1.PRESENTER :- ATINKUT D. MODERATOR: - Dr. Gersam 3/28/2014AUR seminar1 ACUTE URINARY RETENTION

2. Outline of presentation Definition Pathophysiology Risk factors Etiology Urethral strictures BPH Urolithiasis Clinical presentation Management options Summary references 2 3. Acute Urinary Retention 3/28/2014AUR seminar3 Definition:- Painful inability to void, with relief of pain following drainage of the bladder by catheterization. 4. Pathophysiologic mechanism of AUR 3/28/2014AUR seminar4 1. BOO( bladder out flow obstruction) Out flow obstruction by A) Mechanical :- physical narrowing of the urethral channel related to the volume of the prostate gland , other mass, or stricture. B) Dynamic obstruction:- refers to the tension within and around the urethra. When obstruction is caused by BPH, dynamic obstruction is caused by the prostate capsular tone and smooth muscle tone within the prostate gland itself. Medications and other factors also play a role in selected patients. 5. Pathophysiologic contnd.. 3/28/2014AUR seminar5 2) Neurologic impairment Occur due to interruption of sensory or motor nerve supply to the detrusor muscle. This is most commonly seen in spinal cord injuries, progressive neurologic diseases, diabetic neuropathy, and cerebrovascular accidents Less common, but important, neurologic causes include epidural abscess and epidural metastasis, that can compress the spinal cord and thereby cause urinary retention as well as back pain and lower extremity neurologic impairments 6. Pathophysiologic contnd.. 3/28/2014AUR seminar6 3). Over distention Acute urinary retention may result when a precipitating event results in an acute distended bladder in the setting of an inefficient detrusor muscle This most often occurs in patients with obstructive urinary symptoms at baseline, who are then subjected to an insult to the lower urinary tract, such as a fluid challenge (eg, alcohol, intravenous hydration), bladder distention during general anesthesia, or epidural analgesia without an indwelling Foley catheter. 7. 3/28/2014AUR seminar7 Medications Multiple medications are implicated in the cause of urinary retention, principally involving anticholinergic and sympathomimetic drugs Pharmacologic agents associated with urinary retention.docx 8. RISK FACTORS 3/28/2014AUR seminar8 Age Age over 70 years Symptom score Use of the AUA symptom score (IPSS) permits quantitation of symptom severity and monitoring of symptom progression over time . Prostate volume Prostatic volumes greater than 30 mL as measured by trans rectal ultrasound have been associated with AUR Urinary flow rate Urinary flow rate of less than 12 mL/sec carries an RR of 3.9. 9. Etiology 3/28/2014AUR seminar9 BPH 53 percent Constipation 7.5 percent Prostate cancer 7 percent Urethral stricture 3.5 percent Postoperative 5 percent Neurologic disorder 2 percent Medications/drugs 2 percent Urinary tract infection 2 percent Urolithiasis 2 percent Miscellaneous 16 percent 10. 3/28/2014AUR seminar10 AUR may also be related to a variety of other factors Malignancy bladder neoplasm, other tumors causing spinal cord compression Phimosis or paraphimosis, which is prolonged foreskin retraction with swelling of the glans constricting the foreskin 11. 3/28/2014AUR seminar11 Pelvic masses Genitourinary infections acute prostatitis, urethritis, perianal abscess Other anorectal manipulation, acute sickle crisis, malpositioned indwelling urinary catheter. 12. Causes of AUR 3/28/2014AUR seminar12 1) Urethral Stricture common in men with most patients acquiring the disease due to injury or infection The most common etiology for stricture is iatrogenic injury due to urologic instrumentation (eg, oversized resect scope or the placement of indwelling catheters. 