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Urinary Retention, Emergency Medicine

Basics

Description

- Acute urinary retention (AUR): - Sudden inability to void spontaneously - Occurs most frequently in men >60 yr old - Most common cause of AUR in the ED is benign prostatic hyperplasia (BPH)

- Multiple diagnostic considerations, following list is not exhaustive - Anatomic: - Penis: - Phimosis - Paraphimosis - Meatal stenosis - Foreign-body constriction

- Urethra: - Tumor - Pelvic masses - Prolapse of pelvic organs - Foreign body - Calculus - Urethritis - Stricture - Meatal stenosis (can also be seen in females) - Hematoma - Vulvar edema after vaginal delivery

- Sensory/paralytic: - Diabetes - Multiple sclerosis - Spinal cord syndromes

  • Acute urinary retention (AUR):Sudden inability to void spontaneouslyOccurs most frequently in men >60 yr oldMost common cause of AUR in the ED is benign prostatic hyperplasia (BPH)

Etiology

  • Multiple diagnostic considerations, following list is not exhaustive
  • Anatomic:Penis:PhimosisParaphimosisMeatal stenosisForeign-body constrictionUrethra:TumorPelvic massesProlapse of pelvic organsForeign bodyCalculusUrethritisStrictureMeatal stenosis (can also be seen in females)HematomaVulvar edema after vaginal deliveryProstate gland:Benign prostatic hypertrophyCarcinomaProstatitisContracture of bladder neckProstatic infarction
  • Neurologic causes:Motor/paralytic:Spinal shockSpinal cord syndromesSensory/paralytic:DiabetesMultiple sclerosisSpinal cord syndromes
  • Drugs:AntihistaminesAnticholinergicsAntispasmodicsTricyclic antidepressantsα-Adrenergic stimulatorsNarcoticsNSAIDs

Diagnosis

Signs and Symptoms

  • Lower abdominal or suprapubic discomfort
  • Patients may appear restless or in distress
  • Chronic urinary retention usually painless

History

  • Past medical history:History of urinary retention?History of BPH or prostate cancer?History of other cancer?History of radiation treatment?History of pelvic trauma?
  • Any signs or symptoms of infection including an abscess?
  • Any signs or symptoms of calculus?
  • Any neurologic symptoms?
  • History of or current IV drug abuse?
  • Back pain?
  • Complete list of all medications

Physical Exam

  • Vitals (Any evidence of infection? Shock?)
  • Abdominal exam
  • Rectal exam
  • Genitourinary exam; consider pelvic exam in all women
  • Thorough neurologic exam if appropriate
  • In the trauma patient, evaluate for evidence of urethral injury

Essential Workup

Due to the multiple causes of AUR a thorough history and physical exam are imperative, and will determine further workup

Diagnosis Tests & Interpretation

Lab

  • Basic chemistry to assess renal function only if concerned for acute renal insufficiency (this usually does not occur in AUR)
  • No benefit to PSA test in ED; usually elevated in setting of AUR
  • Urinalysis if indicated on history or exam

Imaging

  • Abdominal or pelvic US or CT abdomen/pelvis if concerned for mass, malignancy, abscess, bladder calculi, or other anatomic etiologic agent
  • Neuro or spinal imaging if there is concern for an acute neurologic process

Diagnostic Procedures/Surgery

Postvoid residual: More than 200 mL is usually considered abnormal.

