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RETENTION OF URINE DR AHMED REHMAN FCPS (URO)  Assistant Professor of Urology
Causes of Frequency – Dysuria <ul><li>Acute Cystitis  and urethritis  </li></ul><ul><li>VUR, and vesical diverticulum  neu...
Physiology of bladder  <ul><li>Low pressure reservoir (compliance / distensibility)  400-550 cc at around 5cm water (<15cm...
Micturation Reflex <ul><li>Afferants from bladder activate sacral spinal cord centre which through their efferants cause C...
Inability to Pass Urine <ul><li>Retention of Urine </li></ul><ul><ul><ul><li>When patient, despite an urge to void, is una...
Types of Retention <ul><li>Acute Retention </li></ul><ul><ul><li>Agonizing painful condition with intense urge </li></ul><...
Causes of retention - boys <ul><li>Phemosis </li></ul><ul><li>Scab – meatal ulcer  </li></ul><ul><li>External meatal steno...
Causes of retention - girls <ul><li>Synechia vulvae  Urethritis </li></ul><ul><ul><li>uncommon </li></ul></ul><ul><li>Uret...
Causes of retention – young males <ul><li>Meatal ulcer / stenosis </li></ul><ul><li>Urethral stricture / stone / abscess /...
Causes of retention – young females <ul><li>Hysterical conversion reaction </li></ul><ul><li>Drugs /anesthesia </li></ul><...
Causes of retention – elderly males <ul><li>BPH, CaP, abscess </li></ul><ul><li>Stone,  Ca UB, clot retention </li></ul><u...
Causes of retention – elderly females <ul><li>Atrophic urethritis </li></ul><ul><li>Meatal stenosis </li></ul><ul><li>Ca U...
History  <ul><li>Duration  </li></ul><ul><li>Painfull? </li></ul><ul><li>Precipitating factors </li></ul><ul><li>Preceding...
History <ul><li>Catheterization  </li></ul><ul><ul><li>Easy </li></ul></ul><ul><ul><li>Caliber </li></ul></ul><ul><ul><li>...
Examination  <ul><li>Meatus </li></ul><ul><li>Urethra </li></ul><ul><li>Bladder Ac / Ch  </li></ul><ul><li>DRE  </li></ul>...
Investigations  <ul><li>Urine RE/ CS </li></ul><ul><li>RFTS </li></ul><ul><li>US  </li></ul><ul><li>X ray KUB </li></ul><u...
Treatment  <ul><li>Urethral catheterization </li></ul><ul><ul><li>Technique  </li></ul></ul><ul><ul><ul><li>Explain / cons...
Urethral catheterization Technique <ul><ul><ul><li>Cleaning = aniseptics </li></ul></ul></ul><ul><ul><ul><li>Females – sep...
Urethral catheterization Technique <ul><li>Relax ---------- valium </li></ul><ul><li>Push whole length in – till bifercati...
Urethral catheterization Technique <ul><li>Resistance  -- look for help </li></ul><ul><ul><li>refer  </li></ul></ul><ul><u...
<ul><li>Closed drainage system </li></ul><ul><li>Antibiotecs </li></ul><ul><li>Size of cath </li></ul><ul><li>Leakage  blo...
Chronic Retention <ul><li>High residual volume urine , >250cc </li></ul><ul><li>Longstanding, painless, not precisely palp...
Chronic Retention <ul><li>Treatment  </li></ul><ul><ul><li>INTERNAL CATHETERIZATION  </li></ul></ul><ul><ul><li>NOT EXTERN...
Chronic Retention <ul><li>Complications </li></ul><ul><ul><li>Hematuria  </li></ul></ul><ul><ul><ul><li>slow decompression...
RETENTION WITH OVERFLOW / PARADOXICAL INCONTENANCE <ul><li>Incontinence associated with a full bladder  </li></ul><ul><li>...
