Management of acute urinary retention

Acute urinary retention (AUR) is a common urological emergency, characterized by a sudden and painful inability to pass urine. There is high variability within and among countries in its management, which can be explained not only by differences in access to care but also by a lack of harmonization and consensus on the best way to proceed. Immediate treatment consists of bladder decompression, usually by a urethral catheter, although a suprapubic catheter offers several advantages not often exploited by urologists. Until recently, secondary management consisted almost exclusively of prostatic surgery within a few days (emergency surgery) or a few weeks (elective surgery) after a first AUR episode. The greater morbidity and mortality associated with emergency surgery, and the potential morbidity associated with prolonged catheterization, has led to the increasing use of a trial without catheter; this involves catheter removal after 1-3 days, allowing the patient to void in 23-40% of cases, and surgery, if needed, at a later stage. Alpha1-adrenergic blockers given before catheter removal improve the chances of success. A high prostate-specific antigen level and postvoid residual urine volume, and response to alfuzosin treatment after a first AUR episode managed conservatively, may help to identify patients at risk of an unfavourable outcome.     

非甾体类消炎药对骨折愈合影响的研究进展

骨折后或骨折术后为了缓解疼痛临床上常用非甾体类消炎药（non—steroidalanti—inflammatorydrug,NSAID）镇痛。近年来研究发现NSAID在镇痛的同时对骨折愈合会产生不良影响。这一发现越来越引起各国学者的注意,笔者就此研究进展综述如下。     

Urodynamic evaluation of surgical outcome in patients with urinary retention due to central lumbar disc prolapse

AIMS: To investigate whether acute urinary retention due to central lumbar disc prolapse is reversible after emergency spinal surgery. METHODS: Eight patients (two males, six females) with a mean age of 31.5 years (range, 18-42 years) with urinary retention due to lumbar disc prolapse were studied. An emergency surgery was performed within 48 hours (mean, 42 hours) after the onset of urinary retention. Urodynamic study was performed before and after the operation. RESULTS: All patients had acontractile detrusor without bladder sensation and four of seven patients had inactive external sphincter on electromyogram at presentation. Two patients were unable to void up to 1 and 5 months after surgery and were then lost for follow-up. The remaining six patients could void with straining or changing their voiding postures (bending forward), postoperatively. A follow-up urodynamic study was performed in all patients from 1 month to 6 years postoperatively. All patients demonstrated acontractile detrusor on cystometrogram. On external sphincter electromyogram, four patients had normal activities. The remaining four patients recovered electromyographic activities, but two of them had denervation motor unit potentials and two had low activities. CONCLUSIONS: Bladder function was irreversible after spinal surgery, whereas urethral function showed a better recovery in patients with acute urinary retention due to central lumbar disc prolapse. However, most of our patients could empty their bladder only by straining or changing their voiding postures postoperatively.     

Urinary retention due to herpes virus infections

Urinary retention is uncommon in patients with herpes zoster and anogenital herpes simplex. Seven patients (four men, three women) with a mean age of 68.1 years (range, 35–84) with urinary retention due to herpes zoster (n = 6) or anogenital herpes simplex (n = 1) were studied. Six patients had unilateral skin eruption in the saddle area (S2–4 dermatome) and one patient with herpes zoster had a skin lesion in the L4–5 dermatome. All patients had detrusor areflexia without bladder sensation, and two of them had inactive external sphincter on electromyography at presentation. Clean intermittent catheterization was performed, and voiding function was recovered in 4–6 weeks (average, 5.4) in all patients. Urodynamic study was repeated after recovery of micturition in three patients, and they returned to normal on cystometrography and external sphincter electromyography. Acute urinary retention associated with anogenital herpes infection has been thought to occur when the meninges or sacral spinal ganglia were involved, and, in conclusion, this condition may be considered to be reversible. Neurourol. Urodynam. 17:613–619, 1998. © 1998 Wiley-Liss, Inc.     

