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acute urinary retention

is the patient in retention?

why are they in retention?

Mx of urinary retention

  • low threshold for suspecting urinary retention in the elderly in particular - bladder scan
  • if bladder scan > 300mL and patient unable to void:
    • NB. C/I to urethral catheterisation: (consider US guided suprapubic catheter or urology consult instead)
      • recent urologic surgery such as radical prostatectomy
      • urethral strictures
      • acute bacterial prostatitis as risk of septicaemia (although an experienced operator may attempt a gentle catheterisation)
    • if no C/I, place 14-18F urinary catheter to decompress the bladder
      • if difficulty passing catheter:
      • if medication induced or other transient cause such as UTI, then consider in-out catheter
      • if the retention is associated with BPH and high pressure and hydronephrosis on USS then TOV is C/I and patient should be referred to urology reg for TURP
      • in other situations, leave the catheter in situ for at least 3 days for a Trial of Void
          • commence tamsulosin (if no C/I) well prior to Trial of Void as this increases success rate by 50%
          • if Trial of Void fails twice then refer for surgery (TURP reduces risk of recurrence of retention by ~90%)
          • factors favoring successful TOV (only 20-40% of BPH patients will have a successful 1st TOV):
            • age < 65yrs
            • detrusor pressure greater than 35 cm H2O
            • < 1L drained at decompression
            • precipitating event
          • successful TOV patients with BPH have high risk of recurrence of retention - mostly in the following week - ~50% with 1 week, ~2/3rds within 1 year and thus should be commenced on an alpha-1-adrenergic blocker and a 5-alpha reductase inhibitor such as Duodart, as an alpha-1-adrenergic blocker reduced risk of recurrence in 1st 3 months by ~50% and in 1st 6 months by ~30% while the 5-alpha reductase inhibitor has a longer term effect requiring 12 months of Rx
    • clamping the catheter drain tube to slow rate of decompression does NOT seem to be beneficial in reducing adverse effects
    • observe for adverse effects:
      • haematuria - ~10% of patients having an IDC but rarely is an issue - if large clots, will need a 3-way catheter to be inserted to allow bladder washouts to prevent catheter blockage from clots
      • transient hypotension does not usually require Rx
      • post-obstructive diuresis (POD)
        • more common with relief of chronic retention rather than acute retention
        • if initial urine drained > 700mL then monitor subsequent urine output hourly for 6hrs to exclude POD
        • POD is indicated by > 200mL urine output over two hours
        • if POD then monitor fluid balance including urine output, and give iv N Saline (may require other crystalloids pending serum Na level) to replace half the urine output volume
        • if POD persists > 48hrs or is severe, contact urology for possible admission

In-Out catheter approach

  • in general, elderly patients with delirium should have regular post-void bladder scans and if in retention, an in/out catheter up to two times before considering IDC
  • some patients, particularly women who develop retention due to opiates, etc, should be considered for in-out catheter and trial of void in ED

IDC and Early trial of void in ED

  • some patients who develop acute urinary retention may be suitable for a trial of void within hours of IDC being inserted - in particular, those with an acute cause such as use of opiates for pain
  • those with constipation should have this addressed prior to TOV
  • if being admitted to a ED short stay unit overnight, it may be best to remove the IDC at midnight rather than 6am and this will generally allow earlier discharge and higher voiding volumes 1)
  • optional active voiding protocol
    • this allows a shorter trial of void time by prefilling the bladder with saline
    • Instill 250-400 cc of STERILE SALINE via the lumen of the Foley catheter into the bladder via gravity drainage or slow push
    • Clamp the Foley
    • Deflate the catheter balloon and remove the catheter from the bladder.
    • Record the amount of saline that was instilled into the bladder.
    • Immediately assist the patient to void. Report the amount instilled and the amount voided to the physician within one hour a. Unless the patient reports extreme bladder fullness or pain, give the patient one hour to urinate
    • If the patient fails the voiding trial, the doctor to decide to do in and out catheterization or place a new Foley catheter

IDC and urology referral - NOT for Trial of Void

  • high risk patients should be referred to urology as likely to need TURP:
    • BPH with high pressure obstruction - hydronephrosis

IDC and Delayed Trial of Void Mx in Western Health

  • low risk adult patients could potentially aim to have a TOV within 3-4 days 2)
  • however, for adult patients with acute urinary retention within Western Health ED's should have:
    • instructions for Mx of leg bag
    • provided with leg bags
    • referred to the DPU retention clinic at Western Hospital by faxing to 56205:
      • a Day Procedure Unit booking form (AD 32) PLUS,
    • fax a Community Access Referral Form for PACFU (AD 172) to fax 56529
    • fax to outpatients on 56856, an outpatient appointment referral form for retention clinic (along with the ED discharge letter)
    • if you can follow all the above you deserve a medal!
    • DPU will contact patient to arrange a trial of void - current wait list is around 6 weeks
    • urology request all patients with prostatism (? urinary retention requiring an IDC) be prescribed Duodart (Tamsulosin/Dutasteride 400mcg/500mcg, dosed 1 tablet once a day) prior to the trial of void. All patients being commenced on Duodart need to be discussed with the Urology Registrar or consultant on duty.
      • This is not within PBS authority guidelines unless “initiated by a urologist for Rx of lower urinary symptoms due to benign prostatic hyperplasia” and thus may need to be notated as “non-PBS” but fortunately at $35 is similar in price to a PBS dispensation.
urinary_retention_acute.txt · Last modified: 2023/01/14 00:09 by wh

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