13. Etiology of urethral stricture 3/28/2014AUR seminar13 Location Anterior Urethra Meatus Instrumentation, iatrogenic, hypospadius, Pendulous urethra Instrumentation, iatrogenic, hypospadius, skin disorders (lichen sclerosus), sexually transmitted infections, crush injury Bulbar urethra Instrumentation, iatrogenic, skin disorders (lichen sclerosus), sexually transmitted infections, crush injury, straddle type injury Posterior Urethra Membranous urethra Instrumentation, pelvic fracture with urethral distraction defects Prostatic urethra Instrumentation, radiation therapy for prostate cancer (external beam radiation therapy, brachytherapy) Bladder neck Instrumentation, radiation therapy for prostate cancer (external beam radiation therapy, 14. Urethral Injury urethrography Posterior urethra Nearly always ass. With pelvic # Crush, blunt, penetr. Or iatrogenic Associated bladder inj. Blood at meatus Failure to void Full bladder Perineal swelling Displaced prostate- DRE 3/28/2014AUR seminar14 15. Urethral 3/28/2014AUR seminar15 Classes of injury Complete or partial Difficult to say which Further classes based on radiograph Management (Immediate) Stretch - indwelling cath until able to void Partial tear careful! attempt - SPC then voiding CUG 16. Urethral 3/28/2014AUR seminar16 Management Complete ?? - ?? immediate indirect/ endoscopic cath with SPC - SPC drainage, ante/retrograde evaln later, complications - urethrotomy *stricture - open urethropasty *incontinence - endoscopic repair *impotence 17. Urethral 3/28/2014AUR seminar17 Anterior urethra Rare & isolated Bulbar urethra >> Stradle injury Direct blow Shaft # during activity pelvic # Penet. injury blood at meatus Unable to void urethrograpy Perin./penile echimosis 18. Urethral 3/28/2014AUR seminar18 Initial managemnt SPC diversion alone +/- debridement Primary surgical repair Definitive Rethrograde & voiding - urethrotomy - anstomotic urethroplasty 19. Urethral stricture 3/28/2014AUR seminar19 Caused by:- Inflammatory Congenital Traumatic Instrumental , indwelling catheter and endoscopy Post operative Open prostectomy Amputation of penis 20. complications 3/28/2014AUR seminar20 Retention of urine Urethral diverticulum Peri-urethral abscess Urethral fistula Rectal prolapse 21. 3/28/2014AUR seminar21 Diagnosis Urethroscopy Urethrography Treatment Dilation with elastic or metallic boogie Urethrotomy , internal visual incision of stricture Urethroplasty, Excision and end to end anastomosis, patch urethroplasty 22. 3/28/2014AUR seminar22 23. BPH 3/28/2014AUR seminar23 24. BPH 3/28/2014AUR seminar24 BPH occurs in men over 50 years of age; By the age of 60 years 50 per cent of men have histological evidence of BPH and 15 per cent have significant lower urinary tract symptoms 25. 3/28/2014AUR seminar25 Etiology Unknown Aging Hormonal effects Androgen is important for both normal & abnormal growth of the prostate 90% of prostatic androgen is in form of DHT( from testicular androgen & 10% from adrenal androgen) Stromal epithelial cells interaction produce growth factors (epidermal GF, insulin like GF,fibroblast GF) Increased estrogen increase the expression of AR in aging prostate & increase prostate size 26. Pathogenesis (Gland Enlargement) 3/28/2014AUR seminar26 Occurs as results of increased Number of epithelial & stromal cell ( increased cell proliferation) Disruption of equilibrium between cell death & cell proliferation(decreased in cell death) Androgen requiring during development, puberty,& aging Castrated men or no androgen results no BPH 27. 3/28/2014AUR seminar27 Common symptoms (symtomatology) Prostatism =LUTS Classified in to irritative obstructive frequency Weak urine stream urgency Difficulty starting urination urge incontinency Dribbling enuresis Needing to urinate several times Straining Sensation poor bladder emptying 28. Symptomatology 3/28/2014AUR seminar28 Scoring system IPSS AUA Used for assessment of symptom severity Assess the response to therapy Detect symptom progression ( in watchful waiting Rx) Can not used to establish the DX of BPH(infections,tumor ,bladder disease will have a high ipss) According to IPSS 0-9 mildly symptomatic 8-19 moderately symptomatic 20-35 severely symptomatic 29. Effects of BPH Initially bladder becomes hypertrophied Increase postvoidal residuals ,poor contractility LUTS & Boo Urinary retention Hematuria ,urinary infection Stone formation ,trabeculation Bladder irritability ,renal insufficiency 3/28/2014AUR seminar29 30. DDX of BOO 3/28/2014AUR seminar30 BPH BNC Bladder stone Urethral stricture Prostatic cancer Neurogenic bladder 31. Diagnosis of BPH 3/28/2014AUR seminar31 To pathologist is microscopic Dx(cellular proliferation of stomal & epithelial elements) To radiologist makes the Dx in presence of bladder neck elevation of cystogram phase of IVP or enlarged prostate To urodynamist -elevated voiding pressure -low urinary rate To practicing urologist is constellation of sign & symptom 32. Diagnosis.. Hx onset of the symptoms Age Hx of STD Determine which symptoms are predominant( irritative or obstructive) Determine severity of the symptoms by IPSS) Hx of hematuria ,UTI,diabetis ,NS disease ,urinary retention, surgery ofLUT 3/28/2014AUR seminar32 33. Diagnosis.. 