Critical evaluation of the problem of chronic urinary retention after orthotopic bladder substitution in women

PURPOSE: We studied the possible causes of chronic retention after radical cystectomy and orthotopic bladder substitution in women. MATERIALS AND METHODS: Between January 1995 and January 2001, 136 women with a mean age plus or minus standard deviation of 52 +/- 8 years underwent standard radical cystectomy and orthotopic substitution for organ confined bladder cancer. Videourodynamics, pelvic floor electromyography, pelvic floor magnetic resonance imaging and pan-endoscopy were done. In the last 37 cases some technical modifications were adopted to circumvent the development of chronic urinary retention. RESULTS: One woman died postoperatively of massive pulmonary embolism. Of the 100 patients evaluable at a mean followup of 36 months 95 were continent in the daytime, 86 were continent at night, 2 were completely incontinent and 16 were in chronic retention. Videourodynamics showed that retention was mechanical in nature due to the pouch falling back in the wide pelvic cavity, resulting in acute angulation of the posterior pouch-urethral junction. In addition, herniation of the pouch wall through the prolapsed vaginal stump was observed in most cases. Pelvic floor electromyography demonstrated complete pelvic floor silence during voiding. No abnormality of the pelvic floor or rhabdosphincter was noted on magnetic resonance imaging. Pan-endoscopy showed a normal urethra with no urethroileal stricture. A 4 mg. dose of the alpha1-adrenergic blocker doxazosin daily was ineffective, excluding the possibility that sprouting from adjacent adrenergic neurons into the denervated proximal urethral muscles may have been the cause of this problem. After omental packing behind the pouch, suturing of the peritoneum on the rectal wall to the vaginal stump, suspension of the latter by the preserved round ligaments and suspension of the pouch near its dome to the back of the rectus muscle at cystectomy the incidence of chronic retention decreased from 18.7% (14 of 75 cases) before to 8% (2 of 25) after modifications. Furthermore, after vaginal wall descent was mechanically corrected by a pessary there was significant improvement in evacuation. CONCLUSIONS: Strong evidence was provided that chronic urinary retention after orthotopic substitution is due to anatomical rather than to functional or neurogenic reasons. Modifications to increase back support of the pouch with ventral suspension near its dome and support the vaginal stump are recommended to avoid this complication.     

Non-selective and cyclo-oxygenase-2-specific non-steroidal anti-inflammatory drugs impair the hyperaemic response of skin to brief axillary artery occlusion

Background. Cyclo-oxygenase-2 (COX-2)-specific inhibitors aremarketed as safer analgesics than non-selective non-steroidalanti-inflammatory drugs. However, there has been conflictingevidence concerning endothelial function and cardiovascularrisk after COX-2 inhibitor use. We investigated forearm skinvascular reactivity to brief axillary artery occlusion in healthyvolunteers after a single dose of the non-steroidal anti-inflammatorydrugs ibuprofen (non-selective) and rofecoxib (COX-2 specific). Methods. Ten healthy male volunteers were studied. Forearm skinblood flow was measured using laser Doppler flowmetry. Two non-invasiveprobes were placed on the volar surface of the forearm. Themagnitude of hyperaemic response to brief (20 s) and prolonged(5 min) occlusion of the axillary artery was measured beforeand 2–3 h after administration of ibuprofen 800 mg orrofecoxib 25 mg. The transient hyperaemic response ratio (THRR),defined as the net peak hyperaemic flow-flux divided by thenet baseline flow-flux, was calculated. Each volunteer receivedboth drugs in random order at least 1 week apart. Results. Ibuprofen and rofecoxib increased net baseline bloodflow (median (range): ibuprofen, from 23.3 (12.1–40.8)to 31.5 (17.4–77.3); rofecoxib, from 22.0 (14.6–41.0)to 29.9 (19.5–112.0); P<0.01). The net hyperaemic peakflow-flux after brief and prolonged occlusion was unchangedafter both drugs. THRR was reduced by both drugs (ibuprofen,from 2.92 (2.38–3.86) to 2.09 (1.45–3.54); rofecoxib,from 3.36 (2.06–5.16) to 2.67 (1.15 –3.84); P<0.01). Conclusions. Both COX-2 and non-selective non-steroidal anti-inflammatorydrugs, when given to healthy volunteers as single therapeuticdoses, decrease skin microvascular tone but do not impair maximalvasodilatory ability. Br J Anaesth 2003; 91: 353–6     

Maximum urethral closure pressure and sphincter volume in women with urinary retention