 
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Retention of urine

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Retention of urine

  1. 1. RETENTION OF URINE DR AHMED REHMAN FCPS (URO) Assistant Professor of Urology
  2. 2. Causes of Frequency – Dysuria <ul><li>Acute Cystitis and urethritis </li></ul><ul><li>VUR, and vesical diverticulum neurogenic bladder / decompensation of bladder Cystocele / UV prolapse vesical calculus, foreign body neoplasm of blader, urethra, prostate and penis </li></ul><ul><li>bladder neck stenosis, Post urethral,valve Urethral stricture Enlarged prostate--------- benign / malignant / inflammatory Urethral Stone / foreign body impaction Ext, meatal stenoaia Phemosis / fused synichae, </li></ul><ul><li>Detrusor sphincter dyssynergia frequency – dysuria syndrome </li></ul><ul><li>Atrophic urethritis (senile) </li></ul><ul><li>Distal urethral syndrome </li></ul><ul><li>Abacterial cystitis /urethritis ( mycoplasma, herpes, chemical) </li></ul><ul><li>TB, schistosomiasis </li></ul><ul><li>Intersitial cystitis </li></ul><ul><li>Cystitis cystca and Alkaline encrustin cystitis </li></ul><ul><li>Pregnancy, diabetes, LVF, CCF, diuretics, polyuria </li></ul>
  3. 3. Physiology of bladder <ul><li>Low pressure reservoir (compliance / distensibility) 400-550 cc at around 5cm water (<15cm) </li></ul><ul><li>Sensations of fullness ( 250cc +) </li></ul><ul><li>Initiation and maintenance of Contractions till its complete evacuation (micturation 60cm, IVP >80cm + UF <15cc/min = BOO) (BOO, VUR, diverticulum, DSD, LMNL bladder, cystocele) </li></ul><ul><li>volentarily voiding / inhibition of mict. </li></ul><ul><li>Antireflex mech </li></ul><ul><li>Contenance (trigone, neck, internal & external sphincters, urethra) </li></ul>
  4. 4. Micturation Reflex <ul><li>Afferants from bladder activate sacral spinal cord centre which through their efferants cause Contraction of detrusor and relaxation of sphincters </li></ul><ul><li>Higher Centre facilitate or inhibit pons / mid brain </li></ul><ul><ul><li>Medial pontine nuclei Micturation </li></ul></ul><ul><ul><li>Lateral pontine nuclei inhibition </li></ul></ul><ul><ul><li>DSD </li></ul></ul>
  5. 5. Inability to Pass Urine <ul><li>Retention of Urine </li></ul><ul><ul><ul><li>When patient, despite an urge to void, is unable to push urine out of bladder due to either infravesical obstruction or inability to generate effective detrusor contractions. Correct catheterization yields urine relieving symptoms. </li></ul></ul></ul><ul><li>Anuria </li></ul><ul><ul><ul><li>A condition when either urine is not being produced ( pre-renal & renal) or is not reaching urinary bladder (post-renal / obstructive). No urge to void. Even on correct catheterization, no urine is drained. </li></ul></ul></ul><ul><li>Extravasion </li></ul><ul><ul><ul><li>Leakage of urine into tissues / body cavity (peritoneum) </li></ul></ul></ul>
  6. 6. Types of Retention <ul><li>Acute Retention </li></ul><ul><ul><li>Agonizing painful condition with intense urge </li></ul></ul><ul><ul><li>Well defined palpable & tender bladder </li></ul></ul><ul><li>Chronic Retention </li></ul><ul><ul><li>Painless condition of incomplete bladder evacuation / high residual urine, (>250cc) </li></ul></ul><ul><ul><li>Bladder percussible but not well palpable/tender </li></ul></ul>
  7. 7. Causes of retention - boys <ul><li>Phemosis </li></ul><ul><li>Scab – meatal ulcer </li></ul><ul><li>External meatal stenosis </li></ul><ul><li>Urethritis </li></ul><ul><li>Urethral stricture </li></ul><ul><li>Urethral trauma </li></ul><ul><li>Post. & ant. Urethral valves </li></ul><ul><li>Vesical / urethral calculus </li></ul><ul><li>Blader neck stenosis </li></ul><ul><li>Neurogenic bladder </li></ul><ul><li>Constipation </li></ul><ul><li>Drugs </li></ul>