3/28/2014AUR seminar33 P/E general assessment (chest,cvs,anemia,external genitalia) Abdominal examination Bladder distention Dullness Tenderness 34. Diagnosis. 3/28/2014AUR seminar34 DRE prostate size,consistance,noduls -pelvic floor tone flactuance &pain - prostate size does not correlate with symptoms severity & degree of urodynamic obstruction & Rx outcome Prostate is large,smooth,convex,elastic,firm,mucosa moves over the prostate Ns examination (r/o cavaequina lesions) 35. Investigations 3/28/2014AUR seminar35 U/A dipstick & /or via centrifuged sediment for blood,bact,prot,glucos -cytology for severe irritable symptom -urine culture PSA to R/o prostatic Ca which can coexist with BPH Large BPH may have slightly elevated PSA PSA value >4ng/ml or DRE induration or nodularity needs transrectal us & multiple biopsy PSA & DRE increase the detection rate of prostate Ca over DRE alone 36. Investigations. 3/28/2014AUR seminar36 Serum creatinine to R/o renal insufficiency occurs in 13% of case BPH with RI increase the risk of post.op. complication with RI 25% 17% without RI Help to evaluate the pt.with occult & progressive renal damage secondary to silent prostatism Postvoidal residual urine -obtained after voiding of urine with a catheter transabdominal us NV= less than 5 ml (78%), less than 12ml(100%) 37. Investigations. 3/28/2014AUR seminar37 Pressure flow studies -done to distinguish b/n low pressure flow rate secondary to Boo & decompensated bladder - Reliable if Boo not Dxed by flow rate, initial evaluation & PVR uroflometry - electrical recording of the urine flow rate -noninvasive urodynimic test -quantifies strength of urine stream -2 to 3 voids with voided volume 150 to 200ml in flow rate clinic 38. 3/28/2014AUR seminar38 Watchful waiting: In patients with mild symptoms. Medical treatment 1. Alpha reductase inhibitor: affects the epithelial component of the prostate, resulting in reduction in the size of the gland and improvement in symptoms. 2. Alpha-adrenoceptor blacker: affect subtype alpha-1 adrenoreceptors. (dynamic component of obstruction). 3. Combination. Surgical treatment: Minimally invasive or open. By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS TREATMENT 39. 3/28/2014AUR seminar39 A- Absolute indications: Upper urinary tract affection. Uremia Recurrent attacks of acute retention. Severe obstructive symptoms (high IPSS score). By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS Indications of surgical intervention B- Relative indications: Moderate symptoms (moderate IPSS score). Recurrent UTI. Hematuria. Stone bladder. 40. 3/28/2014AUR seminar40 Transurethral resection of the prostate. Transurethral incision of the prostate Transurethral needle abelation Ballon dilatation. Transurethral microwave treatment. Intraprostatic stents. By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS Minimally-invasive surgery 41. 3/28/2014AUR seminar41 Transvesical Transurethral Retropubic perineal or perineal By Mohammed Ibrahim, MBBcH Revised by M.A.Wadood , MD, MRCS Open Surgery (Prostatectomy) 42. Open prostatectomy. 3/28/2014AUR seminar42 Contraindications small fibrous gland The presence of prostate cancer Previous prostatectomy Pelvic surgery that obliterate access to the prostate gland 43. Prostatectomy.. 3/28/2014AUR seminar43 Post-op Mx Measure output input Bladder irrigation Effective pain mx 1st p.o.day fluid diet, ambulation ,deflate balloon(10ml) & irrigate residual clot 2nd p.o.day regular diet 3rd p.o.day remove retro pubic 4th p.o.day discharge with catheter 5- 7 pod day remove catheter 44. Prostatectomy.. 3/28/2014AUR seminar44 Complications Bleeding -urethral catheter traction with 50ml of saline to compress the bladder neck & prostatic fossa -bladder irrigation to prevent clot formation -the inflow through urethral catheter &out flow through the suprapubic tube -if the bleeding persist cystoscopic inspection of the prostatic fossa &bladder neck -if marked bleeding continue to persist open re-exploration 45. Complications 3/28/2014AUR seminar45 Perforation of the bladder & prostatic capsule (IN TURP) Incontinency (if damaged external sphincter mechanism) Retrograde ejaculetion(80-90%) & impotence (3-6% due to damage of the nerves associated with erection) Bladder neck contracture Urethral stricture Sepsis Death(0.2 to 0.3%) 46. Complications. 