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Acute urinary retention (AUR)

inability to voluntarily pass urine

Most common urologic emergency [1]. In men, AUR is most often secondary to benign prostatic hyperplasia
(BPH); AUR is rare in women.

PATHOGENESIS
Outflow obstruction MC. The flow of urine is impeded with outflow obstruction by
mechanical and/or dynamic factors.
Mechanical obstruction refers to a physical narrowing of the urethral channel
Dynamic obstruction refers to increased muscle tone within and around the urethra

Neurologic impairment AUR may develop secondary to the interruption of the sensory or motor nerve
supply to the detrusor muscle. AUR may be related to incomplete relaxation of the urinary sphincter
mechanism (dyssynergia), which can result in elevations in both voiding pressures and post-void residual
volumes. pinal cord injuries from trauma, infarct or demyelination, epidural abscess and epidural metastasis,
Guillain-Barr syndrome, diabetic neuropathy, and stroke.

Inefficient detrusor muscle AUR may occur in patients with an inefficient detrusor muscle when a
precipitating event results in an acute distended bladder (eg, with a fluid challenge, during general or epidural
analgesia without an indwelling catheter). This most often occurs in patients with obstructive urinary symptoms
at baseline.

Infection Infections may lead to AUR in the setting of inflammation that causes obstruction. For example, an
acutely-inflamed prostate gland from acute prostatitis can cause AUR, particularly in men who already have
BPH. Genital herpes may cause AUR both from local inflammation as well as sacral nerve involvement.

Trauma Patients with trauma to the pelvis, urethra, or penis may develop AUR from mechanical disruption

Other AUR may also occur postoperatively or in the postpartum period.

Medications
i. Sympathomimetics (alpha+beta-adrenergic agents)
ii. Antidepressants
iii. Antiarrhythmics
iv. Anticholinergics
v. Antiparkinsonian agents
vi. Hormonal agents
vii. Antipsychotics
viii. Antihistamines
ix. Antihypertensives
x. Muscle relaxants

PRESENTATION
Inability to pass urine + lower abdominal and/orsuprapubic discomfort + restless +distress.

EVALUATION
History: of retention or lower urinary tract symptoms, drugs, prostate disease (hyperplasia or cancer), pelvic or
prostate surgery, radiation, or pelvic trauma

PE In patients with AUR of unknown etiology, the physical examination should include the following:
Lower abdominal palpation
Rectal examination: evaluate for masses, fecal impaction, perineal sensation, and rectal sphincter tone.
Pelvic examination: Women with urinary retention should have a pelvic examination.
Neurologic evaluation: assessment of strength, sensation, reflexes, and muscle tone.

Laboratory studies - urinalysis and urine culture; serum chemistries and creatinine, CBC, PSA

DIAGNOSIS - bladder ultrasound 300 cc in a patient unable to void


If this volume exceeds 400 cc, the catheter is typically left in place.
For 200 to 400 cc, the decision to leave the catheter is guided by the clinical scenario
< 200 cc, immediate catheter removal and a voiding trial is appropriate for most patients.

Management:
It is reasonable to proceed with catheterization, which is both diagnostic and therapeutic. In others where
the diagnosis is less clear, a bladder ultrasound may help establish the diagnosis.
Initial management of AUR involves prompt bladder decompression. UpToDate suggest initial treatment
with an indwelling urethral catheter, rather than a suprapubic catheter.
We suggest complete drainage of the bladder with initial catheterization. Hematuria, transient hypotension,
and postobstructive diuresis are common, but rarely clinically significant.
The majority of patients can be managed as outpatients once bladder decompression is accomplished.
Hospitalization is indicated for patients who are uroseptic or who have obstruction related to malignancy or
spinal cord compression.
If it caused by drugs, stop it or lower in strength or fix the mechanical causes of obstruction.