Clinical Science Session

Retensio Urin

Preseptor:
Hj. Liza Nursanty, dr., SpB., FInaCS., MKes
Disusun Oleh :
Selvi Putri Oktari 12100117116

SMF Ilmu Bedah Program Pendidikan Profesi Dokter

Fakultas Kedokteran Unisba
Rumah Sakit Al Islam Bandung
2018
 ANATOMI
O The organs of the urinary system, which
include the kidney, ureter, and bladder, are
located in the retroperitoneum.
URINARY BLADDER
URETHRA
Histologi
Bladder

Consist of
▰Epitel transisional
▰Lamina propria
▰Smooth muscle
▰Adventitia
 PART OF URETHRA

Part Length Morphology

Pars preprostatic 0,5 – 1,5 cm Transitional Epithelium

Pars prostatic 3 – 4 cm Transitional Epithelium

Pars membranosa 1 – 1,5 cm Pseudostratified columnar

epithelium

Pars bulbosa and pars 15 cm Stratified squamous epithelium

pendulosa
RETENSIO URINE
 Definisi
▰ is a state where a person can not urinate (micturition) when
bladder is full but are unable to remove urine.
▰ Urinary retention is the inability to empty the bladder completely.
 EPIDEMIOLOGY
▰ Men : women= 10 : 1
▰ 10% of men in their 70 s have experienced acute urinary
retention (AUR) over a 5-yr period
▰ The risk increases to one in three over 10 yr.
▰ UR is rare in younger men; men in their 70 s are at five times
more risk of AUR than men in their 40 s.
▰ A 60-yr-old man would have a 23% probability of
experiencing AUR if he were to reach the age of 80
 ETIOLOGY
a. Weakness of the detrusor muscle contractions, usually due to
neurologic abnormalities as high as sacral II - IV.
b. Increase peripheral resistance may occur in orrificium uretrae
internum until prepuce, an outline is usually caused by:
▰ Trauma: bladder trauma, trauma to the urethra, penis trauma
▰ The most common underlying causes in women are infection or
inflammation occurring postpartum or secondary to herpes,
Bartholin’s abscess, acute urethritis, or vulvovaginitis
▰ AUR is rare in children and is usually associated with infection or
occurs postoperatively.
 CLASSIFICATION
1. Acute Retention
▰AUR is usually characterised by the sudden, painful inability to void;
painless AUR is rare and is often associated with central nervous system
pathology
▰The exact cause of AUR is unclear; however, several mechanisms have
been suggested. These include increased resistance to flow of urine with
either mechanical obstruction (urethral stricture, clot retention) or dynamic
obstruction (increased a-adrenergic activity, prostatic inflammation);
bladder overdistension (immobility, constipation, drugs inhibiting bladder
contractility.
AUR may be further subdivided into :
1. Precipitated AUR :may be triggered by :
- anaesthesia,
- excessive fluid intake,
- bladder overdistension,
- urinary tract infections (UTIs),
- prostatic inflammation,
- excessive alcohol intake, or
- use of drugs with sympathomimetic or
anticholinergic drugs
2. Spontaneous AUR : no triggering event is
identified and most commonly associated
with benign prostatic hyperplasia (BPH) and
is regarded as a sign of progression
 CLASSIFICATION
Chronic Retention

The etiology can be divided into :

• High-pressure chronic retention (HPCR) and
• Low-pressure chronic retention (LPCR).

The terms high and low refer to the detrusor pressure at the end of
micturition
 CLASSIFICATION
Chronic Retention
▰HPCR
▻Bladder outlet obstruction usually exists in HPCR
▻Poor urinary flow rates  constantly raised bladder pressure
(during storage and voiding phases of micturition)  backward
pressure on the upper tract drainage  bilateral hydronephrosis
▰LPCR
▻Other patients may have large-volume retention in a very compliant
bladder with no hydronephrosis or renal failure, and they are said to
have LPCR.
▻Urodynamic studies in these patients show low detrusor pressures,
low flow rates, and very large residual volume
 ETIOLOGY

Infections :
• cystitis, prostatitis, ureteritis.
Tumors:
• Tumors bladder, prostate tumors (BPH), prostate
Ca, Ca penis
Congenital:
• Urakus, diverticular bladder, Ekstrofia bladder,
urethral stenosis
phimosis
Urinary tract stones:
• Vesicolitiasis, Stone prostate, urethral stone.
 SYMPTOM

a. Retensi urine acute condition b. Retensi urin chronic condition

• Great discomfort • Mild discomfort
• Pain • Straining
• Hesistance • Frequent of micturition
• Distension of lower abdomen • Dribbling
 ACUTE RETENTION
Acute retention
•The most common presentation is a patient with
• lower abdominal pain and swelling,
• an inability to pass urine (or passing only small amounts of
urine)
• A palpable mass that arises from the pelvis  dull to
percussion
•Although it is stated that patients with AUR usually do not have
previous LUTS
•Although AUR is primarily a clinical diagnosis, a bladder volume
scan (if available) will further confirm the diagnosis before
catheterisation.
 CHRONIC RETENTION

