Rosen & Barkin's 5-Minute Emergency Medicine Consult (742 page)

See Also (Topic, Algorithm, Electronic Media Element)

• Chancroid
  
• Epididymitis/Orchitis
  
• Gonococcal Disease
  
• Herpes, Genital
  
• Lymphogranuloma Venereum
  
• Pelvic Inflammatory Disease
  
• Prostatitis
  
• Syphilis
  
• UTIs, Adult
  
• UTIs, Pediatric
  
• Vaginal Discharge/Vaginitis
  

CODES

• 098.0 Gonococcal infection (acute) of lower genitourinary tract
  
• 131.02 Trichomonal urethritis
  
• 597.80 Urethritis, unspecified
  

BASICS

• Acute urinary retention (AUR):
  
  • Sudden inability to void spontaneously
    
  • Occurs most frequently in men >60 yr old
    
  • Most common cause of AUR in the ED is benign prostatic hyperplasia (BPH)
    

• Multiple diagnostic considerations, following list is not exhaustive
  
• Anatomic:
  
  • Penis:
    
    • Phimosis
      
    • Paraphimosis
      
    • Meatal stenosis
      
    • Foreign-body constriction
      
  • Urethra:
    
    • Tumor
      
    • Pelvic masses
      
    • Prolapse of pelvic organs
      
    • Foreign body
      
    • Calculus
      
    • Urethritis
      
    • Stricture
      
    • Meatal stenosis (can also be seen in females)
      
    • Hematoma
      
    • Vulvar edema after vaginal delivery
      
  • Prostate gland:
    
    • Benign prostatic hypertrophy
      
    • Carcinoma
      
    • Prostatitis
      
    • Contracture of bladder neck
      
    • Prostatic infarction
      
• Neurologic causes:
  
  • Motor/paralytic:
    
    • Spinal shock
      
    • Spinal cord syndromes
      
  • Sensory/paralytic:
    
    • Diabetes
      
    • Multiple sclerosis
      
    • Spinal cord syndromes
      
• Drugs:
  
  • Antihistamines
    
  • Anticholinergics
    
  • Antispasmodics
    
  • Tricyclic antidepressants
    
  • α-Adrenergic stimulators
    
  • Narcotics
    
  • NSAIDs
    

DIAGNOSIS

• Lower abdominal or suprapubic discomfort
  
• Patients may appear restless or in distress
  
• Chronic urinary retention usually painless
  

• Past medical history:
  
  • History of urinary retention?
    
  • History of BPH or prostate cancer?
    
  • History of other cancer?
    
  • History of radiation treatment?
    
  • History of pelvic trauma?
    
• Any signs or symptoms of infection including an abscess?
  
• Any signs or symptoms of calculus?
  
• Any neurologic symptoms?
  
• History of or current IV drug abuse?
  
• Back pain?
  
• Complete list of all medications
  

• Vitals (Any evidence of infection? Shock?)
  
• Abdominal exam
  
• Rectal exam
  
• Genitourinary exam; consider pelvic exam in all women
  
• Thorough neurologic exam if appropriate
  
• In the trauma patient, evaluate for evidence of urethral injury
  

Due to the multiple causes of AUR a thorough history and physical exam are imperative, and will determine further workup

• Basic chemistry to assess renal function only if concerned for acute renal insufficiency (this usually does not occur in AUR)
  
• No benefit to PSA test in ED; usually elevated in setting of AUR
  
• Urinalysis if indicated on history or exam
  

• Abdominal or pelvic US or CT abdomen/pelvis if concerned for mass, malignancy, abscess, bladder calculi, or other anatomic etiologic agent
  
• Neuro or spinal imaging if there is concern for an acute neurologic process
  

Postvoid residual: More than 200 mL is usually considered abnormal.

Chronic urinary retention

TREATMENT

Address any life-threatening presentation

• Identify and treat any life-threatening presentation
  
• Prompt bladder decompression:
  
  • Try placement of 14–18F urinary catheter
    
  • If unable to pass a 14–18F catheter and there is a history of prior transurethral procedure or known stricture, downsize to a 10–12F
    
  • In men with no prior instrumentation and unable to pass catheter, consider a 20–22F catheter with a coudé tip
    
  • If unable to pass a catheter, then either suprapubic aspiration as a temporizing measure or placement of suprapubic catheter is indicated
    
• Defer catheterization of the ureter in the trauma patient suspected of having a ureteral injury (gross hematuria, high-riding prostate on rectal exam, blood at the meatus) until a retrograde urethrogram has been done
  

• Drain bladder and monitor urine output:
  
  • Rapid decompression following catheter placement may result in transient gross hematuria, rarely clinically significant
    
  • Postobstructive diuresis:
    
    • Can be a complication of AUR in the catheterized patient
      
    • No randomized trials comparing rapid and intermittent bladder decompression
      
    • It is generally now felt that rapid bladder decompression is safe provided that supportive care is available if hypotension develops
      
• Probably best to observe for 2–3 hr after bladder decompression to ensure that a postobstructive diuresis does not cause clinical deterioration
  
• Place leg catheter bag before discharge if catheter is to remain indwelling
  
• Educate patient and family on catheter care.
  
• Although commonly used, prophylactic antibiotics are not indicated for patients with an indwelling urinary catheter and no evidence of infection
  
• Start patients with BPH on an α-blocker
  
• Consider stopping any medication that may be contributing to AUR
  
• Treat constipation if appropriate
  

• Prazosin HCl (Minipress) for treatment of BPH: Initially 1 mg PO BID to TID, slowly increase to 20 mg/d in div. doses
  
• Tamsulosin (Flomax) is an α-1 antagonist used to treat BPH: 0.4 mg PO QD after the same meal daily; may increase to 0.8 mg PO QD
  
• Alfuzosin (Uroxatral) is an α-blocker used to treat BPH: 10 mg PO daily after the same meal each day
  
• Terazosin (Hytrin) facilitates urinary flow in the presence of BPH: Start 1 mg PO QHS, max. 20 mg/d
  

FOLLOW-UP