  8. 8. Causes of retention - girls <ul><li>Synechia vulvae Urethritis </li></ul><ul><ul><li>uncommon </li></ul></ul><ul><li>Urethral stricture / trauma </li></ul><ul><li>Vesical / urethral calculus </li></ul><ul><li>Blader neck stenosis </li></ul><ul><li>Neurogenic bladder </li></ul><ul><li>Constipation Drugs </li></ul>
  9. 9. Causes of retention – young males <ul><li>Meatal ulcer / stenosis </li></ul><ul><li>Urethral stricture / stone / abscess / trauma </li></ul><ul><li>Bladder stone </li></ul><ul><li>Drugs / anesthesia </li></ul><ul><li>Spinal shock / neurogenic bladder / DSD </li></ul><ul><li>Prostatitis / prostatic abscess </li></ul><ul><li>utrethritis </li></ul><ul><li># penis </li></ul><ul><li>Para phemosis / phemosis </li></ul>
  10. 10. Causes of retention – young females <ul><li>Hysterical conversion reaction </li></ul><ul><li>Drugs /anesthesia </li></ul><ul><li>Pain ( parturition, epi-, vaginal surgery) </li></ul><ul><li>Retroverted gravid uterus </li></ul><ul><li>MS </li></ul><ul><li>Cystocele / bladder stone </li></ul><ul><li>Neurogenic bladder </li></ul>
  11. 11. Causes of retention – elderly males <ul><li>BPH, CaP, abscess </li></ul><ul><li>Stone, Ca UB, clot retention </li></ul><ul><li>Stricture/stone/abscess /rupture –urethra </li></ul><ul><li>Meatal stenosis, Phemosis, para-phemosis </li></ul><ul><li>Drugs / anesthesia, </li></ul><ul><li>Disc prolapse / cauda equina syndrome </li></ul><ul><li>spinal shock , neurogenic bladder </li></ul><ul><li>Ca penis </li></ul><ul><li>Bladder neck stenosis / hypertrophy </li></ul><ul><li>Diabetic sensory neuropathy </li></ul><ul><li>Pelvic surgery, anal fissure, hemorrhoids </li></ul><ul><li>Obstructed hernia </li></ul>
  12. 12. Causes of retention – elderly females <ul><li>Atrophic urethritis </li></ul><ul><li>Meatal stenosis </li></ul><ul><li>Ca UB, clot retention </li></ul><ul><li>Neurogenic blader, </li></ul><ul><li>Carancle </li></ul><ul><li>Stricture / stone/rupture –urethra </li></ul><ul><li>Cystocele/ prolapse </li></ul><ul><li>Drugs / anesthesia, </li></ul><ul><li>Disc prolapse / cauda equina syndrome </li></ul><ul><li>spinal shock </li></ul><ul><li>Bladder neck stenosis / hypertrophy </li></ul><ul><li>Diabetic sensory neuropathy </li></ul><ul><li>Pelvic surgery, anal fissure, hemorrhoids </li></ul><ul><li>Obstructed hernia </li></ul><ul><li>Urethral diverticulum </li></ul>
  13. 13. History <ul><li>Duration </li></ul><ul><li>Painfull? </li></ul><ul><li>Precipitating factors </li></ul><ul><li>Preceding LUTS </li></ul><ul><li>Other urinary complaints </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Medical illnesses - D/D, co-morbidity </li></ul>
  14. 14. History <ul><li>Catheterization </li></ul><ul><ul><li>Easy </li></ul></ul><ul><ul><li>Caliber </li></ul></ul><ul><ul><li>Urine quantity / color </li></ul></ul><ul><ul><li>Where / by whom </li></ul></ul><ul><ul><li>TWOC </li></ul></ul>
  15. 15. Examination <ul><li>Meatus </li></ul><ul><li>Urethra </li></ul><ul><li>Bladder Ac / Ch </li></ul><ul><li>DRE </li></ul><ul><li>Hernia </li></ul><ul><li>Neurological ex </li></ul><ul><ul><ul><li>Higer mental functions </li></ul></ul></ul><ul><ul><ul><li>Cranial nerves </li></ul></ul></ul><ul><ul><ul><li>Lower limb </li></ul></ul></ul><ul><ul><ul><li>perineum - sensations </li></ul></ul></ul>
  16. 16. Investigations <ul><li>Urine RE/ CS </li></ul><ul><li>RFTS </li></ul><ul><li>US </li></ul><ul><li>X ray KUB </li></ul><ul><li>Urodynamics </li></ul><ul><li>Cystoscopy </li></ul>
  17. 17. Treatment <ul><li>Urethral catheterization </li></ul><ul><ul><li>Technique </li></ul></ul><ul><ul><ul><li>Explain / consent ( need / discomfort) </li></ul></ul></ul><ul><ul><ul><li>Keep Items ready </li></ul></ul></ul><ul><ul><ul><li>Theatre / dressing room / bed </li></ul></ul></ul><ul><ul><ul><li>Supine posture legs separated </li></ul></ul></ul><ul><ul><ul><li>Female – knee bent & separated, feet together </li></ul></ul></ul><ul><ul><ul><li>Gloves </li></ul></ul></ul>