▰Finding : persistent residual volumes of >300 ml (some authors

suggest >500 ml) after voiding
▰Patients may be asymptomatic or may describe low volume
micturition, increased frequency, or difficulty initiating and maintaining
micturition. nocturnal incontinence, a palpable but painless bladder,
and signs of chronic renal failure. LUTS are uncommon.
▰In both types of retention,urinalysis should always be performed and
a catheter specimen of urine (CSU(. Urea, creatinine, and electrolytes
should be checked;
▰Renal ultrasound is indicated in patients with high-volume retention
and in patients with abnormal renal function
▰Prostate-specific antigen (PSA) testing is best avoided during the
acute episode
MECHANISM
1. Bladder filled progressively increased until the treshold at
the wall above the threshold value
2. Arise nerve reflexes (reflex micturition) are trying to empty
the bladder or if it fails, at - least raises awareness of the
urge to urinate.
 Consequences of urinary retention

▰ Overstretched 1000 – 3000 ml urin

▰ Decreased force of contraction
▰ Stagnation of urine can cause infection and can spread to the
urinary system
In the early stages (phase compensation)
▰ muscle walls become hypertrophied and thickened bladder.
▰ With decompensasi, contraktile be reduced and weak.
Changes in bladder due to
obstruction…
▻ Trabekulasi  became strained muscles and so
interwoven rough overview on the mucosal surface.
▻ Cellules hypertrophy  pressure of 3 -4 x more
likely to try to remove urine from obstruction.
Consequently pushed the superficial mucosa muscle
bundle
▻ Mucosa  If there is an acute infection of the
mucosa  become red and edema
 COMPLICATION
▻ Vesicoureteric reflux
▻ Hidroureter
▻ Hydronephrosis
▻ Renal failure
▻ Hernia
▻ Hemorrhoid
▻ Stone deposition can cause irritation  hematuria
 DIAGNOSIS
Anamnesis:
•obstructive and irritative symptoms. I: frequency, urgency, disuria, nocturia.
O: poor stream, hesistence, terminal dribbling, incomplete voiding.
Physical examination:
•rectal especially on a palpable prostatic hyperplasia enlarged prostate, chewy
consistency, flat surface, asymmetry and protruding into the rectum. The
more severe the degree of prostatic hyperplasia upper limit of the more
difficult to be touched.
Laboratory tests:
•a role in determining the presence or absence of complications.

Imaging examination:
•In the intravenous pielografi visible lesion contrast filling defect at the base
of the bladder or ureter distal end turned up shaped like a hook.
Uroflowmetry: decreases of flow urine.
 MANAGEMENT
▰ Management of urinary retention principle is:
1) Improve the general state
2) Removing the urine as soon as possible.
3) A causal treatment.
▰ Fig. 2 – Management of acute
retention after catheterisation.
LUTS = lower urinary tract
symptoms;
▰ TURP = transurethral
resection of the prostate;
▰ TWOC = trial without catheter.
▰ Fig. 3 –
Management of
chronic urinary
retention.
▰ CISC = clean
intermittent self-
catheterisation;
LTC = long-
▰ term catheter;
TURP =
transurethral
resection of the
▰ prostate.
 MANAGEMENT

Removing the urine as soon as possible by

• Catheterization
• Suprapubic puncture
• cystotomy
 MANAGEMENT
A causal treatment :
• Phimosis: Circumcision
• Infection: Appropriate antibiotics
• Stricture: Conservative and or operative.
• Urinary tract stones: operative
• Neurologic: physiotherapy
• BPH : alfa adrenergic blockers (alfuzosin, tamsulosin for
three days starting at the time of catheter insertion)
• Prostate tumors
● prostate hyperplasia transurethral resection, open
prostatectomy, cryosurgery
● prostatectomy prostate carcinoma, estrogen,
orchidectomy open
 TRIAL WITHOUT CATHETER
(TWOC)

▰ Involves catheter removal (usually in two to three

days) and determination if the patient can
successfully void
▰ Success rates for initial TWOC have ranged from
20 – 40%
▰ Factors that favor successful trial of void includes :
▻ Age <65 yo
▻ Detrusor pressure > 35 cmH2O
▻ A drained volume of < 1 L at catheterization
 ALPHA- BLOCKERS AND
TRIAL WITHOUT CATHETER

▰ AUR due to BPH may be associated with an increase in alfa

adrenergic activity.
▰ Inhibition of these receptors by alfa blockers may decrease
bladder outlet resistence  micturition
▰ Alfuzosin 10 mg daily for 2 – 3 day after catheterisation
▰ Continued use of alfuzosin significantly reduced the risk of
BPH surgery in the first 3 mo
 COMPLICATION
▰ Incontinence paradox
▰ bladder stones
▰ Hematuria
▰ Cystitis
▰ Pyelonephritis
▰ vesico-ureteric reflux
▰ Hidroureter
▰ Hydronephrosis
▰ Renal failure
PREVENTION AND RISK

▰ Risk factors include men >70 yr of age with LUTS

▰ An International Prostate Symptom Score (IPSS) >7 (ie,
moderate or severe LUTS)
▰ A flow rate of 40 cm2 or a PSA >1.4 ng/ml.
▰ Studies have suggested that hesitancy may also predict a
greater risk of subsequent AUR.
▰ Placebocontrolled trials have shown that treatment with 5a-
reductase inhibitor
 PROGNOSIS

▰ Dubia, depending on
▻ what the cause of urinary retention and
▻ the complications that may occur.
 In some cases the causative treatment of infections
such as antibiotic therapy to treat complaints of
retention, but in the case of malignancy prognosis can
be poor.
▰ THANKYOU