Urinary retention: Urinary retention: causes and treatment causes and treatment optionsoptions

Dr. Mátyás Benyó UNIVERSITY OF DEBRECEN

MEDICAL AND HEALTH SCIENCE CENTERDEPARTMENT OF UROLOGY

Causes of decreased urine Causes of decreased urine outputoutputLower urinary tract obstructionUpper urinary tract obstructionDecreased urine consumptionRenal failureShock reaction

Lower urinary tract Lower urinary tract obstructionobstruction Causes:

◦ Stricture (infection, trauma, congenital)

◦ Stone (bladder, urethra)

◦ Prostate (BPH, tumor, infection)

◦ Trauma or tumor (bladder, urethra, cervix, rectum, penile)

◦ Constipation

◦ Bladder hypofunction, sphincter overactivity

Overflow inkontinence Consequences:

Infection, stone formation, detrusor hypertrophy, bladder hypofunction, reflux, renal failure

Diagnosis of lower urinary Diagnosis of lower urinary tract obstructiontract obstructionPatient’s history:

◦Urological hystory, symptoms (fever, burning urine), duration, medication, possible alien body

Physical examination◦Penile (phimosis, tumor), urethra,

prostate, lower abdomen (bladder)Tests

◦Urine (if possible), CRP, WBC, creatinin, GFR

Ultrasound

Indication for stenting of Indication for stenting of lower urinary tractlower urinary tractObstruction (causes)Severe vesico-ureteral refluxRegistration of urine output:

◦ Hypovolaemia, long lasting operations, shock …Bladder or urethra injury In case of special wound healing (penile

operations)

Not indications◦ Nursing aspects◦ If cause can be solved (e.g. constipation)

If the cause is solved/over, the catheter should be removed

Types of bladder urinery Types of bladder urinery diversiondiversion(Condom catheter–

nursing aspects)Intermittant or

indwellig bladder catheter

Suprapubic catheterCystostomy

CathetersCathetersExternal diameter: French (Charriére =

1/3mm)With or without balloon1; 2; 3 chanelledFlexible or rigidTiemannSillicone„Pigtail” Sizes:

◦ Green: 14 Ch◦ Orange: 16 Ch◦ Red: 18 Ch

Intermittant self Intermittant self catheterisationcatheterisationIf the cause of lower urinary tract

obstruction can’t be solved (e.g. spinal cord injury)

Sterile – aseptic – cleenPatient education10-14 Ch (traumatisation ↓)4-5x daily – fluid intakeResidual urine should be below 400ml

Instruments of insertion of Instruments of insertion of indwelling catheterindwelling catheterDesinfectantSterile gloves of forcepsLubricantCatheterFluid for balloon inflation(thread, lidocain for fixingcatheter without balloon)

Proper techique is essentialProper techique is essential

Removal of the catheterRemoval of the catheterBalloon deflationIf not removable

◦ cutting the valve◦ Overinflation of the balloon◦ Suprapubic puncture of the balloon

Contraindications of urathral Contraindications of urathral bladder catheterbladder catheterIn case of the followings suprapubic

catheter is indicated

Severe prostatitis, urethritisUrethral traumaTumor of the external genitalia

Catheter induced nosocomial Catheter induced nosocomial infectioninfectionthe urinary tract is the

commonest source of nosocomial infection, particularly when the bladder is catheterised

Most CAUTIs are derived from the patient’s own colonic flora

most important risk factor is the duration of catheterisation

Catheter induced nosocomial Catheter induced nosocomial infectioninfection• the ascent of microorganisms from the urethra is

the most common pathway that leads to a UTI, especially organisms of enteric origin (e.g. E. coli and other Enterobacteriaceae)

• A single insertion of a catheter into the urinary bladder in ambulatory patients results in urinary infection in 1-2% of cases. Indwelling catheters with open-drainage systems result in bacteriuria in almost 100% of cases within 3-4 days. The use of a closed-drainage system, including a valve to prevent retrograde flow, delays the onset of infection, but ultimately does not prevent it. It is thought that bacteria migrate within the mucopurulent space between the urethra and catheter, and that this leads to the development of bacteriuria in almost all patients within about 4 weeks.

Catheter induced nosocomial Catheter induced nosocomial infectioninfection• The more compromised the natural

defence mechanisms (e.g. obstruction, or bladder catheterisation), the fewer the virulence requirements of any bacterial strain to induce infection.

• The virulence concept also suggests that certain bacterial strains within a species are uniquely equipped with specialised virulence factors, e.g. different types of pili, which facilitate the ascent of bacteria from the faecal flora, introitus vaginae or periurethral area up the urethra into the bladder, or less frequently, allow the organisms to reach the kidneys to induce systemic inflammation.

Catheter induced nosocomial Catheter induced nosocomial infection - preventioninfection - prevention• two priorities: the catheter system should remain

closed and the duration of catheterisation should be minimal

• remove unnecessary catheters• drainage bag should be always kept below the level

of the bladder and the connecting tube• For patients using intermittent catheterisation and

short-term catheterisation, routine prophylaxis with systemic antibiotics is not recommended

• Antibiotic irrigation of the catheter and bladder is of no advantage

• the catheter is in place, systemic antimicrobial treatment of asymptomatic catheter-associated bacteriuria is not recommended, is recommended only for symptomatic infection with broad-spectrum antibiotics based on local susceptibility patterns

• Long-term antibiotic suppressive therapy is not effective

Catheter induced nosocomial Catheter induced nosocomial infectioninfectionHealthcare workers should be

constantly aware of the risk of cross-infection between catheterised patients. They should observe protocols on hand washing and the need to use disposable gloves

Patients with urethral catheters in place for > 10 years should be screened annually for bladder cancer

Catheter induced nosocomial Catheter induced nosocomial infectioninfectionA minority of patients can be

managed with the use of the non-return (flip) valve catheters

Catheter induced nosocomial Catheter induced nosocomial infectioninfectionClinicians should always consider

alternatives to indwelling urethral catheters that are less

prone to causing symptomatic infection. In appropriate patients, suprapubic catheters, condom drainage

systems and intermittent catheterisation are each preferable to indwelling urethral catheterisation

Catheter induced nosocomial Catheter induced nosocomial infectioninfectionWritten catheter care protocols

are necessaryHealth care workers should

observe protocols on hand hygiene and the need to use disposable gloves between catheterised patients

Catheter insertion and Catheter insertion and choice of catheterchoice of catheter• An indwelling catheter should be

introduced under antiseptic conditions• Urethral trauma should be minimised

by the use of adequate lubricant and the smallest possible catheter calibre.

