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Peer reviewed

A guideline for the nursing assessment and management of urinary retention in elderly hospitalised patients

Abstract

The objective of this project was to develop a guideline for the nursing assessment and management of urinary retention in hospitalised older adults. The guideline was developed from a review of the literature and from consultation with a multidisciplinary expert panel. These experts provided feedback through a structured process known as the Delphi technique. Based on findings from both sources, a final guideline was developed which provides a framework for the nursing assessment and management of urinary retention in hospitalised older adults. This foundational work provides the basis for further research and evaluation of the management of urinary retention.

Introduction

Urinary retention commonly affects older people, and disproportionately more men than women 1-3. Early detection is important as the adverse outcomes associated with delayed response to an overly distended bladder are significant and include urinary tract infection and renal complications 4. on the other hand, catheter insertion that is premature or inappropriate exposes patients to unnecessary catheter associated infection and urethral trauma. one of the dilemmas for clinicians is that urinary retention is not always a straightforward diagnosis as symptoms can be masked, particularly in patients with neurological disorders, or in patients with cognitive impairment, i.e. delirium or dementia.

Joan OstaszkiewiczRN, MNurs Research Fellow, Deakin University-Southern Health Nursing Research Centre, Melbourne VIC

Professor Beverly O’ConnellRN, MSc, PhD, FRCNA Chair in Nursing, Deakin University-Southern Health, Melbourne VIC Australian and New Zealand Continence Journal Editorial Committee member

Dr Chantal skiBA, Hons, PhD Research Fellow, St Vincent’s Health, Melbourne VIC

Correspondence to:Ms Joan Ostaszkiewicz Deakin University-Southern Health Nursing Research Centre, Monash Medical Centre, Clayton VIC Email: joan.ostaszkiewicz@deakin.edu.au

Having diagnosed urinary retention, the other critical issue for

clinicians is to differentiate between those patients who require

immediate bladder decompression and those who do not.

Many clinicians are guided in this decision by protocols that

prescribe a threshold post void residual urine volume (PVR) or

a range of PVR values as the basis for determining whether or

not to catheterise a patient. There is some evidence to suggest,

however, that reliance on PVR as the basis for determining the

appropriateness of urinary catheterisation for older adults is

limited 2.

An Australian survey conducted in 2006 on current assessment

and management practice for urinary retention completed by

medical and nursing staff in an aged care rehabilitation facility,

confirmed anomalies in practice 5. Specifically, this study revealed

that clinicians in the aged care setting commonly encountered

patients with undiagnosed urinary retention and that there were

no guidelines to inform their practice.

To fill this gap, our project was to review the literature on the

management of urinary retention and to develop a guideline for

the initial management of this condition in hospitalised older

adults. As nurses are usually the first point of care for patients

with this condition in hospital settings, the guide was developed

for this group. This paper describes the process used to develop

the guideline and details the guideline for further discussion and

research.

Method

To develop the guideline, we searched for and reviewed

the literature on urinary retention to form the basis of a

draft guideline. This was then peer reviewed by an expert

multidisciplinary panel in an iterative consultation process.

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review of the literature

The literature was searched using the database EBSCohost

and included CINAHL, Health Source: / Academic Edition

and MEDLINE. Keywords were identified from a preliminary

review of the literature. Topic relevant keywords included:

‘urinary retention’, ‘acute urinary retention’, ‘chronic urinary

retention’, ‘bladder scan’ and ‘post-void residual urine volume’,

‘older adults’, ‘hospital’, ‘guidelines’, ‘protocols’ and ‘clinical

pathways’. The reference lists of topic relevant publications were

reviewed for additional publications. No arbitrary limitation

was placed on the age of the data and, hence, data were located

between 1981 and 2005. The full documents of all abstracts

considered potentially relevant were retrieved and the main

issues were summarised.

Searches in websites of peak national and international

organisations with expertise in continence or urology were

also used to collect information on definitions, assessment and

management recommendations and guidelines pertaining to

urinary retention.

Consultation with multidisciplinary expert panel

Clinical experts specialising in gerontology, urology and

continence medical and nursing practice were approached by the

project team and invited to participate in the multidisciplinary

expert panel. Using a Delphi technique 6, they were invited to

comment on information obtained from the literature and on

drafts of the developing guideline. The purpose of the Delphi

technique is to elicit information and expert comments from

participants in an iterative way so as to facilitate problem solving,

planning and decision-making until a consensus is reached 7. In

order to reach consensus about the guideline, the experts were

consulted on three separate occasions. Where clinical expert

opinion varied, we consulted the research literature.

