Diferencia entre revisiones de «Acute urinary retention»

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== Background ==
==Background==
[[File:Urinary system.png|thumb|'''(1) Human urinary system:''' (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra. <Br>'''Additional structures:''' (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.]]
[[File:2605 The Bladder.jpg|thumb|Anatomy of the male bladder, showing transitional epithelium and part of the wall in a histological cut-out.]]
*Urologic emergency characterized by sudden inability to pass urine
*Most common cause is [[benign prostatic hyperplasia]] (BPH)
*Rare in women


*Urinary retention is the inability to void resulting in bladder distention
==Clinical Features==
*Symptoms include frequency, urgency, hesitancy, dribbling, decrease in voiding stream  
[[File:Urinary retention.jpg|thumb|Patient with acute urinary retention and dramatic bladder distention.]]
*A sense of incomplete emptying
*Suprapubic abdominal distention and/or pain
*Most commonly affects adult men 2/2 BPH, however must exclude neurologic disease (ie Cord compression)
*Frequency, urgency, hesitancy, dribbling, decrease in voiding stream
**Common causes: BPH, prostatic carcinoma, bladder carcinoma, urethral stricture, spinal cord disease or trauma, and blood clots
**Uncomon causes: phimosis, paraphimosis, urethritis, urethral calculus, foreign body, medications(primarily anticholinergics but also narcotics, phenothiazines, sympathomimetics, cyclic antidepressants, antihistamines, antihypertensives, and muscle relaxants)


== Work-Up ==
==Differential Diagnosis==
*UA, UCX, CBC, Chem Panel
{{Urinary retention DDX}}
*Complete GU/Rectal exam
{{DDX abdominal distention}}


== Treatment ==
==Evaluation==
*Bladder Decompression
[[File:Ultrasound of trabeculated urinary bladder.jpg|thumb|Ultrasound of distended from urinary retention. Note trabeculated wall, which is a sign of urinary retention.]]
**Pass 16F Foley catheter(larger if large blood clots)
[[File:Harnverhalt.jpg|thumb|Bladder distension from acute urinary retention seen on CT.]]
**If unable to pass Foley catheter, try a 16F [[Coude catheter]]
*[[UA]]/Urine cultures
**If still unable, try a smaller size, obtain urologic consult, or perform suprapubic catherization
*Chemistry
*CBC (if suspect infection or massive hematuria)
*Bedside [[ultrasound]] (to verify retention)
**Incomplete retention is PVR > 50ml and > 100ml in patients > 65 years of age<ref>Shenot PJ. Urinary Retention. Merck Manual. August 2014. http://www.merckmanuals.com/professional/genitourinary-disorders/voiding-disorders/urinary-retention</ref>
**Post-void residual of 150-200 cc is particularly concerning


== Disposition ==
==Management==
*Consider admission to Urology if uncontrolled pain, obstruction with infection, or inability to clear large clots
===Bladder Decompression===
*Pt with obstructive uropathy, go home with catheter and leg drainage bag
*Urethral catheterization
*Follow up with Urology within 1 week
**Pass 14-18F Foley catheter (larger if blood clots)
**Rate of decompression: rapid complete drainage
***At one time, rapid complete bladder decompression was thought to increase the rate of potential complications, however partial drainage and clamping does not reduce these complications and may increase risk for [[UTI]]<ref>Management of urinary retention: rapid versus gradual decompression and risk of complications</ref>
*If unable to pass Foley, consider:
**[[Coude catheter]]
**[[Suprapubic catheterization]]


== See Also ==
===Other Considerations===
[[UTI]]
*Blood clot
**Use 20-24F triple-lumen catheter to irrigate bladder until clear
*Consider α-blocker as outpatient if concern for BPH (e.g. [[tamsulosin]] 0.4mg QHS)
**Results in significant increase in voiding success
**Possibility of orthostatic hypotension
*Urology consult
**Consider for precipitated retention (e.g. stricture, prostatitis, cancer) or need for [[suprapubic catheterization]]


[[Pyelonephritis]]
==Disposition==
===Admission===
Admit for:
*[[Post-obstructive diuresis]] >200mL/hr for 2 hours or 3L over 24 hours (will need fluids and electrolyte monitoring/repletion)
*Elevated BUN/Cr ([[acute renal failure]])
*Significant [[hematuria]] or clot retention
*New neurologic cause (e.g. [[cord compression]])


[[Coude Catheter]]
===Discharge===
*Otherwise consider discharge with catheter placed to leg bag and urology follow up within 1 week
 
==See Also==
*[[Coude catheter]]
*[[Suprapubic catheter placement]]
*[[Suprapubic bladder aspiration]]
*[[Suprapubic catheter changing or replacement]]
*[[Post-obstructive diuresis]]
 
[[Category:Urology]]
 
==References==
<references/>
 
<references/>

Revisión actual - 22:11 15 nov 2023

Background

(1) Human urinary system: (2) kidney; (3) renal pelvis; (4) ureter; (5) urinary bladder (6) urethra.
Additional structures: (7) adrenal gland; (8) renal artery and vein; (9) inferior vena cava; (10) abdominal aorta; (11) common iliac artery and vein; (12) liver; (13) large intestine; (14) pelvis.
Anatomy of the male bladder, showing transitional epithelium and part of the wall in a histological cut-out.

Clinical Features

Patient with acute urinary retention and dramatic bladder distention.
  • Suprapubic abdominal distention and/or pain
  • Frequency, urgency, hesitancy, dribbling, decrease in voiding stream

Differential Diagnosis

Urinary retention

Abdominal distention

Evaluation

Ultrasound of distended from urinary retention. Note trabeculated wall, which is a sign of urinary retention.
Bladder distension from acute urinary retention seen on CT.
  • UA/Urine cultures
  • Chemistry
  • CBC (if suspect infection or massive hematuria)
  • Bedside ultrasound (to verify retention)
    • Incomplete retention is PVR > 50ml and > 100ml in patients > 65 years of age[1]
    • Post-void residual of 150-200 cc is particularly concerning

Management

Bladder Decompression

  • Urethral catheterization
    • Pass 14-18F Foley catheter (larger if blood clots)
    • Rate of decompression: rapid complete drainage
      • At one time, rapid complete bladder decompression was thought to increase the rate of potential complications, however partial drainage and clamping does not reduce these complications and may increase risk for UTI[2]
  • If unable to pass Foley, consider:

Other Considerations

  • Blood clot
    • Use 20-24F triple-lumen catheter to irrigate bladder until clear
  • Consider α-blocker as outpatient if concern for BPH (e.g. tamsulosin 0.4mg QHS)
    • Results in significant increase in voiding success
    • Possibility of orthostatic hypotension
  • Urology consult

Disposition

Admission

Admit for:

Discharge

  • Otherwise consider discharge with catheter placed to leg bag and urology follow up within 1 week

See Also

References

  1. ↑ Shenot PJ. Urinary Retention. Merck Manual. August 2014. http://www.merckmanuals.com/professional/genitourinary-disorders/voiding-disorders/urinary-retention
  2. ↑ Management of urinary retention: rapid versus gradual decompression and risk of complications


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