AROU

1. Introduction
2. Definition
3. Classifications
4. Causes
5. Management
1) Emergency
2) Definitive
1. History
2. Examination
3. Investigation
4. Treatment
6. Follow up
7. Conclusion
Introduction
AROU is the emergency urologic condition because it disrupts the natural flow of urine and
normal function of urinary system and patient experiences increasingly agonizing suprapubic pain
associated with severe urgency as the bladder continues to stretch and fill with urine.

Definition
Urinary retention is defined as the inability to empty the bladder partially or completely with
or without lower abdominal pain.

Classifications
Retention of urine can be classsified into three types according to onset, pain and residual volume.
1. Acute retention of urine (AROU)
Acute retention of urine is defined as the sudden onset of painful inability to void with
relief of pain following drainage of the bladder by catheterization in which catheterization
volume is usually 500-800 ml.
This may be spontaneous (BPH, PC) or precipitated by an event (anaesthetic drugs, non-
prostatic abdominal or perineal surgery and immobility following surgical procedure).
2. Chonic retention of urine (CROU)
Chronic retention of urine is defined as the conditiion in which certain volume of urine is
present in the bladder after voiding or attempted voiding. (NICE describe RV = >1000 ml)
This may be LPCR (normal creatinine value and absence of hydronephrosis on USG) or
HPCR (elevated creatinine value which falls in post catheterization and usually with
hydronephrosis on USG).
3. Acute on chronic retention of urine
Acute on chronic retention of urine is defined as the condition of chronic retention in
which sudden onset of painful inability to void is present with relief of pain following
drainage of the bladder by catheterization in which cathetrization volume is >800 ml.

Retention of urine can also be classified into two types according to aetiology.
1. Obstructive urinary retention
It may result from prostate (BPH & PC), stones (bladder & urethra), stricture & stenosis,
BXO, phimosis and paraphimosis.
2. Non-obstructive urinary retention
It may result from infection & inflammation (prostatitis, cystitis, urethritis and
vulvovaginitis), Neurologic (Sroke, diabetic cystopathy, neurologic bladder, neurotropic virus
involving the sensory dorsal root ganglia of S2-4), traumatic, anticholinergic/
sympathomimetic/ antihistaminic drugs, psychologic condition (Shy bladder syndrmoe),
poisoning and alcohol.

Management of a 70 years old male presenting with AROU

Initial/ Emergency management
After taking concise history and examination including confirmation of bladder distension,
urethral catheterization is mandatory to relieve pain and record the amount of urine drained.
Controlled drainage must be done to avoid decompressive haematuria. If the trial of catheterization
is failed, timely inform to Urologist for SPC insertion.

Definitive management
Definitive treatment is approached with the knowledge of aetiology of AROU. Causes of
AROU in 70 years old may patient most probably due to BPH. Other causes may be PC, vesicle stone
and stricture.
Firstly, the patient is discussed about TWOC after the bladder drill.
History taking
Thorough history taking is done about LUTS, haematuria, previous instrumentation &
surgery, DM, drugs and previous episode. IPSS/ AUA symptom score is recorded.
Physical examination
Proper physical examination is done including DRE and focused neurological examinations.
In DRE, anal tone, BCR and size, consistency and nodularity of prostate are evaluated. Neurological
examinations include preneal sensation, sacral reflex and jerk of lower limb. Urethral examination is
done to exclude urethral stricture, meatal stenosis, abscess and fistula.
Laboratory investigations
Laboratory investigations such as Urinalysis, Urine C&S, U&C, Sugar, E+, WBC, PT, INR and
Seology are done. If BPE is evaluated in DRE, PSA test is done after counselling the patient about PSA
test.
USG (TAB/ TRUS)
Classical transabdominal USG is the non invasive and first choice imaging for AROU patient.
Bladder should be distended for optimal view and resolution of bladder and adjacent organs like
prostate. It reveals prostate volume, contour, IVPP, prostatic calculi, bladder wall thickness, intra-
vesicle pathology, PVR, echolucent lesion in peripheral portion of prostate and upper tract dilatation
such as hydronephrosis and hydroureter and stone.
PVR should be done in patients who are selected for WW so that they can be monitored
closely as they might need surgery at some stage.
TRUS is the commonest modality for TRUS guided prostate biopsy for suspect of PC.
KUB X-Rays
KUB X-Rays reveal urinary tract stones as well as osteoblastic secondary from PC.
IVU
IVU is not indicated as a routine investigation but is usually reserved for patients with history
of haematuria to exclude tumour.
NECT (KUB)
It is not routinely used in AROU patient but it may be recommended if KUB X-Rays reveal no
radio-opaque stone in patient with hydronephrosis to assess the radio-lucent stone and others
abnormalities of urinary tract.
Uroflowmetry
It is a non-invasive urodynamic test and a peak flow rate of <15ml/sec is associated with
good treatment outcomes. Q max <5ml predict subsequent retention.
Pressure/ Flow study
Simultaneous measurement of the urinary flow rate and intravesicle pressure at the time of
micturition can differentiate hypotonia from BOO. This test is regaded as the gold standard
investigation to diagnose BOO due to prostate enlargement. Poor flow of urine with a high
intravesicle pressure denotes BOO.
Urethrocystoscopy
It is not recommended as a routine procedure. It is used in patients with haematuria and
provides visual information of prostate, evidence of BOO like trabeculations, sacculations,
diverticulations and stone.
IPSS/AUA symptom score