• Antibiotic-impregnated catheters may decrease the frequency of asymptomatic bacteriuria within 1 week. There is, however, no evidence that they decrease symptomatic infection. Therefore, they cannot be recommended routinely.

Catheter induced nosocomial Catheter induced nosocomial infectioninfectionPrevention – once more !!!Prevention – once more !!!• The catheter system should remain closed• The duration of catheterisation should be minimal.• Topical antiseptics or antibiotics applied to the

catheter, urethra or meatus are not recommended• Benefits from prophylactic antibiotics and antiseptic

substances have never been established, therefore, they are not recommended

• Removal of the indwelling catheter after non-urological operation before midnight might be beneficial

• Long-term indwelling catheters should be changed at intervals adapted to the individual patient, but must be changed before blockage

• Chronic antibiotic suppressive therapy is generally not recommended

• The drainage bag should always be kept below the level of the bladder and the connecting tube

Catheter induced nosocomial Catheter induced nosocomial infectioninfectionTreatmentTreatment• While the catheter is in place, systemic antimicrobial

treatment of asymptomatic catheter associated bacteriuria is not recommended, except in certain circumstances, especially before traumatic urinary tract interventions

• In case of asymptomatic candiduria, neither systemic nor local antifungal therapy is indicated, but removal of the catheter or stent should be considered

• Antimicrobial treatment is recommended only for symptomatic infection

• In case of symptomatic CAUTI, it might be reasonable to replace or remove the catheter before starting antimicrobial therapy if the indwelling catheter has been in place for > 7 days.

• In case of candiduria associated with urinary symptoms, or if candiduria is the sign of systemic infection, systemic therapy with antifungals is indicated

Upper urinary tract Upper urinary tract obstructionobstruction Causes:

◦ Stricture (infection, trauma)

◦ Stone (ureter, pyelon)◦ Bladder(stone, alien body,

tumor, detrusor hypertrophy)

◦ Trauma ortumor (cervix, sigma, colon, prostate…)

◦ Surgical procedure around the ureter (surgery, gynaecology, transplantology)

◦ Kidney(tumor or cyst)

Diagnosis of upper urinary Diagnosis of upper urinary tract obstructiontract obstructionPatient’s history:

◦ Urological hystory, symptoms (fever, burning urine), duration, medication, possible alien body

Physical examination◦ Penile (phimosis, tumor), urethra, prostate,

lower abdomen (bladder)Tests

◦ Urine (if possible), CRP, WBC, creatinin, GFRUltrasound, X-ray, iv urograpgy, CT

Indication for stenting of Indication for stenting of lower urinary tractlower urinary tractObstruction (causes)Preparation for surgery:

◦Urology (PNL, URS, pyeloplasty…)◦Surgery, gynaecology

◦ Postoperative care:◦Urology (PNL, URS, pyeloplasty…)◦Surgery, gynaecology◦Transplantology

TreatmentTreatmentUreter catheter

Easy to remove Immobilisation4-6 Ch

DJ stent indwellingHarder to remove4-6 Ch6 week– 1 year(plastic/metal)

Percutan nephrostomy8-… ChLife quality…

UrethrocystoscopyUrethrocystoscopy

First step of insertion of Uretercatheter or DJ stent

Method:Stone cutting postoionDesinfection and isolation of the meatus Lubricant0 degree lens in the urethra than 70 degree

optics in the bladder Identification of ureteral orifice

Instruments:Instruments:

DesinfectantIsolation towelLubricantWater pipeOutflow pipeLigh source and cableCystoscopOptics (0-70)

InstrumentsInstruments

Uretercatheter, double-J Uretercatheter, double-J stentingstentingCystoscop with a working

channel Identification of ureteral

orificeLeading the uretrecatheter to

the pyelumFixing the uretrecatheter to

the indwelling bladder catheter

Removal: ◦ UC: „pulling”◦ DJ: cystoscopy

InstrumentsInstruments desinfectant Desinfectant Isolation towel Lubricant Water pipe Outflow pipe Ligh source and cable Cystoscop Optics (0-70) 5-6 Ch ureter catheter 0.035mm flexible URS guidewire Contrast stuff Bladder catheter

InstrumentsInstruments

Percutan nephrostomyPercutan nephrostomy In case of severe supravesical postrenal

obstruction when larger diameter is needed (>8Ch) OR when UC or DJ has failed

Requirements X-ray and ultrasound

Can be emergency situationProper hemostatis is necessary

Percutan nephrostomyPercutan nephrostomyMethodProne positionDesinfectant, isolationLocal anasthesia with lidocainPuncturind a calix with a needle by

ultrasound guidanceContrast material, guidewire (X-ray)DilatationDrainpipeFixing the tube

Percuta nephrostomyPercuta nephrostomy

Thank you for your Thank you for your attention!attention!Videos:

◦Self catheterisation◦Insertion of indwelling bladder

caheter◦Cystoscopy-DJ