Makindo Medical Notes

Related Subjects: |Acute Urinary Retention |Chronic Urinary Retention |Urinary Catheterisation

Consider catheterization when bladder volume is assessed as greater than 500 mls, especially if the patient exhibits pain, agitation, or delirium. If a bladder scanner is not available, base the decision on clinical findings and measure the residual volume. The most common cause of urinary retention in men is benign prostatic hyperplasia (BPH). Men with an enlarged prostate may experience lower urinary tract symptoms such as urinary retention (acute or chronic), frequency, urgency, or nocturia.

Quick Guide

About

• Patient presents with inability to urinate and pain.
• Patients with dementia or who are mute may not complain of pain but may show signs of distress.

Aetiology: Often Multifactorial

• Acute painful inability to urinate with a full bladder.
• General causes include prostate infection, bladder overdistension, excessive fluid intake, alcohol consumption, sexual activity, debility, and bed rest.
• Drugs: Decongestants, antihistamines, amphetamines, morphine, hyoscine, and tricyclic antidepressants.
• Other causes: Urethral stricture, BPH, prostate cancer, bladder neck contracture, urethral stones, and foreign bodies.
• Neurological causes: Multiple sclerosis (MS), Parkinson's disease, spinal cord injury, stroke, spinal anesthesia, surgery, or tumors.
• Females: Organ prolapse, pelvic mass, gravid uterus, vulvovaginitis, and herpes.

Clinical Presentation

• A full bladder is often palpable.
• A bladder scan (if available) shows volume over 500 mls.
• The patient usually experiences pain and discomfort.
• Take a detailed drug and physical history, and exclude constipation and UTI.
• Consider performing a rectal examination after catheterization.
• Document the urine volume in the patient's notes.

Investigations

• Use bladder ultrasound (USS) to confirm a full bladder.
• Order tests: FBC, U&E, CRP, calcium levels.
• Perform urinalysis and send for culture if indicated.

Management

• Allow the patient to attempt urination in a quiet, undisturbed environment. Running water (taps or shower) may help. Some patients may find it easier to urinate in a warm bath or shower, especially if suffering from painful genital herpes.
• If residual volume is less than 1 liter and no drug therapy has been initiated, start Tamsulosin 400 mcg once daily. Plan a TWOC in 72 hours or arrange for one in the community within 7-10 days.
• If residual volume is over 1 liter with abnormal kidney function, contact on-call urology for admission. Manage the patient with fluid balance, lying and standing blood pressures, and daily weight checks.
• If residual volume is over 1 liter but renal function is normal, the patient may have acute-on-chronic retention. Refer to the urology TWOC clinic with appropriate medication (Tamsulosin), if not already started. Treat UTI and constipation. If AKI or CKD is suspected, exclude obstructive causes and seek advice.

Trial Without Catheter (TWOC)

• Trial Tamsulosin hydrochloride (alpha-1 adrenergic antagonist) for at least two days for acute urinary retention. Review treatment initially after 4-6 weeks, then every 6-12 months.
• If the patient fails a second TWOC, reinsert the catheter and consider urology follow-up. Further TWOCs can be attempted, preferably in a specialist clinic, but multiple failed attempts may necessitate a long-term catheter.

Caution with Catheterization: Discuss with Urology

• Recent urethral surgery.
• Unexplained hematuria.
• History of false passages or strictures.
• Pelvic or perineal trauma, fractured pelvis, or urinary infection.

Unable to Pass a Urethral Catheter

• Use 2 tubes of instillagel and try again with a 14 French catheter. If this fails, refer to on-call urology.
• Use a straight, taut technique to prevent urethral kinking. Ask the patient to cough while applying gentle pressure to help pass the catheter.
• If significant resistance is felt, stop the procedure.
• If catheterization is successful, inflate the balloon and ensure urine flow. Always retract the foreskin in uncircumcised males.
• If needed, attempt using a coude catheter or needle aspiration of the bladder as a temporary solution until suprapubic catheterization is possible.

Large Prostate

• In patients with an enlarged prostate and raised PSA levels, a 5α-reductase inhibitor (such as finasteride or dutasteride) can be considered.
• A combination of an alpha-adrenoceptor blocker and a 5α-reductase inhibitor may be offered if symptoms persist.

Suprapubic Catheters

• If a suprapubic catheter falls out, it must be replaced urgently to prevent the tract from closing. SPC replacement should occur as soon as possible, typically within one hour.
• Ensure the bladder is full before replacing the catheter by filling it with 300 ml normal saline.
• If recent SPC failures occur, consider bladder stones and obtain imaging (XR KUB or USS KUB). Refer to urology for SPC reinsertion if needed.

Alternatives

• Intermittent self-catheterization.
• Suprapubic catheterization.
• In extreme cases, bladder aspiration using a green needle may be necessary when other options fail.

References

• Lower Urinary Tract Symptoms in Men: Management - NICE Guidance