Differential Diagnosis

Chronic urinary retention

Treatment

Pre-Hospital

Address any life-threatening presentation

Initial Stabilization/Therapy

  • Identify and treat any life-threatening presentation
  • Prompt bladder decompression:Try placement of 14 " 18F urinary catheterIf unable to pass a 14 " 18F catheter and there is a history of prior transurethral procedure or known stricture, downsize to a 10 " 12FIn men with no prior instrumentation and unable to pass catheter, consider a 20 " 22F catheter with a coude tipIf unable to pass a catheter, then either suprapubic aspiration as a temporizing measure or placement of suprapubic catheter is indicated
  • Defer catheterization of the ureter in the trauma patient suspected of having a ureteral injury (gross hematuria, high-riding prostate on rectal exam, blood at the meatus) until a retrograde urethrogram has been done

Ed Treatment/Procedures

  • Drain bladder and monitor urine output:Rapid decompression following catheter placement may result in transient gross hematuria, rarely clinically significantPostobstructive diuresis:Can be a complication of AUR in the catheterized patientNo randomized trials comparing rapid and intermittent bladder decompressionIt is generally now felt that rapid bladder decompression is safe provided that supportive care is available if hypotension develops
  • Probably best to observe for 2 " 3 hr after bladder decompression to ensure that a postobstructive diuresis does not cause clinical deterioration
  • Place leg catheter bag before discharge if catheter is to remain indwelling
  • Educate patient and family on catheter care.
  • Although commonly used, prophylactic antibiotics are not indicated for patients with an indwelling urinary catheter and no evidence of infection
  • Start patients with BPH on anα-blocker
  • Consider stopping any medication that may be contributing to AUR
  • Treat constipation if appropriate

Medication

  • Prazosin HCl (Minipress) for treatment of BPH: Initially 1 mg PO BID to TID, slowly increase to 20 mg/d in div. doses
  • Tamsulosin (Flomax) is anα-1 antagonist used to treat BPH: 0.4 mg PO QD after the same meal daily; may increase to 0.8 mg PO QD
  • Alfuzosin (Uroxatral) is anα-blocker used to treat BPH: 10 mg PO daily after the same meal each day
  • Terazosin (Hytrin) facilitates urinary flow in the presence of BPH: Start 1 mg PO QHS, max. 20 mg/d

Follow-Up

Disposition

Admission Criteria

  • Significant postobstructive diuresis requiring IV fluids or pressors
  • Sepsis
  • Obstruction related to spinal cord compression
  • Consider in patient with obstruction due to malignancy or mass
  • Any process requiring acute urologic or surgical intervention

Discharge Criteria

Most patients can be discharged

Followup Recommendations

Most patients will need follow-up for ongoing evaluation and management of AUR as well as catheter management

Pearls and Pitfalls

  • Carefully evaluate for evidence of a mass or malignancy as the cause of AUR.
  • Carefully evaluate for evidence of spinal cord compression as the cause of AUR.
  • Take a thorough drug history including over-the-counter medications, especially if no other clear reason for AUR.

Additional Reading

  • Barrisford GW, Steele GS. (2012, Apr 27) Acute Urinary Retention. Retrieved from www.uptodate.com.
  • Rochelle JL, Shuch B, Belldegrun A. Urology. In: Brunicardi FC, Andersen DK, Billiar TL, et al. Schwartzs Principles of Surgery. New York, NY: McGraw Hill; 2009.
  • Tintinalli JE, ed in chief. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. McGraw-Hill Medical Publishers; 2011.

See Also (Topic, Algorithm, Electronic Media Element)

UTIs

Codes

ICD9

  • 598.9 Urethral stricture, unspecified
  • 600.91 Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS)
  • 788.20 Retention of urine, unspecified
  • 594.2 Calculus in urethra
  • 605 Redundant prepuce and phimosis
  • 788.29 Other specified retention of urine

ICD10

  • N35.9 Urethral stricture, unspecified
  • N40.1 Enlarged prostate with lower urinary tract symptoms
  • R33.9 Retention of urine, unspecified
  • N21.1 Calculus in urethra
  • N47.1 Phimosis

SNOMED

  • 267064002 Retention of urine (disorder)
  • 236646007 Benign prostatic hypertroph with outflow obstruction (disorder)
  • 76618002 Urethral stricture (disorder)
  • 20342001 calculus in urethra (disorder)
  • 449826002 Phimosis (disorder)