In addition to consulting multidisciplinary experts, the

penultimate draft of the guideline was circulated among a

group of nurses working in an aged care rehabilitation facility

and feedback was sought on its clinical usefulness. Comments

obtained from this group were incorporated into the design of

the final draft of the guideline.

Findings

results of review of the literature

The review of literature revealed the following three main

definitions:

• Urinary retention is a failure to empty thebladder totally – a

condition that is clinically diagnosed as either acute or chronic 8.

• “Acuteurinaryretentionisapainful,palpableorpercussible

bladder, when the patient is unable to pass any urine” 9(p.176).

• Chronicurinaryretention is“anon-painfulbladder,which

remains palpable or percussible after the patient has passed

urine” 9(p.176).

The International Consultation on Incontinence further

recommends that transient voiding difficulty in older adults

be differentiated from chronic urinary retention 9. The need

to differentiate patients with urinary retention combined with

high pressures (i.e. hydronephrosis, kidney back pressure and

congestion and an elevated serum creatinine) from patients with

urinary retention combined with low pressures is also advised 10.

The literature search yielded no specific clinical management

guidelines on the topic of urinary retention. There were a

number of guidelines published on disease processes where

urinary retention may present as a symptom (i.e. benign prostatic

hypertrophy, or spinal cord disease) and on the issues of urinary

catheterisation and intermittent catheterisation.

Although there were no specific guidelines on urinary retention,

there was a large volume of related literature; this was grouped

according to the key issue or theme addressed by each

publication. The first theme centred on prevalence, and the

impact and management of acute urinary retention as a symptom

of disorders such as benign prostatic hypertrophy, or following

pelvic surgery. This literature revealed important information

on risk factors for urinary retention in older adults such as

faecal impaction, impaired mobility, neurological disorders (i.e.

stroke, Parkinson’s Disease, Multiple Sclerosis), longstanding

diabetes, medicines (i.e. antihypertensives, anticholinergics,

antispasmodics, atropine, sedatives), urethral obstruction, spinal

cord injury or disease, spinal anaesthesia and surgical disturbance

of bladder innervation. These risk factors were included in the

guideline.

Another major topic area gleaned from the literature focused

on the physiological effects of ageing on bladder function.

Studies showed that, as people age, their bladder contractility

decreases 11, 12; factors that may explain this change include

detrusor fibrosis 13, increased collagen deposition 14 and a loss

of acetylcholinesterase-positive nerve terminals 15. Not only

do many older people have reduced bladder contractility,

but many frail older adults also have a concurrent overactive

bladder, a condition termed detrusor hyperactivity with impaired

contractility (DHIC) 16-18. This condition can cause frail older

adults to have a large PVR and concurrent lower urinary tract

symptoms such as urinary incontinence.

In light of these findings, one of the challenges for clinicians

is that many older adults with impaired bladder contractility

or DHIC may have few or no symptoms. Where symptoms

are limited to urinary incontinence, this can be erroneously

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attributed to other factors. The condition can be further

concealed by the presence of other conditions, for example

dementia. Cognisant of the potential for clinically unsuspected

urinary retention in certain groups, some researchers have

recommended routine screening for PVR for all patients

admitted to general rehabilitation units 19, for incontinent

nursing home residents 20, 21 and for all patients with lower

urinary tract symptoms 22.

The literature on PVR presented variable �ndings that challenge

the reliability of using PVR as a measure for diagnosing clinically

signi�cant urinary retention For example, even in healthy older

adults, the presence of retained urine (i.e. PVR) may represent

normal ageing as Bonde and colleagues 1 identi�ed in a normative

sample of 140 older adults aged over 75 years, who had PVRs

ranging from 0-150mls, and averaged 45mls for women and

90mls for men. Another study of healthy community dwelling

people, over 55 years of age, found that detrusor contractions

declined signi�cantly with age and this decline was associated

with lower urine �ow rates and a small increase (generally

≤50mls) in PVR 23.

The critical question is: at what volume does a residual volume

become clinically signi�cant? This was not answered as the

literature revealed a wide range of PVR values that require

attention. (Table 1).

After reviewing urinary retention in 100 elderly hospitalised

individuals, Grosshans and colleagues claimed that, “… no

one value is considered signi�cant as a normal or pathological

value” 2(p.637) and have called for further research in order to

better de�ne what may constitute a normal PVR value among

elderly persons, and to determine its signi�cance. To further

illustrate the proposition that proper bladder emptying and

the clinical signi�cance of PVR varies from one person to the

next, Taylor and Kuchel 35(p.1923) state that “repeated PVR values

of 250mls in an older woman who is asymptomatic without

urinary frequency or recurrent urinary tract infections probably

requires no further action, whereas, the same individual

who is symptomatic and has renal failure, or evidence of

hydronephrosis on ultrasound, requires a urology referral”.

