Retention

Question 1

Cause of retention?

Answer 1

• UTI
• BPH
• prostate
  • UTI
  • Prostatic cancer
  • Bladder cancer
  • Neuropathic bladder - MS, Parkinson’s, stroke, DM. Alzheimers
  • Nerve damage - sciatica, cauda equina
  • Schistosomiasis
  • Extrinsic mass compression (cystocele, fibroids, ovarian cyst, constipation)

cauda equina,

anticholinergics, • Urethral stricture - congenital or acquired
• Weakened bladder muscle
• Renal stones/clot
• Meatal stenosis

Question 2

what is TURP

Answer 2

Transurethral resection of the prostate (TURP) is now the standard technique. A working sheath is placed in the urethra through which a hand-held device with an attached wire loop is placed. A cutting diathermy is run through the loop so that it can be used to shave away prostatic tissue. When successful, it is an excellent operation that does not involve entering the abdomen but it can have complications. Bleeding may be difficult to control. Irrigating fluid may be absorbed into the circulation via cut veins. An indwelling catheter is required until bleeding has stopped. Urethral stricture can occur. There can be retrograde ejaculation after operation or damage to the nerves can cause erectile dysfunction.

Question 3

acute retention?
chronic retention?
acute on chronic?

Answer 3

• Acute
○ Painful
○ >600 ml, dull to percussion
○ Acute confusion common
○ Caused by BPH, strictures, drugs, blood clots, alcohol, constipation, post op, infection, neuro
○ Treat with suprapubic or urethral catheter
• Chronic
○ Painless with postvoid residual urine
○ Can be suggested by bedwetting or enlarged bladder on palpation/percussion
○ High pressure affects renal function
○ Low pressure doesn’t
○ Presents with LUTS
○ Complications are UTI, renal failure
○ Only catheterize if there is pain
○ Intermittent self-catherization can be advised
§ If >1 litre monitor for post-obstructive diuresis
• Acute on chronic
○ Painful with very large residual (>1.5 litre)
○ Can be painless and only noticed with overflow incontinence (usually nocturnal)
○ Causes AKI (very high creatinine), hyperkalaemia, metabolic acidosis, post-obstructive diuresis (needs IV fluids), hyponatraemia, infection

Question 4

NICE mx of voiding Sx

Answer 4

• Active surveillance
  
  • Reassurance, lifestyle advice, follow-up
  • NHS choices
  • Bladder and Bowel Foundation website
  • Don’t cut back on too much fluid
  • Avoid constipation
  • Diet, exercise, smoking, alcohol
  • Limit caffeine
• Conservative management
  
  • Pelvic floor muscle training
  • Bladder training
• Next step for patients with severe voiding Sx is Alpha1-blocker ie tamsulosin / doxazosin / alfuzosin
  
  • Review at 4-6 weeks then every 6-12 mo
• Higher risk patients with enlarged prostate get 5-alpha reductase inhibitor ie dutasteride or finasteride
  
  • Review at 3-6 mo
• Patients with both severe Sx and enlarged prostate get both
• Patients with mixed voiding and storage Sx - alpha blocker AND anticholinergic eg oxybutynin/tolterodine/darifenacin
• Secondary care:
  
  • Catherization (intermittent, indwelling urethral or suprapubic)
  • TURP
  • TUVP vaporisation
  • HoLEP (holmium laser enucleation of the prostate)
  • Open prostatectomy for prostate >80g