Emergency- Urinary retention

Question 1

A 62M with a 6 month history of LUTS attends A&E with inability to void and is uncomfortable. How would you assess this patient?

Answer 1

I am concerned that this patient may have an acute urinary retention therefore will aim to the see the patient immediately. If I was referred this patient on the phone I would instructed the team in A&E to perform a bladder scan and set up a catheter trolley.
I would assess the patient in ABCDE approach in accordance to the ATLS algorithm and would assume that the A&E team would have started O2, IV access and obtained bloods [FBC, U&Es, Coag, CRP]
I would examine the abdomen assessing for previous surgical scars and a palpable bladder, that would have been confirmed with a bladder scan. DRE can wait after catheterisation
I would take a focussed history from the patients on duration, general history of LUTs, associated VH, risk factors of AUR, their past medical history and clarify if they are on any anticoagulants.
I would proceed with inserting a 2 way 16ch or 18ch catheter under aseptic technique. If there is an suspicion of VH causing clot retention I would insert a 22ch 3 way catheter instead.

Question 2

What are causes of AUR?

Answer 2

BPH, UTI, constipation, haematuria causing clot retention, Bladder cancer, Prostate cancer, pelvic prolapses and masses, post GA surgery, Medication [Anticholinergics], pain, neurological disorders [MS], Spinal injury [S2-4]

Question 3

What investigations would you perform?

Answer 3

Once catheterised I would perform:
Urinalysis +/- urine cultures
Bloods: FBC, U&Es, CRP. I would perform a PSA though knowing it would be high due to instrumentation and retention to ensure I don’t miss potential metastatic prostate cancer that caused the AUR
If patient spikes a temp then blood cultures
USS if patient has deranged U&Es

Question 4

A&E failed to catheterise. How would you approach?

Answer 4

I would try again with a 16ch 2 way catheter using 2-3 lots of instillagel, ensuring patient is flat.
If that doesnt work I am aware you can try a caude tip catheter which is slight curved at the tip but in my hospital I would move onto either an introducer or flexible cystoscopy. I am generally comfortable with introducer but if there is any difficult I would abandon and move onto a flexible cystoscopy for visualisation, guidewire and an open tip catheter to railroad over the wire.
If that doesn’t work then I need to consider an SPC

Question 5

Catheter is in using a flexible cystoscopy and he has now passed 400ml/hr for the past 3 hours. How do you proceed?

Answer 5

I am concerned that this patient may have a post obstructive diuresis. My priority to to correct electrolyte imbalance and fluid management. I would replace his fluid loss with saline solution at volume of 75% of the previous hour urine output.
I would monitor the U&Es in 12hrs and reassess.

Question 6

What do you need to perform an SPC

Answer 6

Seldinger SPC catheter kit
Scalpel
1% lidocaine 10ml
Large needle to draw up lidocaine, green needle to inject
Guidewire
Betadine wash
Drape, swabs, syringe with 5-10ml sterile water for balloon inflation
catheter bag

Question 7

Describe your technique for SPC insertion

Answer 7

Consent patient, ensure lying flat. use USS if available, look for bladder but landmarks are 2 fingerbreadth above the pubic symphsis
Inject LA there and aspirate urine.
Keep the needle in and wire through needle. needle out
Trocar railroad over the guidewire, then insert trocar until urine out.
Wire out and cover the sheath, catheter in, inflate balloon and attach to bag.
Remove sheath.