LUTSRETENTION OF URINE,

ANURIA

DR AHMED REHMAN

FCPS (URO)

Assistant Professor of Urology

Learning Objectives

To understand the definitions &

Know causes of

Be able to take elaborate history

And conduct a relevant clinical exam

Be able to suggest relevant investigations

LUTS - OBSTRUCTIVE

Static Obstruction (Mass related Increase in Urethral resistance). Poor flow

/ thin stream Hesitancy Intermittency of stream Sense of incomplete evacuation of bladder

Terminal dribbling Retention of urine

Acute / chronic

LUTS - I RRITATIVE

Dynamic Obstruction (Increased adrenergic tone in prostate)Urgency

Frequency

Day time / Night time (nocturia)Urge incontinence

Dysurea

Pain associated with act of micturationBurninng, scalding

Causes of Frequency – Dysuria

• Infections & inflammations nonspecific - Acute Cystitis, urethritis, prostatitis specific - TB, schistosomiasis, Intersitial cystitis Abacterial cystitis /urethritis (

mycoplasma, herpes, chemical) Cystitis cystca and Alkaline encrustin cystitis• BOO +/- sec. infection

Phemosis / fused synichae, Ext. meatal stenosis Urethral Stone / foreign body impaction, Enlarged prostate--------- benign /

malignant / inflammatory/abscess bladder neck stenosis, Post urethral,valve Urethral stricture

neoplasm of bladder, urethra, prostate and penis vesical calculus, foreign body

• Neurogenic

Detrusor sphincter dyssynergia ,neurogenic bladder ,spine trauma, multiple seclerosis.DM

• Stones , vesical , urethral, ureteric• Inncomplete bladder evacuation

VUR, and vesical diverticulum Cystocele / UV prolapse decompensation of bladder / bladder atonia BOO

• Malignancy CIS UB, bladder & prostatic CA

• Miscellaneous Drugs . Anticholinergic, frequency – dysuria syndrome Atrophic urethritis (senile) Distal urethral syndrome Pregnancy, diabetes, LVF, CCF, diuretics, polyuria

Inability to Pass Urine

Retention of Urine 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.

Anuria 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. No urine in bladder on USG, Even on correct catheterization, no urine is drained..

<100 cc urine / 24hrs

Extravasion Leakage of urine into tissues / body cavity (peritoneum

Bladder rupture / perforation

Oligurea<300 ml urine / 24 hrs

Renal failureWhen kidneys no longer able to maintain

renal functionsAcute: sudden, potentiality reversibleSudden rise of S creatinine by 1Chronic: insidious, progressive. nonreversible

Types of Retention

Acute RetentionAgonizing painful condition with intense

urgeWell defined palpable & tender bladder

Chronic RetentionPainless condition of incomplete bladder

evacuation / high residual urine, (>250cc)Bladder percussible but not well

palpable/tender

Causes of retention - boysPhemosisScab – meatal ulcer External meatal stenosisUrethritisUrethral strictureUrethral traumaPost. & ant. Urethral valves Vesical / urethral calculusBlader neck stenosisNeurogenic bladderConstipationDrugs

Causes of retention - girls

Synechia vulvae Urethritis

uncommon

Urethral stricture / trauma

Vesical / urethral calculus

Blader neck stenosis

Neurogenic bladder

Constipation Drugs

Causes of retention – young males

Meatal ulcer / stenosis

Urethral stricture / stone / abscess / trauma

Bladder stone

Drugs / anesthesia

Spinal shock / neurogenic bladder / DSD

Prostatitis / prostatic abscess

utrethritis

# penis

Para phemosis / phemosis

Causes of retention – young females

Hysterical conversion reaction

Drugs /anesthesia

Pain ( parturition, epi-, vaginal surgery)

Retroverted gravid uterus

MS

Cystocele / bladder stone

Neurogenic bladder

Causes of retention – elderly malesBPH, CaP, abscessStone, Ca UB, clot retentionStricture/stone/abscess /rupture –urethraMeatal stenosis, Phemosis, para-phemosis Drugs / anesthesia, Disc prolapse / cauda equina syndromespinal shock , neurogenic bladderCa penis Bladder neck stenosis / hypertrophyDiabetic sensory neuropathyPelvic surgery, anal fissure, hemorrhoidsObstructed hernia