3/28/2014AUR seminar46 TUR-syndrome In 2% of all TURP Due to absorption irrigating fluid through cut open veins Characterized by (hyponatremia Na+ ,HPT,nauesa& vomiting,bradicardia,visual disturbance,mental confusion) Risk factors (gland>45gm,resection time >90mnt & much fluid for irrigation RX diuretics &correct electrolytes 47. Nephrolithiasis / urolithiasis 3/28/2014AUR seminar47 Stone formation in the kidney Affect about 4-15% of population Males are more commonly affect Multifactorial in etiology 48. Risk factors for stone formation 3/28/2014AUR seminar48 49. Pathopysiology 3/28/2014AUR seminar49 Randals plaque Supersaturati on Decreased inhibitors 50. Types of stones 3/28/2014AUR seminar50 Oxalate calculus (calcium oxalate) Phosphate Uric acid Cystine Xanthine 51. Clinical presentation 3/28/2014AUR seminar51 Asymptomatic Flank pain Hematuria Flank mass( Hydronephrosis) Hematuria Ureteric colic Passage of stone Symptoms of UTI 52. 3/28/2014AUR seminar52 53. Investigation 3/28/2014AUR seminar53 KUB U/S U/A IVU CT scan(spiral with contrast) 54. Renal stone diseases 3/28/2014AUR seminar54 55. 3/28/2014AUR seminar55 56. management 3/28/2014AUR seminar56 Conservative Adequate hydration Dietary modification Medical treatment of underlying conditions follow up U/S Surgical Indications Failed expectant treatment Large stone size Evidence of obstruction Presence of infection Non functioning kidney with pain and stone 57. Surgery contd 3/28/2014AUR seminar57 Minimally Invasive I. ESWL II. PNL( Percutaneous nephrolithotomy) Open surgery I. Pyelolithotomy II. Extended pyelolithotomy III. Nephrolithotomy IV. Nephrectomy 58. Clinical manifestations of AUR 3/28/2014AUR seminar58 AUR presents as the abrupt inability to pass urine. lower abdominal and/or suprapubic discomfort patients are often restless, and may appear in considerable distress AUR is superimposed upon chronic urinary retention Chronic urinary retention is most often painless presence of hematuria, dysuria, fever, low back pain, neurologic symptoms, or rash. Younger patient age, a history of cancer or intravenous drug abuse, and the presence of back pain or neurologic symptoms suggest the possibility of spinal cord compression. Finally, a complete list of prescribed and over the counter medications should be obtained. 59. Physical examination 3/28/2014AUR seminar59 previous history of retention, prostate cancer, surgery, radiation, or pelvic trauma. Lower abdominal palpation The urinary bladder may be palpable, either on abdominal or rectal examination. Deep suprapubic palpation will provoke discomfort. Rectal examination A rectal examination should be done in both men and women, to evaluate for masses, fecal impaction, perineal sensation, and rectal sphincter tone. A normal prostate examination does not preclude BPH as a cause of obstruction. Pelvic examination Women with urinary retention should have a pelvic examination. Neurologic evaluation The neurologic examination should include assessment of strength, sensation, reflexes, and muscle tone. 60. Investigations 3/28/2014AUR seminar60 Urine analysis CBC Serum electrolytes RFT and LFT Ultrasound if pelvic mass suspected cystoscopy 61. ACUTE MANAGEMENT Initial management of AUR 3/28/2014AUR seminar61 management of acute urinary retention (AUR) involves prompt bladder decompression accomplished with urethral or suprapubic catheterization Patients who have had recent urologic surgery (eg, radical prostatectomy or urethral reconstruction) and develop acute retention should not have urethral catheterization 62. Management contnd 3/28/2014AUR seminar62 Emergency drainage Emergency drainage of the bladder in acute retention may be undertaken by: Urethral catheterization Suprapubic puncture ??? Suprapubic cystostomy. Urethral catheterization or bladder puncture is usually adequate, but cystostomy may become necessary for the removal of a bladder stone or foreign body, or for more prolonged drainage, for example after rupture of the posterior urethra or if there is a urethral stricture with complications 63. SUPRAPUBIC PUNCTURE Bladder puncture may become necessary if urethral catheterization fails. It is essential that the bladder is palpable if a suprapubic puncture is to be performed 3/28/2014AUR seminar63 64. SUPRAPUBIC PUNCTURE 