  18. 18. Urethral catheterization Technique <ul><ul><ul><li>Cleaning = aniseptics </li></ul></ul></ul><ul><ul><ul><li>Females – separate labia – clean from before backwards, hold till cath complete </li></ul></ul></ul><ul><ul><ul><li>Prepuse – retract & clean </li></ul></ul></ul><ul><ul><ul><li>Drape </li></ul></ul></ul><ul><ul><ul><li>instill gel – hold 2 min / clamp </li></ul></ul></ul><ul><ul><ul><li>Hold penis with non-dominent hand glans towards head end == Curve “S” ---  “U” </li></ul></ul></ul><ul><ul><ul><li>Use dominant hand for cath </li></ul></ul></ul><ul><ul><ul><li>Gently push cath - non touch technique </li></ul></ul></ul><ul><ul><ul><li>Deep / slow breathing </li></ul></ul></ul>
  19. 19. Urethral catheterization Technique <ul><li>Relax ---------- valium </li></ul><ul><li>Push whole length in – till bifercation </li></ul><ul><li>Don’t inflate till clar urine drained </li></ul><ul><ul><li>gel, misplaced, anuria, extravasion </li></ul></ul><ul><ul><li>Inflate while full length inside / pull afterwards </li></ul></ul><ul><ul><li>Use water = not saline </li></ul></ul><ul><ul><li>Don’t inflate = blood, not sure of position </li></ul></ul><ul><li>Note color amount of urine </li></ul><ul><li>C/S </li></ul><ul><li>Post cath heamaturia - slow/ intermitant / high </li></ul>
  20. 20. Urethral catheterization Technique <ul><li>Resistance -- look for help </li></ul><ul><ul><li>refer </li></ul></ul><ul><ul><li>Suprapubic puncture abscess </li></ul></ul><ul><ul><li>Marryfield introducer </li></ul></ul><ul><ul><li>coude tip cath </li></ul></ul><ul><ul><li>trocar cath == ingram / bard </li></ul></ul><ul><ul><li>Open s/p </li></ul></ul><ul><ul><li>irethral instrumentation = bougies / optical </li></ul></ul><ul><li>Retract prepuse back </li></ul><ul><li>Documentation of procedure </li></ul><ul><li>Exam abdomen </li></ul>
  21. 21. <ul><li>Closed drainage system </li></ul><ul><li>Antibiotecs </li></ul><ul><li>Size of cath </li></ul><ul><li>Leakage blocked / spasm </li></ul>
  22. 22. Chronic Retention <ul><li>High residual volume urine , >250cc </li></ul><ul><li>Longstanding, painless, not precisely palpable, dull to percussion </li></ul><ul><li>High / low pressure ch. Retention </li></ul><ul><li>Upper tract dilatation / deterioration </li></ul><ul><li>Causes </li></ul><ul><ul><li>Long standing BOO </li></ul></ul><ul><ul><li>LMNL </li></ul></ul>
  23. 23. Chronic Retention <ul><li>Treatment </li></ul><ul><ul><li>INTERNAL CATHETERIZATION </li></ul></ul><ul><ul><li>NOT EXTERNAL CATH </li></ul></ul><ul><ul><li>CATH IS NOT A RISK FOR INFECTION, IT RATHER CURES INFECTION </li></ul></ul><ul><ul><li>CURE OF PYO-CYSTITIS IS DAINAGE LIKE I/D FOR ABSCESS </li></ul></ul>
  24. 24. Chronic Retention <ul><li>Complications </li></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><ul><li>slow decompression </li></ul></ul></ul><ul><ul><ul><ul><li>clamp / non-gravity dependant / elevate </li></ul></ul></ul></ul><ul><ul><li>Crit >200 mmole = post obst diuresis </li></ul></ul><ul><ul><ul><li>Concentration ability </li></ul></ul></ul><ul><ul><ul><li>Fluid overload / backlog </li></ul></ul></ul><ul><ul><ul><li>Osmotic diuresis </li></ul></ul></ul><ul><ul><li>Dehydration / ellectrolyte disturbances </li></ul></ul><ul><ul><ul><li>Replacement of fluid / Na </li></ul></ul></ul><ul><ul><ul><ul><li>ml to ml replacement on hourly basis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Later -- one litre less then prvious days output </li></ul></ul></ul></ul><ul><ul><ul><ul><li>oral / intravenous saline. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Potassium only if low ---- renal failure </li></ul></ul></ul></ul><ul><li>Infection </li></ul>
  25. 25. RETENTION WITH OVERFLOW / PARADOXICAL INCONTENANCE <ul><li>Incontinence associated with a full bladder </li></ul><ul><li>Almost same as ch. retention </li></ul>
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