Causes of retention – elderly females

Atrophic urethritisMeatal stenosisCa UB, clot retentionNeurogenic blader,Carancle Stricture / stone/rupture –urethra

Cystocele/ prolapse

Drugs / anesthesia,

Disc prolapse / cauda equina syndrome

spinal shock

Bladder neck stenosis / hypertrophy

Diabetic sensory neuropathy

Pelvic surgery, anal fissure, hemorrhoids

Obstructed hernia

Urethral diverticulum

Work up

ASSESSMENTASSESSMENT-Essential information from

patientLUTS (including QoL Score)

Other Urinary symptoms (eg hematuria)

Previous pelvic surgery (eg Ant Resection)

Neuropathy (eg Parkinsonis, MS,CVA)

Cardiac Problems

Diabetes Mellitus

Fluid Intake & out put chart.

History

Duration of retention

Painfull?

Precipitating factors

Preceding LUTS

Other urinary complaints

Differential diagnosis

Stage of disease

Medical illnesses - co-morbidity

History

Catheterization EasyCaliberUrine quantity / colorWhere / by whom TWOC

EVALUATION BPH symptom scoring

AUA scoring (scoring chart)

AUA SOURCE

Urinary Symptoms (Symptom Score Criteria)

Not at all

Less than 1 time in 5

Less than half the time

About half the time

More than half the time

Almost Always

1. Incomplete emptying

Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

0 1 2 3 4 5

2. Frequency

Over the past month, how often have you had to urinate again less than two hours after you finished urinating?

0 1 2 3 4 5

3. Intermittency

Over the past month, how often have you found you stopped and started again several times when you urinate?

0 1 2 3 4 5

4. Urgency

Over the past month, how often have you found it difficult to postpone urination?

0 1 2 3 4 5

AUA SCORE

Urinary Symptoms (Symptom Score Criteria)

Not at all

Less than 1 time in 5

Less than half the time

About half the time

More than half the time

Almost Always

5. Weak Stream

Over the past month, how often have you had a weak urinary stream?

0 1 2 3 4 5

6. Straining

Over the past month, how often have you had to push or strain to begin urination?

0 1 2 3 4 5

None 1 time 2 times 3 times 4 times 5 or more times

7. Nocturia

Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got in the morning?

0 1 2 3 4 5

AUA Symptom Score

QUALITY OF LIFE DUE TO URINARY PROBLEMS

Delighted Pleased Mostly Satisfied

Mixed-about equally satisfied and un-satisfied

Mostly dis-satisfied

Unhappy Terrible

If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?

0 1 2 3 4 5 6

ASSESMENTASSESMENTCLINICAL

Per abdominal examination and DRENORMALDISTENDED BLADDERSIGNS OF RENAL FAILUREALWAYS EXAMINE

EXTERNAL URINARY MEATUSEPIDYDIMES FOR EPIDYDIMITIS

DREProstate (size/symmetry/consistency), Anal Tone,Rectal masses

Examination

MeatusUrethraBladder Ac / Ch DRE Hernia Neurological ex

Higer mental functions Cranial nerves Lower limb perineum - sensations

ASSESSMENTASSESSMENTLab & Other tests

URINALYSIS / CS

CBE

BLOOD UREA & SERUM CREATININE

U.S.G. RENAL TRACT (POST VOID URINE)

CXR, ECG, RBS.

PSA ? Role of IVU ? Role of Urodynamics

UROFLOWMETRY,PRESSURE FLOW STUDIES.

