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)
Etiology
- 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
- Prostate gland:
- Benign prostatic hypertrophy
- Carcinoma
- Prostatitis
- Contracture of bladder neck
- Prostatic infarction
- Neurologic causes:
- Motor/paralytic:
- Spinal shock
- Spinal cord syndromes
- Sensory/paralytic:
- Diabetes
- Multiple sclerosis
- Spinal cord syndromes
- Drugs:
- Antihistamines
- Anticholinergics
- Antispasmodics
- Tricyclic antidepressants
- α-Adrenergic stimulators
- Narcotics
- NSAIDs
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 catheter
- If unable to pass a 14 " 18F catheter and there is a history of prior transurethral procedure or known stricture, downsize to a 10 " 12F
- In men with no prior instrumentation and unable to pass catheter, consider a 20 " 22F catheter with a coude tip
- If 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 significant
- Postobstructive diuresis:
- Can be a complication of AUR in the catheterized patient
- No randomized trials comparing rapid and intermittent bladder decompression
- It 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)