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.
Table of Contents
from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES ©
Longwood Information LLC 4822 Quebec St NW Washington DC 20016-3229
1.202.237.0971 fax 1.202.244.8393 electra@clark.net
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD
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