Makindo Medical Notes.com

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. The most common cause of urinary retention in men is benign prostatic hyperplasia. Men with an enlarged prostate can have lower urinary tract symptoms associated with obstruction, such as urinary retention (acute or chronic), frequency, urgency or nocturia.

Quick Guide

About

• 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 mentioned.
• 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

Clinical

• 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

Investigations

• Get Bladder USS to confirm full bladder.
• Check FBC, U&E, CRP, Ca
• Urinalysis and send for culture if indicated

Management

• 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 attempts fail 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 either in 72 hours or later 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

Trial without catheter

• Trial Tamsulosin hydrochloride (alpha-1 adrenoreceptor antagonist) 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.
• Further TWOCs can be attempted (typically following a longer interval and preferably in a specialist TWOC clinic), however multiple failed attempts may warrant a long-term catheter, until definitive management can be arranged to treat the underlying cause.

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

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.

Large Prostate

• In patients with an enlarged prostate, a raised prostate specific antigen concentration, and who are considered to be at high risk of progression (such as the elderly), a 5α-reductase inhibitor (such as finasteride or dutasteride) should be used. A combination of an alpha-adrenoceptor blocker and a 5α-reductase inhibitor can be offered if symptoms remain a problem.

Suprapubic Catheters

• 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

Alternatives

• Intermittent self catheterisation
• Suprapubic catheter.
• In extremist when no other option and cannot manage a urethral catheter consider bladder aspiration with a green needed.

References

• Lower urinary tract symptoms in men: management NICE guidance