Management of Acute Urinary Retention in the Emergency Department

Table of Contents

 

About This Issue

Acute urinary retention (AUR) can present with many signs and symptoms, including abdominal or back pain, neurologic signs, and toxidromes, but in all cases, relief of the retention should be the first priority, followed by an investigation for the cause.

What are the advantages and disadvantages of urethral catheterization?

When should suprapubic catheterization be considered?

Are there signs to look for when trauma is the suspected cause of the AUR?

Though point-of-care ultrasound is the primary tool for diagnosing AUR, what are circumstances when CT, urethrogram, or x-rays should be considered?

What are the recommended lab studies that should be ordered? Is PSA testing recommended?

For patients with phimosis or paraphimosis, what are the most effective methods of reduction?

Which alfa blockers should be initiated in the ED?

What is the evidence on naloxone versus methylnaltrexone for reversal of opioid-induced AUR?

How should postobstructive diuresis be managed?

Are there differences in how women, children, and the elderly with AUR should be managed?

What are recommendations on admission, discharge, and follow-up?

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology, Pathophysiology, and Differential Diagnosis
   1. Structural Causes
      1. Benign Prostatic Hyperplasia
   2. Medication/Toxicologic Causes
      1. Medication-Associated Acute Urinary Retention
      2. Opioid and Substance-Associated Acute Urinary Retention
   3. Neurologic Causes of Acute Urinary Retention
   4. Infectious Causes of Acute Urinary Retention
6. Prehospital Care
7. Emergency Department Evaluation
   1. History
   2. Physical Examination
8. Diagnostic Studies
   1. Imaging
   2. Laboratory Studies
9. Treatment
   1. Urethral Catheter Versus Suprapubic Catheter
      1. Safety of Suprapubic Catheters in the Emergency Department
      2. Suprapubic Catheter Insertion
      3. Intermittent Drainage Options
      4. The Challenging Urethral Catheter
      5. Other Catheter Considerations
   2. Phimosis and Paraphimosis
   3. Medication Management
      1. Toxicologic Reversal Agents
   4. Postobstructive Diuresis
10. Special Populations
    1. Women
    2. Children
    3. Elderly Patients
11. Controversies and Cutting Edge
    1. Initial Use of Suprapubic Catheter Instead of Urethral Catheter for Acute Urinary Retention
    2. Antibiotics and Catheterization
    3. Slow Versus Rapid Bladder Decompression
    4. Acute Urinary Retention and Space Travel
12. Disposition
    1. Admit or Discharge
    2. Timing and Necessity of Urology Follow-up
13. Summary
14. Time- and Cost-Effective Strategies
15. Case Conclusions
16. Risk Management Pitfalls for Emergency Department Management of Acute Urinary Retention
17. Clinical Pathway for Emergency Department Diagnosis and Treatment of Acute Urinary Retention in Adult Males
18. Tables and Figures
    1. Table 1. Major Causes of Acute Urinary Retention
    2. Table 2. Pharmacologic Therapies Used for Spontaneous Acute Urinary Retention in the Emergency Department
    3. Table 3. Frequency of Etiologies of Acute Urinary Retention in Women
    4. Table 4. Frequency of Etiologies of Acute Urinary Retention in Children
    5. Figure 1. The Physiology of Micturition
    6. Figure 2. Ultrasound Scans Demonstrating Acute Urinary Retention
    7. Figure 3. Suprapubic Catheterization
    8. Figure 4. Straight and Coudé Catheter Tips
    9. Figure 5. Illustration of Acute Angle of Prostatic Urethra
    10. Figure 6. Anatomy and Ultrasound Image for Penile Nerve Block
    11. Figure 7. Dorsal Slit Procedure Technique for Phimosis
    12. Figure 8. Manual Reduction of a Paraphimosis
19. References

Abstract

Etiologies of acute urinary retention fall into 4 broad categories: structural, medication/ toxicologic, neurologic, and infectious. Although two-thirds of cases in men are related to prostatomegaly, there is also a high burden of concomitant morbid pathology. Acute urinary retention can also result from trauma, drug toxicity, infection, or compressive or demyelinating neurologic pathology, and these must be ruled out, particularly in women, children, and elderly patients. This review provides a best-practice approach to the evaluation and management of acute urinary retention in men, women, and children. Evidence-based recommendations are made regarding the approach to difficult catheterizations, imaging, when to obtain specialty consultation, drug therapies, and the importance of follow-up.

