Approach to Urinary Retention in the Emergency Department - Andrew Lohoar SJRH Emergency Department Rounds

Approach to Urinary Retention in
  the Emergency Department

              Andrew Lohoar
     SJRH Emergency Department Rounds
                June 2021

Objectives
•   Introduction
•   Physiology
•   Etiology
•   Treatment
•   Discussion/Conclusions

Case 1

• 72 y.o. with history of DM, HTN presents to
  peripheral hospital (CCH) with inability to
  urinate x 8 hours

Acute Urinary Retention

• Definition: Painful, palpable or percussable
  bladder when patient is unable to pass any
  urine*

(* Not always perceived by certain patients – i.e. delerium,
neurologic conditions, decreased LOC etc.)

Physiology of Micturition

Physiology of Micturition

Etiology
• Structural – Intrinsic, extrinsic

• Iatrogenic – Pharmacological and
               non-pharmacological

• Infectious – Inflammatory narrowing

• Neurologic – CES, stroke, Parkinson’s, DM

Investigations
• Physical exam

• POCUS, bladder scan

• Labs – to identify renal failure, UTI

Calculating bladder volume with
             POCUS

Treatment
• Goal of therapy:

  1) Decompress bladder

  2) Mitigate cause of retention if possible

Case 1

• 72 y.o. with history of DM, HTN presents to
  peripheral hospital (CCH) with inability to
  urinate x 8 hours

• Attempt at catheterization with standard
  Foley catheter fails

Challenging urethral catheter
                 placement
• Stepwise approach:

   1) Consider contraindications – recent surgery, trauma

   2) Anesthesia/lubricant

   3) Standard tip Foley catheter (or 3-way catheter in patient with
   gross hematuria)

   4) Coudé tip

   5) Silastic catheter

Challenging urethral catheter
         placement

Case 1

• 72 y.o. with history of DM, HTN presents to
  peripheral hospital (CCH) with inability to urinate
  x 8 hours

• Attempt at catheterization with standard Foley,
  Coudé and Silastic all fail

• And there is a blizzard outside..

SPC Kit with Trocar

Challenging urethral catheter
              placement

• Suprapubic cystostomy

SPC – Seldinger Kit

SPC as first line for AUR?

• 86 consecutive patients to ED in Ireland needing catheterization with AUR from BPH

• “In conclusion, this study has shown that the use of suprapubic catheters in acute
  urinary retention significantly reduces the risk of urinary tract infection and
  urethral stricture formation. It also allows for a trial of micturition without the
  discomfort, the urethral trauma and the risk of infection associated with the re-
  insertion of a urethral catheter.”

Slow versus Rapid Bladder
                  Decompression
Rapid versus gradual bladder decompression in acute urinary retention
  Mohamed H. Etafy, Fatma H. Saleh, Cervando – 2017 Urol Ann

•   62 patients with AUR secondary to BPH

•   “We conclude that there is no significant difference between rapid and
    gradual decompression of the bladder in patients with AUR. Hematuria
    and hypotension may occur after rapid decompression of the obstructed
    urinary bladder, but these complications are rarely clinically significant”.

Treatment
• Medications: Alpha-adrenergic blockers

• Follow-up

• Admission

Medication

•   2014 Cochrane review

•   9 RCT comparing alpha blockers to placebo

• “There was some evidence to suggest that alpha blockers increase the success
  rates of trial without catheter, and the incidence of adverse effects was low.
  There was some evidence of a decreased incidence of acute urinary retention. The
  need for further surgery, cost effectiveness and recommended duration of alpha
  blocker treatment after successful trial without catheter remain unknown as these
  were not reported by any trial”

Disposition
• Urology follow-up
  – Timing for trial of voiding: 3-7 days
  – Higher rates of complications with catheter in
    place longer length of time

• Admission
  – Large variation worldwide admission rates
  – Consider admission with sepsis, significant acute
    kidney injury, concerns re: catheter management

Approach to special populations

• Pediatrics

• Women

- Higher incidence serious diagnoses
- Usually require more thorough work-up

Conclusions
• Medical history should include inquiry into neurologic,
  infectious, medication as well as structural etiologies for
  retention
• Consider stepwise approach to difficult urethral
  catheterization
• Consider SPC (using Seldinger approach with U/S guidance)
• No routine antibiotics after catheterization (consider one time
  dose if traumatic or repeated attempts)
• Discharge with alpha blocker if BPH
• Urology follow-up for trial of urination within 7 days

References
• Billet M. Urinary Retention. Emerg Med Clin N Am 37
  (2019) 649–660
• Gelber J. Management of acute Urinary Retention in the
  Emergency Department. Emerg Med Practice 2021 23(3):
  1-25
• Mohamed H. Etafy et al. Rapid versus gradual bladder
  decompression in acute urinary retention. Urol Ann.
  20`17; 9():339-342.
• A. F. Horgan et al. Acute Urinary Retention. Comparison
  of Suprapubic and Urethral Catheterisation. Br J Urology
  (1992). 70, 149-151