Consider catheter when bladder volume assessed > 500 mls and pain or agitation or delirium. If no bladder scanner then catheterise on basis of clinical findings and measure residual
- Patient presents and is unable to micturate and is in pain
- Those with dementia or mute may not complain of pain but may be distressed
Aetiology: often multifactorial
- Acute painful inability to micturate with a full bladder
- General: Prostate infection, bladder overdistension, excessive fluid intake, alcohol consumption, sexual activity, debility, and bed-rest have all been
- Drugs: Decongestants, Antihistamines, Amphetamines, Morphine, Hyoscine, Tricyclic antidepressants
- Other causes: Urethral stricture, BPH, Acute prostatic haematoma, Prostate cancer, Bladder neck contracture, Urethral stone, Foreign body, Iatrogenic e.g. urinary stent occlusion
- Other causes: Neurological disease: MS, Parkinson's, Tabes Dorsalis, Alzheimer's, Spinal cord injury, Stroke, Tumour, Spinal anaesthesia, Surgery, Pain, UTI, Acute prostatitis
- Females: Organ prolapse, Pelvic mass, Gravid uterus, Vulvovaginitis, Herpes
- The bladder is full and often palpable
- Bladder scanner (if available) shows volume > 500 mls
- There is usually pain and discomfort
- Get a drug and physical history, exclude constipation and UTI
- Consider PR examination after catheterised.
- Please record volume of urine in notes
- Get Bladder USS to confirm full bladder.
- Check FBC, U&E, CRP, Ca
- Urinalysis and send for culture if indicated
- Allow the patient to attempt to use the toilet in a quiet place and undisturbed. Run taps/shower.
- Some may find it easier to urinate in a bath or shower to help relax.
- Some with painful genital herpes and pain might be able to micturate in warm saline bath or shower
- If fails then need to insert a urinary catheter the exception would be those with recent pelvic or perineal trauma-fractured pelvis who may have blood at the meatus and need a urology assessment for a suprapubic catheter,
- If residual < 1 litre: if not on drug therapy then start Tamsulosin 400 mcg od. Plan TWOC in the community in 7-10 days. If previous failed TWOC already then referral for urology. TWOC is appropriate (unless medication not started previously)
- If residual > 1 litre and abnormal kidney function: Contact on-call urology for admission. Pt will need careful fluid balance, lying + standing blood pressures and daily weighs
- If residual > 1 litre with normal renal function and no diuresis may be acute on chronic retention.Referral to urology TWOC clinic with appropriate medication (Tamsulosin) if not already started
- Treat any UTI, treat constipation
- If AKI/CKD exclude obstructive causes and get advice
Unable to pass a Urethral Catheter
- Use appropriate technique with 2 tubes of instillagel X1 if still fails for referral to on-call Urology Reg. Use a 14 french in a male. Lift penis up straight and taught to avoid urethral kinking. Pass catheter down with a constant swift motion, all the time conversing with the patient and ensuring he is relaxed. If it stops at prostate level then ask the patient to cough whilst applying gentle pressure -This should allow the external urethral sphincter (see picture) to relax and catheter to pass.-If significant resistance is felt then STOP.-Once in the bladder and catheter pushed up to the hilt and urine is seen/aspirated from catheter then inflate the balloon.-Ensure foreskin retracted back if present
- They may suggest try again with a coude catheter which may be able to navigate the prostatic urethra
- Needle aspiration of the bladder is a time delaying tactic. Insert a green needle in midline 2 cm above symphysis and insert while aspirating. Remove as much urine as possible and record. Can then have suprapubic inserted if needed later.
Trial without catheter
- The catheter may be removed after a number of days if the acute causes resolve. The patient is allowed to pass urine.
- Commence an alpha-adrenoceptor blocker (such as alfuzosin hydrochloride, doxazosin, tamsulosin hydrochloride, prazosin, indoramin or terazosin) should be given for at least two days to manage acute urinary retention.
- Drug Treatment should initially be reviewed after 4-6 weeks and then every 6-12 months.
- if the patient fails for a second time then reinsert the catheter and consider urology outpatient follow up.
Caution with catheter: discuss with urology
- Caution when it occurs after recent urethral surgery
- Unexplained haematuria
- History of false passages /strictures
- Pelvic or perineal trauma-fractured pelvis, Urinary infection
- Suprapubic catheters, if they fall out, must be replaced as a matter of urgency to prevent the tract from closing up. SPC needs to be replaced ASAP, most start closing over after an hour, making replacement difficult-If changing then ensure bladder full prior to the change. Fill the bladder with 300mls N. saline.-If multiple recent SPC failures then consider bladder stones (XRKUB/USSKUB)-If unable to change please contact the urology service as above. If in pain, and SPC out for a significant time, and has normal urethra for urethral catheterisation. Then refer to urology for SPC re insertion as OPD
- Intermittent self catheterisiton
- Suprapubic catheter.
- In extremist when no other option and cannot manage a urethral catheter consider bladder aspiration with a green needed.