A �nal consideration for clinicians is that there is some doubt

in the research literature about the test-retest reliability of

PVR itself, even within a 24-hour period 36-38 . Gri�ths and

colleagues 38 measured residual urine in each of the geriatric

patients in their study at three di�erent times of day, during

two visits at 2-4 week intervals and found large within-patient

variability within that study group.

R esults of consultation with expert panel

The multidisciplinary expert panel was provided with a summary

of the major points found in the literature and panel members

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were invited to agree, disagree or comment on these points. The

findings from this process revealed that they agreed with most of

the proposed content that formed the basis of the draft guideline.

They identified some limitations with the definitions of acute and

chronic urinary retention found in the review of literature. For

example, the definition of acute urinary retention as “a painful,

palpable or percussible bladder, when the patient is unable to

pass urine” 9 does not accommodate patients with acute urinary

retention who have few or none of these symptoms. Similarly,

the definition of chronic urinary retention as “a non-painful

bladder, which remains palpable or percussible after the patient

has passed urine” 9, does not account for patients with chronic

urinary retention whose bladders are not able to be palpated or

percussed. Hence, reliance on the review of literature definitions

for acute and chronic retention as the basis for diagnosing the

type of urinary retention was seen as problematic.

There was no professional consensus in the literature on what

constitutes a threshold PVR and none of the studies reviewed

provided a formula for practice. Members of the expert panel

also expressed varied opinions about what information should

be included in the guidelines to assist healthcare professionals

to interpret PVR. Despite this variability, the expert panel

emphasised that any interpretation of the clinical significance

of PVR should be done in conjunction with other clinical

information. A key message from the expert panel was that the

knowledge and skills required for identifying and managing

urinary retention were highly specialised and that, “… the

management of urinary retention should be underpinned by

specialised individualised clinical decision-making and is context

specific”.

The panel also identified the different factors that underpin

clinical decision making, including:

• Thepersonandtheircarer’spreferencesfortreatment.

• Theirpsychosocialstatusandqualityoflife.

• Thepotentialforuppertractdamage.

• Anyunderlyingpathology.

• Thetypeandseverityofsymptoms.

• Theresultsofinvestigations.

• Whetherornotthepersonneedsandhasassistancetocarry

out treatment for their condition.

Therefore, all these factors were included in the guideline. In

addition, we included information on the major risk factors and

key signs and symptoms for urinary retention in hospitalised older

adults to alert users of the guide to the fact that multiple factors

need to be considered when interpreting PVR in older adults.

Discussion

Retention of urine is widely experienced by older adults and is

often difficult to detect and diagnose. Its management in this

group of patients poses challenges for clinicians as previously

Table 1. PVR values that require attention.

study PVr values study population

Agency for Health Care Policy and Research (1996) 24 >200mls Elderly patients

Borrie et al. (2001) 25 2 consecutive scans ≥150mls Elderly rehabilitation patients

Dromerick & Edwards (2003) 26 150mls Stroke patients

Fonda et al. (2005) 27 >100mls for men Elderly and frail patients >200mls for women

Gray (2000) 28 150-200mls or more Not stated

Grosshans, Passadori & Peter (1993) 2 >50mls Elderly patients on acute care wards

Hilton & Stanton (1981) 29 20-300mls Elderly patients

Mainprize & Drutz (1989) 30 >30mls Women with chronic persistent urinary tract symptoms

ouslander (1981) 31 20-300mls Elderly patients

Resnick (1984) 32 20-300mls Elderly patients

Starer & Libow (1987) 17 300mls Elderly incontinent nursing home residents

Smith & Albazzaz (1996) 33 >300mls Elderly women post surgery for proximal hip fracture

Tam, Wong & Yip (2005) 34 100mls Elderly patients transferred from acute hospital

Wu & Baguley (2005) 19 150mls Geriatric rehabilitation patients

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Figure I. Guidelines for nursing assessment and management of urinary retention in elderly hospitalised patients.

Guidelines for nursing assessment and management of urinary retention in elderly hospitalised patients

Urinary retention manifests either acutely or chronically and is

characterised by......

Please note: These guidelines may accompany, but do not replace, local guidelines and/or sound clinical judgement. There may be individuals with more complex conditions (i.e. multiple sclerosis, spinal patients, etc) for whom these guidelines do not apply.

