PRINCIPLES IN THE

MANAGEMENT OF ACUTE
AND CHRONIC
RETENTION OF URINE
By
ANGEL JOHN
 Urinary retention is the inability to empty the bladder completely,
leading to accumulation of urine within the urinary bladder.

• The adult bladder typically holds 250–450 mL before triggering the micturition
reflex.
• In retention, the patient passes very small amounts of urine or is unable to void at
all, causing progressive bladder distention.
• In severe cases, the bladder may distend to 1500–2000 mL or more.

In urinary retention, kidneys produce urine normally, but outflow is blocked →

distended bladder.
In anuria due to renal failure, kidneys fail to produce urine →
no bladder distension, as the bladder is empty.
TYPES OF URINARY RETENTION

• Acute retention

• Chronic retention

• Acute on chronic retention

 CAUSES
MALE
• BPH in old.
• Stricture urethra in young.
• Trauma-urethral/pelvic.
• Postsurgical-perineal surgeries like haemorrhoidectomy; fistulectomy; fissurectomy; pelvic
surgeries; surgeries for fracture hip/fracture pelvic bone.
• Bladder outlet obstruction.
• Carcinoma of prostate.
• Benign prostatic hyperplasia (BPH)
• Bladder tumour near bladder neck
• Bladder neck hypertrophy
• Prostatitis or urethritis
FEMALE
• Uterine prolapse.
• Urethral stricture.
• Uterine/Ovarian surgeries

IN INFANTS AND CHILDREN

• Posterior urethral valve.
• Meatal stenosis

MISCELLANEOUS
• Faecal impaction
• Clot retention
• Drugs: anticholinergics, opioids
 CLINICAL FEATURES
ACUTE RETENTION
• Painful, sudden inability to pass urine.
• Palpable, tender, distended bladder.
• Dullness to percussion.
• Patient restless, distressed.
• Check lower limb reflexes (exclude neurogenic).

CHRONIC RETENTION
• Usually painless, discovered incidentally.
• Large bladder, often palpable up to umbilicus.
• Overflow incontinence may be present.
• Features of renal failure in severe cases:
– anorexia
– vomiting
– anaemia
– dehydration
INVESTIGATIONS

INITIAL ASSESSMENT

• History: drugs, constipation, previous LUTS, surgeries

• Physical exam:
– Abdominal palpation
– DRE (prostate)
– Perianal sensation, anal tone
– Lower limb reflexes
PER RECTAL EXAMINATION
• To assess prostate size, consistency, nodularity.
• To look for neurological tone of anal sphincter.

Important findings:
• Enlarged, smooth prostate → BPH.
• Hard, irregular prostate → carcinoma prostate.
• Poor sphincter tone → neurogenic bladder.
• Sometimes in acute retention, prostate may be difficult to feel due to full
bladder.
BASIC INVESTIGATIONS
Ultrasound KUB
• To confirm bladder distension
• To evaluate kidneys & ureters for hydronephrosis
• To identify underlying causes (prostate enlargement, stones, masses)

Findings:
• Distended bladder with retained urine
• Increased post-void residual (PVR) volume
• Hydroureter / hydronephrosis in obstructive uropathy
• Enlarged prostate
• Bladder wall trabeculation (chronic obstruction)
Urine Routine & Microscopy
To look for infection, hematuria, crystals
Findings:
• Pyuria → UTI-induced retention
• Hematuria → stone / malignancy / infection
• Crystals → stone disease
• Proteinuria/ketones if diabetic or renal dysfunction

Blood Urea & Serum Creatinine

• Assesses kidney function
• Detects obstructive uropathy-induced renal impairment
Findings:
• Elevated urea/creatinine → acute kidney injury or chronic renal failure from
obstruction
• Electrolyte abnormalities (high potassium in chronic cases)
PSA (if prostate enlargement suspected)
To differentiate BPH vs carcinoma prostate
Findings:
Elevated PSA → prostatitis / BPH / carcinoma

Post-Void Residual (PVR) Measurement

To quantify incomplete bladder emptying
Findings:
• PVR > 100 mL → inadequate emptying
• PVR > 300–400 mL → chronic retention
• Very high PVR (>1 L) → atonic, overstretched bladder
Renal Function Test + Electrolytes
To assess complications from chronic obstruction
Findings:
• Hyperkalemia
• Metabolic acidosis
• Elevated creatinine (post-renal AKI)

X-ray / CT (only if stone or trauma suspected)

Detect urethral trauma, bladder rupture, pelvic fractures, stones
Findings:
• Urethral injury → retrograde urethrogram abnormal
• CT → stones, pelvic fractures, bladder injury
PRINCIPLES OF MANAGEMENT OF ACUTE RETENTION

Goals
• Immediate bladder decompression
• Diagnose underlying cause
• Prevent recurrence
• Manage complications
Initial Step — Catheterization
First-line: Urethral catheterisation (14F Foley)

