• History
  • Is the problem acute or chronic?
    • Pain – tends to indicate that the problem is acute when associated with urinary retention
    • Lack of pain may suggest chronic bladder outflow obstruction with relatively high post void residuals, requiring outpatient workup
  • Baseline urinary tract function?
    • Difficult starting or stopping stream
    • Difficulty maintaining stream
    • How many times do you void during the day / wake up at night to void?
  • Previous history of bladder related issues / prostate issues
  • General patient factors?
    • Is the patient mobile or confined to bed?
    • Have they required opioids frequently?
    • Are they elderly?
    • Are they on any other drugs with anticholinergic properties?
    • What type of surgery? For example, ultra-low anterior rectal resections or spinal surgery can cause a neuropraxia affecting bladder function
• Examination
  • Broad approach required
    • Abdominal examination – bladder palpation and abdominal examination
    • Genitourinary examination – including prostate examination
    • PR exam – size and shape of prostate, presence of constipation, perineal sensation

• Unrecognised urinary retention, bladder over distension which over the long term may result in irreversible detrusor damage
• Bladder scan
  • Simple, often effective. Requires minimal equipment and is safe
  • Not always perfect (e.g. in ascites, abdominal collections, pelvic haematoma, morbid obesity) and is operator dependent
  • Owing to wide variations in PVR in any one client, at least three consecutive readings are recommended to ensure a correct reading
• Abdominal USS
  • Simple and safe. Less convenient than a bladder scan however more reliable
• Measurements required
  • Post Void Residual (estimate / calculation of residual volume of urine after voiding)
    • It is generally considered that a PVR less than 50mL is adequate bladder emptying, while over 200mL is thought to be inadequate
    • Healthy, young person – less than 30mL residual is normal
    • Older person – dependent upon the clinical situation
• Urine MCS, kidney function, FBC, other tests as required

• Common
  • Benign Prostatic Hypertrophy
  • Drug related – Anticholinergic medications, antidepressants, opiate pain relief etc particularly recent changes
  • Urethral stricture
  • UTI
  • Post op status with baseline mild bladder outlet obstruction

Causes of acute urinary retention (in general, male and female)

• Male
  • Obstructive – BPH, Meatal Stenosis, Paraphimosis, Prostate cancer
  • Infective – Balanitis, prostatitis, prostatic abscess
• Female
  • Obstructive – organ prolapse (cystocele, rectocele, uterine prolapse) and pelvic mass (gynaecologic malignancy, uterine fibroid, ovarian cyst and even pregnancy!)
  • Infective – acute vulvovaginitis; vaginal lichen planus; vaginal lichen sclerosis; vaginal pemphigus
• Neurological
  • Disorders of the brain, spinal cord or peripheral nerves can all produce lower urinary tract dysfunction
  • Brain – CVA, concussion, MS, neoplasm, Parkinsons Disease, normal pressure hydrocephalus
  • Spinal Cord – disc disease, dysraphic lesions

• Insert of Foley catheter initially
• Rationalise medications that might be contributing (pain relief, anti-cholinergicsetc)
• Strict adherence to aperients to minimize risk of constipation contributing to symptoms
• Alpha Blockers
  • Can help in BPH, increased bladder neck tone, or prostatitis
  • Risk of postural hypotension – care & counselling in elderly frail patients
  • Risk to patients with upcoming cataract surgery – Floppy Iris Syndrome
• Aim to never remove a catheter after 12pm – TOV should ideally commence in the morning to allow for recognition of failure by day staff
• Failing a TOV
  • Catheter reinsertion
  • Education about management of the leg bag and easing their concerns regarding how to use a tap, how to not get tangled up, how to put on the night bag and empty in the morning
  • Liaison with outpatient services that can help patients at home

• Similar, however in this case the patient has presented with chronic retention?
• Recent PSA testing?
• How long has the poor urinary function been occurring/getting worse (urinary frequency, strained voiding, nocturia, post-terminal dribbling etc)?
• When was the last normal blood test?
• Recent UTI symptoms?

• In this case passage of the IDC yourself may be useful
  • Passage of an IDC through a urethral stricture will quickly prove difficult
  • Passage of an IDC smoothly may represent detrusor failure or bladder outlet obstruction due to benign prostatic hypertrophy, and excludes significant stricture

• Recent history of TURP or urethral surgery demands careful consideration prior to catheterisation – seek urology opinion prior to attempting a catheter
• Prostatic regrowth, urethral/bladder neck scarring and detrusor failure are all important diagnostic possibilities
• Should the patient have a life expectancy of greater than 7years careful diagnostic workup of prostate cancer is required

Causes of chronic urinary retention

• Low pressure failure to empty (detrusor muscle failure -> painless detrusor stretch -> atony -> incomplete emptying)
• High pressure failure to empty due to outlet obstruction (long term BOO -> detrusor hypertrophy -> coarse, thick fibrous band formation -> bladder wall thickening and trabeculation -> high void pressures -> saccule formation -> diverticula formation)

• Insertion of an IDC
• Monitoring of complications
  • Post Void Diuresis (passage of large volumes of urine +++ requiring strict input = output monitoring)
  • Decompression Haematuria – can occur, sometimes requiring washout if recurrent clot blockage of catheter occurs

• Very important to get a history
• If chronic high volume residuals, but stable volumes (<600mL) and nil red flags or signs of infection, renal impairment – outpatient workup without placement of an IDC may suffice
• Always monitor urine output closely following IDC insertion to ensure early detection of post obstruction diuresis

• Selius, B and Subedi, R. Urinary Retention in Adults: Diagnosis and Initial Management. America Family Physician. 2008 Mar 1;77(5):643-650 (Available at:  http://www.aafp.org/afp/2008/0301/p643.html)
• Arianayagam, M et al. Lower Urinary Tract Symptoms. Australian Family Physician. 2011 October. 40(10):758-767 (Available at:  http://www.racgp.org.au/afp/2011/october/lower-urinary-tract-symptoms/)
• Adult Urinary Obstruction, Retention and Bladder Scanning. Home and Community Care (HACC)/Medical Aids Subsidy Scheme (MASS) Continence Project. February 2011 (Available at:  https://www.health.qld.gov.au/__data/assets/pdf_file/0021/436314/clinical-guide-continence-obstr.pdf)