Acute retaintion of urine. Or Mutra ghat

Inability to voied urine.

1. 1

RETENTION OF URINE
Urinary retention is defined as the inability to completely or partially empty the bladder. It is a
sudden painful inability to urinate in spite of a full bladder.
Urinary retention is also known as ischuria.

# Normal micturition cycle:
A. Filling: Impulses from the CNS to sympathetic and pudendal nerves relax the bladder and close
the outlet.
B. Voiding: Inhibition of sympathetic and pudendal impulses. Stimulation of parasympathetic (S2-
4) leads to detrusor contraction → voiding in the absence of obstruction.

Urinary retention is characterized by poor urinary stream with intermittent flow, straining, a sense
of incomplete voiding and hesitancy (a delay between trying to urinate and the flow actually
beginning). As the bladder remains full causes incontinence, nocturia (need to urinate at night) and
high frequency.
Acute retention is a medical emergency, as the bladder may distend (stretch) to enormous sizes
and possibly tear if not dealt with quickly. If the bladder distends enough it will begin to become
painful. The increase in pressure in the bladder can also prevent urine entering from the ureters or
even cause urine to pass back up the ureters and get into the kidneys, causing hydronephrosis, and
possibly pyonephrosis, kidney failure and sepsis.

Anuria means non passage of urine, in practice is defined as passage of less than 50 milliliters of
urine in a day. Anuria is the complete absence of urine production by the kidney for 12 hours or
more.
Oliguria has decreased urine volume to less than 400 ml in a day.
Oliguria is often caused by kidney failure. It may also occur because of some severe obstruction
like kidney stones or tumors. It may occur with end stage renal disease.
Dysuria refers to painful urination. It is one of the irritative bladder symptoms, which includes
urinary frequency and hematuria. This is typically described to be a burning or stinging sensation.
It is most often a result of a urinary tract infection. It may also be due to an STD, bladder stones,
bladder tumors, and virtually any condition of the prostate. It can also occur as a side effect of
anticholinergic medication used for Parkinson's disease.
Polyuria is a condition usually defined as excessive or abnormally large production and/or passage
of urine. Polyuria often appears in conjunction with polydipsia (increased thirst).
Polyuria is physiologically normal in some circumstances, such as cold, diuresis, and after drinking
large amounts of fluids
The most common cause of polyuria in both adults and children is- uncontrolled diabetes mellitus,
causing an osmotic diuresis. Primary polydipsia (excessive fluid drinking), diabetes insipidus.
Various chemical substances (diuretics, caffeine, alcohol). Etc.

2. 2

Causes - There are two general types of urinary retention-
● Obstructive and
● Non-obstructive.

Obstructive retention may result from:
● Cancer
● Kidney or bladder stones
● Enlarged prostate (BPH) in men- BPH is the most common cause in men over 50 years. -
Acute prostatitis and abscess, Prostate cancer.
● Urethral cause- Stone, stricture, urethritis, rupture, phimosis, posterior urethral valves.
● Clot retention in severe hematuria e.g. cancer, trauma.
● Women- pelvic masses, urethral stenosis and diverticulum, uterine prolapse, hysterical
cause etc.
Functional and neurogenic cause- (non-obstructive)-
● Postoperative AUR is common- present with Pain, limited mobility, drugs, bladder nerve
injury e.g. hysterectomy & abdominal resection Prevention is important by catheterization
after surgery to bladder, prostate, urethra.
● Vaginal childbirth
● Infections of the brain or spinal cord
● Diabetes
● Stroke
● Accidents that injure the brain or spinal cord
● Multiple sclerosis
● Heavy metal poisoning
● Pelvic injury or trauma,
● Some children are born with nerve problems that can keep the bladder from releasing urine
Drugs: - These medications include Antihistamines, anticholinergics, antispasmodics, tricyclic
antidepressants. Anesthetics Sympathomimetics.

Neurogenic cause-
▪ Spinal cord injury.
▪ Diabetic neuropathy.
▪ Cauda equina lesions.
▪ Intervertebral disc prolapses.
▪ Neurotropic viruses- Herpes simplex or zoster infections.
▪ Multiple sclerosis.
▪ Transverse myelitis.
▪ Tabes dorsalis.
▪ Weakness of detrusor muscle etc.

3. 3

Symptoms of urinary retention may include:
1. Difficulty in starting to urinate
2. Difficulty in fully emptying the bladder
3. Weak dribble or stream of urine
4. Small amounts of urine during the day
5. Inability to feel when bladder is full
6. Increased abdominal pressure
7. Lack of urge to urinate
8. Strained efforts to push urine out of the bladder
9. Frequent urination
10. Nocturia (waking up more than two times at night to urinate)
On examination-
History taking - The patient's history should focus on a previous history of retention, prostate
cancer, surgery, radiation, or pelvic trauma. The patient should also be asked about the presence
of hematuria, dysuria, fever, low back pain, neurologic symptoms, or rash. Finally, a complete list
of prescribed and over the counter medications should be obtained.
Mostly present with-
▪ Suprapubic bursting pain.
▪ No urination
▪ Strong desire to urinate.
▪ Or dribbling.

Physical Examination should include the following-
Genital examination- look for Phimosis, severe urethral meatal stenosis.
Lower abdominal palpation — The urinary bladder may be palpable, Midline globular tender
suprapubic mass
Digital Rectal examination — A rectal examination should be done in both men and women, to
evaluate for BHP, masses, fecal impaction, perineal sensation, and rectal sphincter tone.
Pelvic examination including Per vaginal examination — Women with urinary retention
should have a pelvic examination.
Neurologic evaluation — The neurologic examination should include assessment of strength,
sensation, reflexes, and muscle tone.

Investigations -
▪ Ultrasonography for any calculi, growth, post voiding residual urine, condition of Kidney,
any injury.
▪ X Ray KUB for calculi
▪ Blood -Urea, Creatinine, sugar levels
▪ CT scan for any pathology
▪ Urine examination for rule out infection

4. 4

▪ PSA for Prostate Cancer
▪ Urodynamic Test for Cystocele
▪ Cystoscopy for status of bladder
▪ MRI Lumbar spine for spinal pathology

Treatment:
Conservative measures in non-obstructive causes: Patient is asked to go out of bed. Take a hot
bath. Parasympathomimetic. If Failure → catheterization.
Urethral catheterization: Nelaton or Foley's: It is absolutely contraindicated in urethral injury.
Proper Sterilization of parts. Adequate lubrication of urethra. Proper catheter size Children 6-12 F
Adults 16 F.
Clot retention- Triway 22F urethral catheter with irrigation. - Evacuation of clots.
Cystoscopy - diagnostic and therapeutic Suprapubic cystocath. done in Urethral trauma, Urethral
stricture, Failure of urethral catheterization
Emergency measures – Suprapubic catheter if urethral trauma or injury are expected - Ureteric
catheter Or DJ stent if Failure.

Treatment of the cause-
TURP for BPH
Urethroplasty for urethral stricture.
Endoscopic crushing of vesical stone.

#Chronic Retention of Urine Causes: Long standing incomplete obstruction.
A) Mechanical: BPH, prostate cancer
B) Functional: Neuropathic flaccid bladder. - Large amounts of residual urine exist. - When the
vesical pressure exceeds the urethral resistance, the patient can pass some urine or dribble
continuously. This is called false or overflow incontinence.