Treatment for BPH

Watchful waiting
It is not recommended in older patient with AROU.
Option to avoid TURP
1. Prostate shrinking drugs
If the patient is not fit for the operation, 5ARI such as Finasteride and Dutasteride
can be given for the benign feeling prostate. In those with malignant feeling prostate
 revealed by TRUS guided biopsy result, LHRH agonist can be given followed by a TWOC
several month later.
These drugs are usually given with alpha blocker such as Tamsulosin and Silodosin
for the prostatic smooth muscle relaxation. Tamsulosin should be omitted if the patient is
planned to do cataract operation for the risk of IFIS (Intra-operative floppy iris syndrome).
2. Phytotherapy
In recent years, plant extract such as saw palmetto and bee pollens are popular. Actions of
these drugs are similar to 5ARI. But, AUA doesn't recommend phytotherapy for LUTS in men.
3. Prostatic stents
4. Long term urethral or SPC catheter
5. CISC
It is not a realistic option but some will be happy and able to do this.

Surgical treatment
TURP
In current urological era, TURP is the gold standard surgical treatment for BPH. This is the
removal of the obstructing tissue of BPH or PC from within the prostate leaving the compressed
outer zone (surgical capsule). An electrically heated wire loop is used through resectoscope to cut
the tissue and diathermy bleeding vessels. The cut chips of the prostate are pushed back into the
bladder by the flow of irrigating fluid and at the end of resection, these are evacuated using specially
designed evacuator, Toomey syringe which allows fluid to be flushed in and out of the bladder.
TUR Syndrome may be present in TURP especially in using the large amount of glycine,
hypotonic irrigating solution. Glycine is usually used in monopolar diathermy. Patient complaint
firstly with visual distubance followed by hypertension, bradycardia and hyponatraemia. Rules of 60
are used in TURP (60 min, 60g, 60 cm height of irrigation) to avoid TUR Syndrome.

Surgical alternatives to TURP

Two broad categories alternative to TURP are minimally invasive and invasive surgery.
1. Minimally invasive surgery
1. TUNA (Transurethral radiofrequency needle ablation)
Low level radiofrequency is transmitted to the prostate via a transurethral
needle delivery system. The resultant heat causes localized necrosis of the prostate.
It is done under LA.
2. TUMT (Transurethral microwave thermotherapy)
Microwave energy can be delivered to the prostate via an intraurethral catheter
(with a cooling system to prevent damage to adjacent urethra) producing prostate
heating and coagulative necrosis. Subsequent shrinkage of the prostate and thermal
damage to the adrenergic neurones (heat induced adrenergic nerve block) relieves
obstruction and symptoms.
This is the opular treatment in US.
3. HIFU (High intensity focus ultrasound)
A focused ultrasound beam can be used to induce a rise in temperature in the
prostate by mean of transrectal probe.
4. Aquablation
It uses high pressure saline to remove parenchymal tissue through a heat free
mechanism hydrodissection. It is also known as water jet ablation and three main
components are included, CPU, robotic hand piece and a console.
5. Prostatic urethral lift (UroLift)
It is aimed to open up the prostatic urethra by retracting the lateral lobes using
anchoring implants inserted transurethrally.
 2. Invasive surgery
TUVP (Transurethral vaporization of the prostate)
In TUVP, the prostate is vaporized and dessicated. TUVP does not provide tissues for
biopsy.
PAE (Prostate artery embolization)
LASER prostatectomy
1) TULIP (Transurethral ultrasound guided LASER induced prostatectomy)
2) VLAP (Visual LASER ablation of the prostate)
3) ILP (Interstitial LASER prostatectomy)
4) HoLEP (Holmium LASER enucleation of the prostate)
5) HoLAP (Holmium LASER ablation of the prostate)
6) HoLRP (Holmium LASER resection of the prostate)
7) PVP (Greenlight photoselective vaporization of the prostate)

3. Open prostatectomy
Indications
1. Large prostate (>100 g)
2. Failed TURP (Bleeding)
3. Too long urethra for resectoscope insertion
4. Too large bladder stone for ESC
Contraindications
1. Small fibrous prostate
2. PC
3. Previous prostatectomy
There are three approach, suprapubic (transvesicle), simple retropubic and
perineal prostatectomy.

Treatment for PC
1) Localized PC
1) Unfit for operation
a. WW
b. AS with regular follow up
2) Fit for operation
a. EBRT
b. BT
c. Cryotherapy
d. HIFU
e. PDT
f. RP & pelvic lymphadenectomy
2) Locally advanced PC
1) Unfit for operation
a. Hormone therapy
2) Fit for operation
a. EBRT
b. RP
3) Advanced PC
1) Unfit for operation (Medical castration & Palliative management)
a. LHRH agonist
b. LHRH antagonist
c. Oestrogen
d. MAB
 2) Fit for operation (Surgical castration)
a. Bilateral subcapsular orchidectomy

Treatment for Vesicle stone

1) Endoscopic cystolitholapaxy
a. ESC (with Mauermayer stone punch & Crocodile)
b. TUVL (with US, EHL & Pneumatic lithotripsy)
c. PCVL
2) Open cystolitholapaxy/ vesicolithotomy

Treatment for Urethral stricture

1) Urethral Dilatation (Filliform dilator following Flexible cystoscopy & GW insertion/ Metal
dilator)
2) Urethrotomy (with Otis urethrotome & Sachse urethrotome)
3) Urethroplasty

Follow up
Regular follow up is mandatory for the 70 years old patient presenting with AROU.

Conclusion
AROU is a common, distressing and dangerous urological problem. And so, there should be
no word hesitation for the managing in the setting of AROU.

Dr Aung Ko Htet