Investigations

Cystoscopy

Retention Treatment

Urethral catheterizationTechnique

Explain / consent ( need / discomfort)Keep Items readyTheatre / dressing room / bedSupine posture legs separatedFemale – knee bent & separated, feet togetherGloves

Urethral catheterizationTechnique

Cleaning = aniseptics Females – separate labia – clean from before

backwards, hold till cath complete Prepuse – retract & clean Drape instill gel – hold 2 min / clamp Hold penis with non-dominent hand glans towards head

end == Curve “S” --- “U” Use dominant hand for cath Gently push cath - non touch technique Deep / slow breathing

Urethral catheterizationTechnique

Relax ---------- valiumPush whole length in – till bifercationDon’t inflate till clear urine drained gel, misplaced, anuria, extravasion Inflate while full length inside / pull afterwards Use water = not saline Don’t inflate = blood, not sure of position

Note color amount of urineC/SPost cath heamaturia - slow/ intermitant / high

Urethral catheterizationTechnique

Resistance -- look for help refer Suprapubic puncture abscess Marryfield introducer coude tip cath trocar cath == ingram / bard Open s/p urethral instrumentation = bougies / optical

Retract prepuse backDocumentation of procedureExam abdomen

Closed drainage system

Antibiotecs

Size of cath

Leakage blocked / spasm

Chronic RetentionHigh residual volume urine , >250cc

Longstanding, painless, not precisely palpable, dull to percussionHigh / low pressure ch. RetentionUpper tract dilatation / deteriorationCauses Long standing BOOLMNL

Chronic Retention

Treatment INTERNAL CATHETERIZATION NOT EXTERNAL CATHCATH IS NOT A RISK FOR INFECTION,

IT RATHER CURES INFECTIONCURE OF PYO-CYSTITIS IS DAINAGE

LIKE I/D FOR ABSCESS

Chronic RetentionComplications Hematuria

slow decompression clamp / non-gravity dependant / elevate

Crit >200 mmole = post obst diuresis Concentration ability Fluid overload / backlog Osmotic diuresis

Dehydration / ellectrolyte disturbances Replacement of fluid / Na

ml to ml replacement on hourly basis Later -- one litre less then prvious days output oral / intravenous saline. Potassium only if low ---- renal failure

Infection

RETENTION WITH OVERFLOW / PARADOXICAL INCONTENANCE

Incontinence associated with a full bladder

Almost same as ch. retention

RENAL FAILURE

PRE-RENAL (hypotention)Hypovolumia, hemmorhage,sepsis,

cardiogenic shock, aneasthesia, hypoxiaa

RENALDrugs, poisons, contrast media, eclampsia,

myoglobinuria, incompatible blood transfusion, DIC

POST RENAL

Causes of post renal anuria

Bilateral PUJ obstruction by stoneUnilateral PUJ obstruction by stone with contralateral ureteric obstructionBILATERAL Ureteric Obstruction

Extramural Tumors of cervix, ovary, uterous, vagina, urinary bladder, prostate, rectum, colon, caecum & lymphomas Idiopathic retroperitoneal fibrosis Retrocaval ureter Pararenal cysts Aberent vessels LIGATURES

Intraluminal Calculus, sloughed papilla, clot, ureteric malignancy, CRYSTALURIA

Intramural Congenital PUJ obstruction or stenosis Ureterocele and congenital small ureteric orifice Strictures ( stone, repair, tuberculosis, schistosomiasis) Ureteric / vecsical malignanncy Kenks & adhesions ( sec to VUR)

Unilateral PUJ or ureteric obstruction in case of Contralateral nephrectomy Already obstructed or nonfunctional Congenitally absent

History taking

Urge to void

Duration

Pain, hemaaturia, stone passage

Symptoms of uremia

Any precipitating event

Clinical exam

Bladder not palpable

Confirmed by cath

Signs of uremia

Workup

Urine usually not available for testing If ==urine osmolality, Na

Urea, critinineSerum ellectroliteArterial Blood gasesHbXray and ultrasound KUBIUV usually contraindicatedRetrograde Urography CT scan (contrast ???????)RENAL SCAN

Management

SUPPORTIVE Renal support - dialysis Infection control Nutritional support Nursinng care Fluid balance

BYPASS PROCEDURES Ureteric catheterization / stenting Nephrostomy

PCN – percutaneous nephrostomy Open

DEFINATIVE PROCEDURESSS

Dialysis

Diffusion across semipermiable membDialyysis fluidsPeritonnealHemodialysisIndications A acidosis I intoxication O overload (fluid) U uremia P pericarditis P polyneuroathy