1. Retention of Urine
Dr Prabha Om
Professor Surgery
SMS Medical College, JAIPUR

3. Definition
Urinary retention is defined as the inability to completely
or partially empty the bladder.
It is a sudden painful inability to urinate inspite of a full
bladder
Urinary retention, also known as ischuria, is a lack of ability to
urinate
Suffering from urinary retention means
you may be unable to start urination
, or if you are able to start, you can’t fully empty your
bladder.

5. Normal micturition cycle:
A. Filling: Impulses from the CNS to
sympathetic and pudendal nerves
relax the bladder and close the outlet.
B. Voiding: Inhibition of sympathetic
and pudendal impulses.
Stimulation of parasympathetic (S2-4)
leads to detrusor contraction →
voiding in the absence of obstruction

6. Urinary retention is characterised by poor urinary stream
with intermittent flow, straining, a sense of incomplete
voiding and hesitancy (a delay between trying to urinate
and the flow actually beginning)
. As the bladder remains full causes incontinence,
nocturia (need to urinate at night) and high frequency.
Acute retention is a medical emergency, as the bladder may distend
(stretch) to enormous sizes and possibly tear if not dealt with quickly.
If the bladder distends enough it will begin to become painful.
The increase in pressure in the bladder can also
prevent urine entering from the ureters or
even cause urine to pass back up the ureters and
get into the kidneys, causing hydronephrosis
, and possibly pyonephrosis, kidney failure and sepsis.
A person should go straight to an emergency department as soon as
possible if unable to urinate when having a painfully full bladder.

7. Anuria means nonpassage of urine,
in practice is defined as passage of less than
50 milliliters of urine in a day
Anuria is complete absence of urine production by the kidney
for 12 hours or more.
Oliguria is decreased urine volume to less than 400 ml in a day.
. Anuria is often caused by failure in the function of kidneys.
It may also occur because of some severe obstruction
like kidney stones or tumours.
It may occur with end stage renal disease.
It is a more extreme reduction than oliguria,
sometimes called anuresis.

8. Causes
There are two general types of urinary retention:
obstructive and non-obstructive.
If there is an obstruction (for example,
kidney stone urine cannot flow freely through
the urinary tract
. Non-obstructive causes include a weak bladder
muscle and nerve problems that interfere with
signals between the brain and the bladder.
If the nerves aren’t working properly,
the brain may not get the message
that the bladder is full.

9. Causes of non-obstructive urinary retention are:
•Stroke
•Vaginal childbirth
•Pelvic injury or trauma
•Impaired muscle or nerve function due to
medication or anesthesia
•Accidents that injure the brain or spinal cord

10. Obstructive retention may result from:
•Cancer
•Kidney or bladder stones
•Enlarged prostate (BPH) in men

11. Causes:
A. Mechanical or obstructive:
1- Bladder:
- Stone, bladder neck obstruction,
cancer.
2- Prostate:
- BPH is the most common cause in
men over 50 years.
- Acute prostatitis and abscess.
- Prostate cancer.

12. 3- Urethra:
-Stone, stricture, urethritis,
rupture, phimosis,
- posterior urethral valves.
4- Clot retention in severe
hematuria e.g. cancer, trauma.
5- Women: pelvic masses,
urethral stenosis and diverticulum,
pelvic prolapse, hysterical.

13. C. Functional and neurogenic:
1. Postoperative AUR is common:
Pain, limited mobility, drugs, bladder nerve
injury e.g. hysterectomy & abdominal resection
Prevention is important by catheterization after
surgery to bladder, prostate, urethra.
•vaginal childbirth
•infections of the brain or spinal cord
•diabetes
•stroke
•accidents that injure the brain or spinal cord
•multiple sclerosis
•heavy metal poisoning
•pelvic injury or trauma ,
• some children are born with nerve problems that can
keep the bladder from releasing urine

14. 2- Drugs:
- Anesthetics
- Anticholinergics
- Sympathomimetics
3- Neurogenic:
- Spinal cord injury.
- Diabetic neuropathy.
- Cauda equina lesions.
- Intervertebral disc prolapse.
- Neurotropic viruses: Herpes simplex or zoster.
- Multiple sclerosis.
- Transverse myelitis.
Tabes dorsalis.

15. Symptoms of urinary retention may include:
•Difficulty in starting to urinate
•Difficulty in fully emptying the bladder
•Weak dribble or stream of urine
•Loss of small amounts of urine during the day
•Inability to feel when bladder is full
•Increased abdominal pressure
•Lack of urge to urinate
•Strained efforts to push urine out of the bladder
•Frequent urination
•Nocturia (waking up more than two times
at night to urinate)

16. History:
- Cause- related:
A complication of BPH
Drugs:
Urethral trauma
Stone disease
- Suprapubic bursting pain, no urine, strong desire to
urinate.
- Acute urine retention should be differentiated from
obstructive anuria.

17. Abdominal Examination:
Midline globular tender suprapubic mass.
Genital examination: Phimosis,
severe urethral meatal stenosis.
Digital Rectal Examination:
BPH, Prostate cancer.