3/28/2014AUR seminar64 65. SUPRAPUBIC CYSTOSTOMY 3/28/2014AUR seminar65 The purpose of supra pubic cystostomy is To expose and, if necessary, allow exploration of the bladder To permit insertion of a large drainage tube, usually a self-retaining catheter To allow supra pubic drainage of a non-palpable bladder Infiltrate using local anesthesia .5% 1% lidocaine with adrenaline layer by layer and supra pubic midline incision 2cm above SP Openrectussheathusingscissors 66. supra pubic (SP) catheter 3/28/2014AUR seminar66 necessary in patients with urethral stricture disease, severe BPH. abnormalities that preclude Foley catheter placement per urethra Ultrasound guidance may be indicated when adhesions are possible from prior abdominal surgery. 67. supra pubic (SP) catheter contnd 3/28/2014AUR seminar67 Suprapubic catheterization is performed under local anesthesia. with steady aspiration until urine is retrieved. A trocar-type suprapubic tube is then passed through a one centimeter skin incision and the catheter advanced over the trocar and sutured in place. The patients undergoing SP catheterization had fewer urinary tract infections and were less uncomfortable than those who were treated with urethral catheters. 68. supra pubic (SP) catheter contnd 3/28/2014AUR seminar68 They Allow assessment of the patient's ability to void before removing the catheter. The risk of complications associated with placement, including bowel perforation and wound infection is high in SP females, who are expected to require long-term bladder drainage. SP catheters prevent bladder neck and urethral dilatation and therefore prevent urinary incontinence due to sphincter dysfunction. They avoid the risk of subsequent urethral stricture, a common complication in men requiring long-term urethral catheterization 69. 3/28/2014AUR seminar69 Duration of catheterization The optimal duration of catheter management prior to a trial of voiding has been evaluated, with some contradictory findings A subsequent observational study from France of 2600 men with AUR found that men who were catheterized for three days or less had greater success with spontaneous voiding than men catheterized for more than three days 70. Trial without catheter(TWOC) 3/28/2014AUR seminar70 involves catheter removal (usually in two to three days) and determination if the patient can successfully void. success rates for initial TWOC have ranged from 20 to 40%. Factors that favor successful trial of void includes age less than 65 years, detrusor pressure greater than 35 cmH2O, a drained volume of less than one liter at catheterization, 71. SURGICAL THERAPY 3/28/2014AUR seminar71 definitive treatment of AUR. symptomatic patients with BPH, transurethral resection of the prostate (TURP) Transurethral resection of the prostate remains the gold standard 72. SUMMARY AND RECOMMENDATIONS 3/28/2014AUR seminar72 Acute urinary retention (AUR) is the most common urologic emergency, affecting 1 in 10 men age 70 and older. Benign prostate hyperplasia (BPH) is the most common underlying condition, but multiple etiologies may cause AUR. Medications are frequently implicated Initial management of AUR involves prompt bladder decompression. We suggest initial treatment with a Foley urethral catheter, rather than a suprapubic catheter A suprapubic catheter may be indicated when obstruction precludes a urethral catheter, and may be preferred in patients who are expected to require longer term decompression. 73. SUMMARY AND RECOMMENDATIONS 3/28/2014AUR seminar73 Hospitalization is indicated for patients who are uro septic, or who have obstruction related to malignancy or spinal cord compression. Emergency surgery for relief of prostatic obstruction is rarely indicated, and carries an increased risk over elective surgery. The majority of patients can be managed as outpatients once bladder decompression is accomplished. Removal of the catheter after a period of time ("trial without catheter" or TWOC) results in successful spontaneous micturition in up to 40 percent of patients with AUR, though recurrent AUR is common. We suggest a trial of catheter removal in one to two weeks The majority of men who have BPH and AUR will ultimately require definitive intervention for their BPH. 74. References 3/28/2014AUR seminar74 Campbell's walsh Urology 9th edition Schwartz's Principles of surgery 9th edit Mannipal urology Upto date 19.2 ed.