Bladder and Suprapubic Cystostomy. Aim at removing the catheter within 3 days.
- The whole volume can be emptied at one time. In a cardiac patient who is in poor general condition, however, the bladder should be emptied slowly, over about 15 minutes, in order to prevent excessive venous return from the pelvis. In the final phase of emptying, the urine may be bloody because of small tears on the bladder mucosa caused by over-distension. The amount of blood in the urine will usually decrease with time.
- Drug treatment Drugs for Treatment of Urinary Retention after Surgery in Adults
- For indications for surgical treatment see Benign Prostatic Hyperplasia.
Further investigations
- In most cases (80%) of BPH-related retention the episode is the first occurrence of retention and therefore warrants follow-up.
- A cleanly voided urine specimen and bacterial culture should be taken from all patients.
- No other investigations are necessary if the patient had his first retention and there is a predisposing factor, e.g. alcohol, exposure to cold, postoperative state, or bed rest associated with an acute illness.
- Retention without an evident cause and recurrent retention are indications for the following laboratory examinations: plasma creatinine, blood glucose, and, in men, plasma prostate-specific antigen (PSA).
- If an increase of plasma creatinine concentration during retention was due to obstruction it normalizes rapidly.
- Retention and catheterization raise PSA concentration. If the value is elevated, it should be controlled after 3-4 weeks.
- Further urological investigations are indicated in recurrent urinary retention.
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