18. Differential diagnosis of acute
retention and obstructive / anuria
• Acute retention obstuctive Anuria
Desire to urinate + - -
Suprapubic pain + - -
Renal pain - - +
General exam. Good May be uremic
Abdominal exam. Tender Full bladder Empty
Loin bladder

19. Treatment:
A) Conservative measures in non-obstructive causes:
Patient is asked to go out of bed.
Take hot bath.
Parasympathomimetics.
Failure → catheterization.

20. Urethral catheterization: Nelaton or
Foley's:
It is absolutely contraindicated in
urethral injury.
Proper Sterilization of parts.
Adequate lubrication of urethra.
Proper catheter size
Children 6-12 F
Adults 16 F

21. Clot retention:
- Triway 22F urethral catheter with irrigation.
- Evacuation of clots.
-Cystoscopy - diagnostic and therapeutic
Suprapubic cystocath: done in
Urethral trauma
Urethral stricture
Failure of urethral catheterization

22. Treatment of the cause e.g.
- TURP for BPH
urethroplasty for urethral stricture
.
- Endoscopic crushing of vesical stone.

23. Chronic Retention of Urine
Causes: Long standing incomplete obstruction
A) Mechanical : BPH, prostate cancer
B) Functional: Neuropathic flaccid bladder.
- Large amounts of residual urine exist.
- When the vesical pressure exceeds the urethral
resistance, the patient can pass some urine or
dribble continuously. This is called false or
overflow incontinence.

24. Differentiation between acute and
chronic urine retention
Acute retention Chronic retention
Urination No urine Overflow
incontinence
Pain Severe, suprapubic, Painless
bursting
Obstruction Complete Partial
Suprapubic + +/-
tenderness

25. Emergency measures –
Urethral catheter
or
Suprapubic catheter
if urethral trauma or injury are expected
- Ureteric catheter
Or DJ stent
if Failure - PCN

26. Causes according to site
In the bladder
⇒ Detrusor sphincter dyssynergia
⇒ Neurogenic bladder (commonly pelvic splanchic nerve damage,
cauda equina syndrome, descending cortical fibers lesion
, pontine micturation or storage center lesions,
demyelinating diseases or Parkinson's disease)
⇒ Iatrogenic scarring of the bladder neck
(commonly from removal of indwelling catheters
or cystoscopy operations)
⇒ Damage to the bladder
In the prostate
⇒ Benign prostatic hyperplasia
⇒ Prostate cancer and other pelvic malignancies
⇒ Prostatitis
.

27. Penile urethra
⇒ Congenital urethral valves
⇒ Phimosis or pinhole meatus
⇒ Circumcision
⇒ Obstruction in the urethra, for example a metastasis or
a precipitated pseudogout crystal in the urine
⇒ STD lesions (gonorrhoea causes numerous strictures,
leading to a rosary bead appearance,
whereas chlamydia usually causes a single stricture)
Other
⇒ Paruresis ( shy bladder syndrome )-, urinary retention can result
⇒ Consumption of some psychoactive substances, mainly stimulants,
such as MDMA and amphetamine.
⇒ Use of NSAIDs or drugs with anticholinergic properties.
⇒ Stones or metastases can theoretically appear anywhere along
the urinary tract, but vary in frequency depending on anatomy
Paruresis, inability to urinate in the presence of others (such as in a public restroom)
, may also be classified as a type of urinary retention, although it is psychological
rather than biological.

28. Investigations
History of complaints and physical examination
Ultrasonography for any calculi, growth,
post voiding residual urine, condition of Kidney
any injury
Xray KUB for calculi
Blood Urea , Creatinine levels
CT Scan for any pathology
Urine examination for infection
PSA for Prostate Cancer
Urodynamic Test for Cystocele
Cystoscopy for status of bladder
MRI Lumber spine for spinal pathology

29. Dysuria refers to painful urination.
It is one of a constellation of irritative bladder symptoms,
which includes urinary frequency and haematuria.
Differential diagnosis
This is typically described to be a burning or stinging sensation.
It is most often a result of a urinary tract infection
It may also be due to an STD, bladder stones,
bladder tumours, and virtually any condition of the prostate.
It can also occur as a side effect of anticholinergic
medication used for Parkinson's disease.

30. Polyuria is a condition usually defined as excessive or
abnormally large production and/or passage of urine .
Polyuria often appears in conjunction with polydipsia
(increased thirst), though it is possible to have one
without the other, and the latter may be a cause or an
effect. Psychogenic polydipsia may lead to polyuria.
Polyuria is physiologically normal in some
circumstances, such as cold diuresis, altitude diuresis,
and after drinking large amounts of fluids

31. The most common cause of polyuria in both adults and
children is uncontrolled diabetes mellitus, causing an
osmotic diuresis.
Primary polydipsia (excessive fluid drinking),
diabetes insipidus
hypercalcemia) or
various chemical substances (diuretics, caffeine, alcohol).
after supraventricular tachycardias, during an onset of
atrial fibrillation, childbirth, and the removal of an
obstruction within the urinary tract.
Cold diuresis is the occurrence of increased urine
production on exposure to cold, which also partially
explains immersion diuresis.
Substances that increase diuresis are called diuretics.

32. THANK YOU