Urinary Retention

7.09 Urinary Retention

Presentation
The patient may complain of increasing dull low abdominal discomfort and the urge to urinate, without having been able to urinate for many hours. A firm, distended bladder can be palpated between the symphysis pubis and umbilicus. Rectal exam may reveal an enlarged and/or tender prostate or suspected tumor.
What to do:



Delaying only long enough for good aseptic technique, pass a Foley catheter into the bladder and collect the urine in a closed bag. Reassuring the patient and having him breathe through his mouth may help relax the external sphincter of the bladder and facilitate the passage of the catheter.



If passage remains difficult in a male patient, distend the urethra with lubricant (K-Y jelly;or diluted lidocaine jelly) in a catheter-tipped syringe (Uroject) and try a 16, 18, or 20 French Foley.



If the problem is negotiating the curve around a large prostate, use a Coude catheter.



If you still cannot drain the bladder, obtain urologic consultation for stylets, sounds, filiforms, and followers.



Check renal and urinary function with a urinalysis, a urine culture and serum BUN and creatinine determinations. Examine the patient to ascertain the cause of obstruction.



If there is an infection of the bladder, give antibiotics.



If the volume drained is modest ( 1-2 liters) and the patient stable and ambulatory, attach the Foley catheter to a leg bag and discharge him, for followup (and probably, catheter removal) the next day.



If the volume drained is small (100-200ml), remove the catheter and search for alternate etiologies of the abdominal mass and urinary urgency.
What not to do:



Do not use stylets or sounds unless you have experience instrumenting the urethra--these devices can cause considerable trauma.



Do not remove the catheter in the ED if the bladder was significantly distended. Bladder tone will take several hours to return, and the bladder may become distended again.



Do not clamp the catheter to slow decompression of the bladder, even if the volume drained is greater than 2 liters.



Do not use bethanechol (Urecholine) unless it is clear that there is no obstruction, the only cause of the distension is inadequate (parasympathetic) bladder tone and there is no possibility of gastrointestinal disease.



Do not routinely treat the bacteria cultured from a distended bladder--they may only represent colonization which will resolve with drainage.
Discussion
Urinary retention may be caused by stones lodged in the urethra or urethral strictures (often from gonorrhea); prostatitis, prostatic carcinoma, or benign prostatic hypertrophy; and tumor or clot in the bladder. Any drug with anticholinergic effects or alpha adrenergic effects such as antihistamines, ephedrine sulfate and phenylpropanolamine can precipitate urinary retention. Neurologic etiologies include cord lesions and multiple sclerosis. Patients with genital herpes may develop urinary retention from nerve involvement. Urinary retention has also been reported following vigorous anal intercourse. The urethral catheterization outlined above is appropriate initial treatment for all these conditions.
 Sometimes hematuria develops midway through bladder decompression, probably representing loss of tamponade of vessels injured as the bladder distended. This should be watched until the bleeding stops (usually spontaneously) to be sure there is no great blood loss, no other urologic pathology responsible, and no clot obstruction.