List of abbreviationsPost void residual – PVRIndwelling catheter – IDCIntermittent catheter – IC

Urinary retention symptoms that warrant attention

> Lower abdominal pain and/or discomfort (this may present as distress or agitation in people who are cognitively impaired), and/or

> Urinary incontinence, and/or> Inability or difficulty to void and/or empty the bladder (see facts about

bladder emptying)

Conduct a nursing assessment

> Brief patient history> Review urinary retention risk factors > Conduct a physical assessment of lower abdomen (inspect, palpate, percuss)> Urinalysis (if possible)> Bladder scan to determine the PVR

Modify and monitor risk factors as medically advised (i.e. improve

mobility, bowel management program, relieve pain, administer

prescribed medications etc)

Modify and monitor risk factors as medically advised (i.e. improve

mobility, bowel management program, relieve pain, administer

prescribed medications etc)

Clinically significant

Not clinically significant

Relieve bladder

distension as medically

advised (i.e. IDC / IC)

Monitor for clinical signs

and symptoms (i.e. observe urine output)

Modify and Monitor Common Risk Factors

> faecal impaction> impaired mobility> neurological conditions

(i.e. multiple sclerosis, stroke, Parkinson’s disease)

> longstanding diabetes> drugs (antihypertensives,

anticholinergics, antispasmodics, atropine, sedatives)

> urethral obstruction (i.e. benign prostatic hypertrophy, urethral stricture, prostate cancer, tumours)

> spinal injury or disease> spinal anaesthesia> surgical manipulation of the bladder

nerves

Facts about Bladder Emptying

> Bladder emptying can be affected by:- a lack of privacy- voiding in unfamiliar places- voiding on command- voiding with a partially or

overfilled bladder- pain

> It is also affected by the above mentioned risk factors

*The Clinical Significance of PVR

There is no professional consensus on the PVR that constitutes an upper or lower threshold

The PVR measurement is one of many factors to be considered in determining treatment options

Other factors to consider include:

> The person’s preferences for treatment

> Psychosocial status, quality of life> The potential for upper tract

damage> The type and severity of symptoms> The results of investigations> Comorbidities, prognosis> Underlying pathology

This project was undertaken by Professor Bev O’Connell and Ms Joan Ostaszkiewicz, Deakin—Southern Health Nursing Research Centre, School of Nursing, Deakin University, Melbourne and Dr Chantal Ski, Hobsons Australia. It was funded by The National Continence Management Strategy: an initiative of The Australian Government Department of Health and Ageing (2006).

Distinguishing Symptoms

PVR / PAIN /

DISTRESS / AGITATION

PVR / NO PAIN /

NO DISTRESS / NO AGITATION

Plan of Care Plan of Care

Notify Medical Practitioner In collaboration with Medical Practitioner, establish the clinical

significance of the PVR*

Relieve bladder distension as medically advised (i.e. IDC / IC)

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82 Vol. 14, No. 3 • Spring 2008

there has been a lack of clear guidance on which to base current

practice. An ongoing dilemma is the lack of consensus about

the clinical signi�cance of PVR in older adults. This absence

of evidence has important implications for nurses who are

often required to make judgements about when to intervene

and seek more specialised advice. The survey of clinicians

that was conducted prior to the development of the guideline

revealed considerable variability in practice in relation to the

management of this condition.

In order to assist nurses’ clinical decision making on this issue,

this research resulted in a guideline that provides a framework for

the nursing assessment and management of urinary retention in

hospitalised older adults. It is based on the best available evidence

at the time it was created and was developed in consultation with

a multidisciplinary expert panel. Information is included on key

signs and symptoms for urinary retention in hospitalised older

adults, risk factors that need to be considered in the decision

making process, factors that a�ect normal bladder emptying,

and on the gap in evidence on the clinical importance of PVR

in older adults. As such, it recommends that nurses interpret the

�nding of PVR in collaboration with a medical practitioner and

in context with other factors (Figure 1).

Although the guideline was developed for the nursing care of

older people in acute and subacute settings, it may also be useful

to other healthcare professionals who are involved in the initial

management of this condition and in other healthcare settings.

It is important that this research be viewed as foundational and

that further trial and evaluation of the guideline is undertaken in

a range of populations and settings.

Acknowledgements

This project was funded by the Department of Health and

Ageing as part of the National Continence Management Strategy.

The authors would like to thank the experts for their valuable

input to the development of the guideline and colleagues who

provided feedback on drafts of the manuscript.

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