Case Presentations

A well-appearing 70-year-old man presents with abdominal pain and an inability to urinate…

• The patient says he is unable to urinate, so you suspect he has benign prostatic hyperplasia.
• The patient also complains of cough and runny nose. He appears well otherwise, and you wonder if it is related to his cold...

You are called to the resuscitation bay as EMS unloads a sick-appearing 20-year-old man…

• The young man’s roommate reports that the patient was first agitated, crying, and picking at his skin, and that he then became unresponsive.
• The patient has a heart rate of 150 beats/min, temperature of 39.7°C, blood pressure of 159/87 mm Hg, respiratory rate of 12 breaths/min, and oxygen saturation of 100%. His skin is warm and dry.
• Your respiratory therapist suggests intubation, your nurse suggests antibiotics, your intern suggests naloxone. You have another plan...

A 14-year-old girl presents, accompanied by her father, with a chief complaint of abdominal pain and trouble walking…

• She describes a week of trouble ambulating, and now she feels too weak to even get out of her chair. She was in the ED yesterday and was discharged home with a diagnosis of viral syndrome.
• She has mild suprapubic tenderness, some urinary incontinence, but no flank tenderness, fevers, vomiting, or loose stool. She provides a history of diarrheal illness 1 month prior. Her legs have 3/5 strength, and she has no back tenderness.
• Her urine pregnancy test is negative.
• You wonder whether this could be a spinal cord process or something else...

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Clinical Pathway for Emergency Department Diagnosis and Treatment of Acute Urinary Retention in Adult Males

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Meigs J, Barry M, Giovannucci E, et al. Incidence rates and risk factors for acute urinary retention - the health professionals followup. J Urol. 1999;162:376-382. (Survey; 8418 patients) DOI: 10.1016/S0022-5347(05)68563-1

7. * Nevo A, Mano R, Livne PM, et al. Urinary retention in children. Urology. 2014;84(6):1475-1479. (Retrospective; 56 patients) DOI: 10.1016/j.urology.2014.08.020

43. * Ahmad I, Krishna N, Small D, et al. Aetiology and management of acute female urinary retention. Br J Med Surg Urol. 2009;2(1):27-33. (Retrospective; 300 patients) DOI: 10.1016/j.bjmsu.2008.10.004

54. * Sarma AV, Wei JT. Clinical practice. Benign prostatic hyperplasia and lower urinary tract symptoms. N Engl J Med. 2012;367(3):248-257. (Clinical practice guideline) DOI: 10.1056/NEJMcp1106637

73. * Kidd EA, Stewart F, Kassis NC, et al. Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. 2015 Dec 10;(12):CD004203. (Cochrane review) DOI: 10.1002/14651858.CD004203.pub3

96. * Mcneill SA, Daruwala PD, MItchell ID, et al. Sustained-release alfuzosin and trial without catheter after acute urinary retention. BJU Int. 1999;84:622-627. (Randomized controlled trial; 81 patients) DOI: 10.1046/j.1464-410x.1999.00277.x

97. * Fisher E, Subramonian K, Omar MI. The role of alpha blockers prior to removal of urethral catheter for acute urinary retention in men. Cochrane Database Syst Rev. 2014 Jun 10;(6):CD006744. (Cochrane review; 9 Randomized controlled trials) DOI: 10.1046/j.1464-410x.1999.00277.x

100. Andriole GL. Benign Prostatic hyperplasia (BPH). Merck Manual. Accessed February 10, 2021. (Online medical reference)

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Keywords: acute urinary retention, AUR, micturition, neurogenic, BPH, prostatomegaly, antihistamine, anticholinergic, opioid, Guillain-Barré, transverse myelitis, cauda equina, zoster, POCUS, catheter, suprapubic, coudé, phimosis, paraphimosis, alfa blocker, diuresis