PURPOSE: In 1988 a syndrome of isolated urinary retention in young women that is associated with electromyographic abnormality of the striated urethral sphincter was described. It was hypothesised that urinary retention resulted from a failure of sphincter relaxation. The electromyographic abnormality causes overactivity of the muscle and may induce changes of work hypertrophy. If the hypothesis that the electromyographic abnormality is the cause of urinary retention is correct, we would expect the urethral sphincter to be enlarged and the urethral pressure profile to be increased in these women. We evaluated the role of static urethral pressure profilometry and transvaginal ultrasound in women in urinary retention. MATERIALS AND METHODS: A total of 66 women in complete or partial urinary retention underwent electromyography of the striated urethral sphincter using a concentric needle electrode, followed by urethral pressure profile and/or urethral sphincter volume measurement by transvaginal ultrasound. RESULTS: Maximum urethral closure pressure plus or minus standard deviation was significantly increased in patients with versus without the electromyographic abnormality (103 +/- 26.4 versus 76.7 +/- 18.4 cm. water, p <0.001). Maximum urethral sphincter volume was also increased in women with versus without the abnormality (2.29 +/- 0.64 versus 1.62 +/- 0.32 cm.3, p <0.001). CONCLUSIONS: The results of this study are consistent with the hypothesis that a local sphincter abnormality is the cause of urinary retention in a subgroup of women. Urethral pressure profilometry and sphincter volume measurement are useful for assessing these cases, especially when sphincter electromyography is not readily available.     

Corticosteroid use after prostate brachytherapy reduces the risk of acute urinary retention

OBJECTIVES: To evaluate the role of short-term steroids after prostate brachytherapy to reduce oedema and thus the risk of urinary retention associated with brachytherapy, as this can require surgical intervention and may even result in incontinence. PATIENTS AND METHODS: A retrospective review was conducted on 400 consecutive patients with early-stage prostate cancer who underwent ultrasonography-guided transperineal brachytherapy. Androgen deprivation was given to 146 patients for 3 months before the implant and 280 received a 2-week course of dexamethasone (4 mg twice daily for 1 week then 2 mg twice daily). Forty-five patients developed acute urinary retention at a median of 12 days after implantation. Univariate and multivariate analyses were used to evaluate the potential risk factors for urinary retention. RESULTS: Acute urinary retention developed in 11.1% of the patients and the risk was predicted by increasing prostate volume at the time of diagnosis. This risk was higher (18.8%) for men receiving no dexamethasone and lower (8.2%) for those who did. In the multivariate analysis the volume at diagnosis and the use of dexamethasone remained significant. The use of steroids counterbalanced the effect of increasing prostate volume on the incidence of retention. The risk of retention was higher in those men receiving androgen deprivation to shrink their prostates than in those whose prostates were of suitable size for implantation at the time of diagnosis. CONCLUSION: Reducing prostate volume by androgen deprivation before brachytherapy may be less important in preventing brachytherapy-related urinary retention than the use of corticosteroids to reduce oedema afterward.     

Long-term results of sacral neuromodulation for women with urinary retention

OBJECTIVE

To review the long‐term results of sacral nerve stimulation in the treatment of women with Fowler's syndrome, over a 6‐year period at one tertiary referral centre.

PATIENTS AND METHODS

Between 1996 and 2002, 26 women with urinary retention were treated by implanting a sacral nerve stimulator. Their case records were reviewed for follow‐up, complications and revision procedures, and the most recent uroflowmetry results.

RESULTS

There were 20 patients (77%) still voiding spontaneously at the time of review (with two having deactivated their stimulator because of pregnancy). Fourteen patients (54%) required revision surgery, and the most common complications included loss of efficacy, implant‐related discomfort and leg pain. The mean postvoid residual volume was 75 mL and mean maximum flow rate 20.8 mL/s.

CONCLUSION

In young women with retention, for whom there is still no alternative to lifelong self‐catheterization, sacral neuromodulation is effective for up to 5 years after implantation. However, there was a significant complication rate, in line with other reports, which may be improved by new technical developments.