Males
• Thorough hand wash; sterile gloves are donned.
• The genitalia are cleaned using soapy antiseptic.
• Lidocaine gel is inserted into the urethra, warn the patient about stinging.
• The jelly should be massaged posteriorly in an attempt to anaesthetise the
sphincter region, and it is of advantage to place a penile clamp for several
minutes.
• A small Foley catheter should be passed while the penis is held taut.
• If no stricture → catheter should pass freely
• After urine drains → advance catheter a few more cm so the balloon is well
inside bladder
(prevents accidental balloon inflation in the prostate)
 Females
• The labia should be parted using the middle and index fingers of the
left hand, which should not be moved once cleaning has been
performed.
•Gently insert catheter through the urethral meatus
•If no stricture → catheter passes freely
•Force must not be used
After Catheterisation
• Record total volume of urine drained
• Examine abdomen
To exclude other causes that mimic retention:
• Ruptured abdominal aortic aneurysm
• Ureteric colic
• Diverticulitis
If the Catheter does not pass
Common causes:
• Poor technique
• Inadequate anaesthesia
• Trauma to urethra
• Urethral stricture
• Large prostatic middle lobe obstructing entry into bladder

 Try a Coudé catheter (curved tip) — sometimes succeeds

 If still unsuccessful → Suprapubic puncture is the next management step
SUPRAPUBIC CATHETER (SPC)

Foley Catheterization Fails → Suprapubic Catheter (SPC)

Indications:
• Severe stricture
• Acute urethral trauma
• Failed urethral catheterization attempts

Types of SPC:
• Malecot catheter (open method)
• Foley catheter (trocar puncture method)
Preparation
• Anaesthetise skin, fascia, and retropubic space using 0.5% lidocaine
• Confirm bladder position by aspiration of urine
Trocar / Needle Technique
• Insert a large-bore needle into bladder
• Pass a fine catheter (Cystofix) through needle → secure in place
• OR use plastic suprapubic trocar & cannula (Add-a-Cath method)
• Pass a 12F Foley through cannula
• Inflate balloon
• Remove cannula + plastic strip

• Do NOT insert trocar if urine cannot be aspirated → risk of bowel injury

• If devices unavailable → perform open SPC
• Small suprapubic incision
• Direct visualization
• Catheter placed under local anaesthetic
IDENTIFY AND TREAT CAUSE
→ BPH / Prostate Enlargement
• Definitive treatment = TURP / prostatectomy
• 5-α reductase inhibitors for large prostates (>35 mL)

→ Stricture Urethra
• Options: dilatation, internal urethrotomy

→ Neurogenic Bladder
• Intermittent self-catheterisation
• Avoids continuous catheter-related infection
 CHRONIC RETENTION MANAGEMENT
1. Immediate Bladder Drainage
Indicated when there is:
– Obstructive uropathy
– Infection
– Significant renal impairment
Early catheterisation prevents worsening renal damage.

2. Monitor for Post-Obstructive Diuresis

After catheterisation, patient may pass litres of urine in 24–48 hrs.
This occurs due to:
– Offloading of retained salt + water accumulated over weeks
– Loss of corticomedullary concentration gradient from chronic back-pressure
– High urea causing osmotic diuresis

3. Elective vs Conservative Management

If renal function is normal and upper tract changes are absent → may manage conservatively or
plan elective surgery.
SPECIAL PROBLEMS IN THE MANAGEMENT
OF CHRONIC RETENTION

[Link] with Low Residual Urine & Good Renal Function

• Chronic retention but low post-void residual urine
• No infection symptoms
• Normal renal function
→ Catheterisation NOT mandatory
→ Can be taken directly for prostatectomy in the next available list.

2. Patients Who Are Uraemic

• High urea/creatinine due to chronic obstruction
→ URGENT catheterisation required
• Benefits:
– Decompresses bladder
– Allows renal function to stabilise before definitive surgery
3. Haematuria
• Common after decompressing a chronically distended bladder.
• Causes:
– Sudden collapse of distended bladder
– Decompression of upper urinary tract
• Usually resolves within 48 hours.

4. Dehydration in Uraemic Patients

• These patients often present dehydrated.
• Mechanism:
– Chronic obstruction → ↓ tubular concentrating ability
– Kidneys cannot reabsorb salt + water
• After catheterisation, this defect becomes obvious → diuresis + risk of
dehydration
5. Post-Obstructive Diuresis
• Patients may pass very large volumes of urine after relief of obstruction.
• Risks:
– Severe salt + water loss
– Hypovolaemia
– Electrolyte imbalance (↓Na⁺, ↓K⁺)

6. Essential Monitoring
To prevent complications:
• Strict input–output charting
• Daily body weight
• Serial serum creatinine & electrolytes
• IV fluids if oral intake insufficient

7. Anaemia in Chronic Retention

• Chronic obstruction → chronic renal impairment → anaemia
• Transfusion indicated ONLY:
– After fluid balance stabilises
– If Hb < 9 g/dL