EMERGENCIES ALL SHOULD KNOW:ACUTE URINARY RETENTION

ACUTE URINARY RETENTION

 Acute retention causing complete anuria is a medical emergency, as the bladder is filled with urine and can stretch to enormous sizes and possibly tear if not dealt with in time. If the bladder distends more, it becomes painful. 

The increase in bladder pressure can also prevent urine from entering the ureters or even cause urine to pass back up the ureters and get into the kidneys, causing hydronephrosis,sometimes kidney failure, and sepsis. A person should go straight to an emergency department  as soon as possible if unable to urinate for a long time and having a  painfully full bladder.

The causes are
Central causes

• Consumption of some drugs like amphetamine etc.,
• patients suffering from mental retardation,multiple sclerosis,stroke,diabetic autonomic neuropathy, 

In the bladder

• neurogenic bladder,spinal cord diseases,bladder neck contracture,etc.

In the prostate

• Prostate enlargement either benign or malignant

  urethra

• Congenital urethral valves
•  pinhole meatus
• Obstruction in the urethra, for example a stricture (usually caused either by injury or STD), 
• obstruction in urethra due to a stone

Urinary retention often occurs without warning. It is basically the inability to pass urine. In some people, the disorder starts gradually but in others it may appear suddenly. Acute urinary retention is a medical emergency and requires prompt treatment. The pain can be excruciating when urine is not able to flow out. Moreover one can develop severe sweating,chest pain,high blood pressure.

In the longer term, obstruction of the urinary tract may cause:

• Bladder stones
• weakness of detrusor muscle of bladder (atonic bladder is an extreme form)
• Hydronephrosis of one/both kidneys leading to renal dysfunction
• Diverticula (formation of pouches) in the bladder wall (which can lead to urine stasis ,stones and infection)

In acute urinary retention, catheterisation or suprapubic cystostomy (SPC) relieves the retention. These catheters are  inserted by preferrably urologist/trained health care professionals under proper antibiotic cover.

 If the procedure is not done in a sterile fashion, it can introduce infection into the bladder. This can result in an infection of the entire urinary tract. Therefore, sterile technique is a must when inserting a foley catheter. Careful washing of hands, meatus, and reusable catheters are also necessary with clean self catheterization techniques.

In the longer term, treatment depends on the cause.

 BPH may respond to Alpha blocker therapy/laser prostate.

 Some people with BPH are treated with medications like finasteride or dutasteride to decrease prostate enlargement. The drugs only work for mild cases of BPH but also have mild side effects. Some of the medications decrease libido and may cause giddiness,/ fatigue.. 

Older patients with ongoing problems may require continued intermittent self catheterisation in case of neurogenic bladder.

When you urinate, the brain signals the bladder muscle to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax. As these muscles relax, urine exits the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.In case of detrusor-sphincter-dyssynergia (DSD) is a condition where some brain/spinal cord diseases contribute to retention of urine.

Urinary retention is a common disorder in elderly males. The most common cause of urinary retention is BPH. This disorder starts around age 50 and symptoms may appear after 10–15 years. BPH is a progressive disorder and narrows the neck of the bladder leading to urinary retention. By the age of 70, almost 10 percent of males have some degree of BPH and 33% have it by the eighth decade of life. While BPH rarely causes sudden urinary retention, the condition can become acute in the presence of certain medications like anti-parkinsonism drugs,anti-psychotics, etc.

In young males, one of the the most common causes of urinary retention is acute infection of the prostate and  the infection is acquired during sexual intercourse.The other common cause is urethral stricture which will be treated succesfully by Optical urethrotomy where the urologist will  incise the stricture under anaesthesia cover.

A woman may experience urinary retention if her bladder sags or moves out of the normal position, a condition called cystocele.The abnormal position of the bladder may cause urine to remain trapped.Cystocele and rectocele are often the results of a dropping of the pelvic support floor for the bladder as seen in mulltiparae,elderly women etc.These are successfully treated by a dedicated urology team.