     

Effect of glycine on recovery of bladder smooth muscle contractility after acute urinary retention in rats

OBJECTIVE: To investigate the effects of glycine on the recovery of bladder smooth muscle contractility after acute urinary retention. MATERIALS AND METHODS: Bladder overdistension was induced in Sprague-Dawley rats by an infusion of saline (twice the threshold volume), maintained for 2 h. From 15 min before emptying of the bladder until 2 h after, saline or glycine solution was infused i.v. At 30 min, 2 h and 1 week after bladder emptying, samples of bladder tissue were taken for muscle strip study, malondialdehyde (MDA) assay, ATP assay, Western blotting for apoptosis-related molecules (Bcl-2, Bax, Caspase-3), and histological analysis including terminal deoxynucleotidyl transferase-mediated nick-end labelling staining. The results were compared among normal control, saline-treated and glycine-treated rats. RESULTS: In the glycine-treated group, muscle strip contractile responses induced by electrical-field stimulation and carbachol were both significantly greater at 1 week after bladder emptying than in the saline-treated group. The results of the ATP assay appeared to correspond with those of the muscle strip study. The saline-treated group had significantly higher MDA levels at 30 min after bladder emptying than the glycine-treated group. At 2 h after bladder emptying, there was significantly more apoptosis and greater leukocyte infiltration in the saline-treated group than in the glycine-treated group. While pro-apoptotic Bax and caspase-3 were down-regulated, Bcl-2 was up-regulated in the glycine-treated group. CONCLUSION: Glycine infusions might improve the contractile responses of bladder smooth muscle after acute urinary retention by reducing oxidative damage and apoptosis.     

Acute urinary retention as a result of a bladder diverticulum

An 11-month-old infant presented with acute urinary retention. He had presented 3 months earlier with complaints of an enlarging abdominal mass that was initially diagnosed as a mesenteric cyst on ultrasonography. Voiding cystourethrogram revealed a large bladder diverticulum. Bladder diverticulum should be a differential diagnosis in children, especially male, presenting with urinary retention, fever and an abdominal mass.     

Inhaled anticholinergic drugs and risk of acute urinary retention

Study Type – Harm (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Inhaled anticholinergic drugs have been associated with the risk of acute urinary retention (AUR), but this association was never studied under real life circumstances nor was this risk ever quantified. Use of inhaled anticholinergic drugs increases the risk of AUR by 40%. The risk of AUR is highest in recent starters, in patients with benign prostatic hyperplasia (BPH), and in patients receiving their anticholinergic drugs via nebulizer. It might be advisable to consider alternatives for inhaled anticholinergic drugs in COPD patients with BPH.

OBJECTIVE

• ? To investigate the association between the use of inhaled anticholinergic drugs and the risk of acute urinary retention (AUR) under real‐life circumstances.

PATIENTS AND METHODS

• ? We conducted a nested case‐control study within a cohort of patients with chronic obstructive pulmonary disease (COPD; as AUR has been associated with the use of inhaled anticholinergic drugs, which are used as first‐line treatment for COPD) from the Integrated Primary Care Information (IPCI) database.
• ? The cohort consisted of all patients with COPD aged ≥45 years, registered between 1996 and 2006, with ≥12 months of valid history. Cases were patients with a first diagnosis of AUR.
• ? To each case, controls were selected matched for age, gender and index date.
• ? Multivariate conditional logistic regression analysis was used to calculate adjusted odds ratios (OR_adj) with 95% confidence intervals (95% CI).

RESULTS

• ? Within the cohort of 22 579 patients with COPD, 209 cases were identified.
• ? Current use of inhaled anticholinergic drugs was associated with a 40% increase in risk for AUR (OR_adj 1.40; 95% CI 0.99–1.98) compared with non‐users.
• ? Among current users, the risk was highest for the recent starters (OR_adj 3.11; 95% CI 1.21–7.98). The risk of long‐acting anticholinergic drug tiotropium was not substantially different from that of the short‐acting anticholinergic ipratropium.
• ? The association was not dose‐dependent, but changed by mode of administration, with nebulizers having the highest risk (OR_adj 2.92; 95% CI 1.17–7.31).
• ? In men with COPD and benign prostatic hyperplasia (BPH) the association was strongest (OR_adj 4.67; 95% CI 1.56–14.0).

CONCLUSION

• ? Current use of inhaled anticholinergic drugs increases the risk of AUR, especially in patients with BPH or if administered via a nebulizer.