Pain

Types
Flank pain Ureteral pain Suprapubic pain Perineal pain

Flank Pain

Description
Pain arising in the area below the rib cage and above the ilium
May be local or referred

Local pain felt in or near the involve organ Referred pain Referred pain
pain projected to an area distant from the position of stimulation site of painful stimulus and the site of referred painful sensation usually share a common segmental innervation

Mechanism
Kidney Pain (T10-12, L1) Ureteral Pain Miscellaneous
Radiculitis
irritation to costal nerves produces costovertebral pain that may radiate to ipsilateral lower abdominal quadrant. unlike true renal pain, pain is positional and related to physical activity

Mechanism
Miscellaneous (cont.)
Retroperitoneal hemorrhage (ruptured AAA) Subdiaphragmatic abscess Gynecologic: cervical cancer, endometriosis Biliary disease Factitious/ drug seeking
Typically give history of multiple narcotic allergies, allergies to contrast, multiple prior stones

Imaging
Intravenous pyelography (IVP) Ultrasonography Computed tomography

Intravenous pyelography
Study of choice for complete visualization of the urinary tract; may be replaced by spiral CT. Indication: flank pain, hematuria, known symptomatic lithiasis, abnormal urine cytology. Contraindicated: renal insufficiency (CR > 2.0), allergy to iodine, multiple myeloma. Delay in appearance of contrast confirms decreased renal function or obstruction.

Ultrasonography
Evaluates the renal collecting system, parenchyma, and retroperitoneum for hydronephrosis, calculi, and abscess. Differentiates solid and cystic masses Usual initial examination in pregnant patients Advantages: easy to perform, noninvasive, no ionizing radiation, widely available, visualizes radiolucent calculi Disadvantages: tissue nonspecificity, lack of contast media, small field of view, dependence on operator skill and patient physique.

Computed Tomography (CT)

Images renal parenchyma, urinary tract, and surrounding tissue; ideal for neoplasms, trauma, and abscess. Spiral CT may replace IVP for evaluation of urolithiasis. Advantages: wide field of view, detailed visualization of anatomy, urinary system imaged with administration of IV contrast, readily available Disadvantages: need for contrast media, cost, low soft-tissue contrast resolution

Computed Tomography (CT)

Examination for malignancy must have pre- and postcontrast images. A solid enhancing mass is renal cell carcinoma until proven otherwise.

Initial Management
Evaluation and baseline lab and imaging studies should help narrow the differential diagnosis. Pain management: Once diagnosis is made, use appropriately effective analgesics (rapid relief obtained by IV administration) Infectious: appropriate antibiotics
Infection with high-grade obstruction requires immediate attention: drainage of abscess

Initial Management
Patients with calculi generally can be seen as outpatients if pain and nausea are controlled and there is no infection.

Kidney Pain
Typical dull and constant ache in the costovertebral angle and just below the 12th rib. Spread along the subcostal area toward the umbilicus or lower abdominal quadrant

Kidney Pain
Mechanism
sudden distention of the renal capsule by edema (acute pyelonephritis) or back pressure (acute obstruction/hydronephrosis) some renal disease painless due to slow progression (cancer, staghorn calculus, chronic obstruction)

Kidney Pain - Cause

Inflammatory
Acute pyelonephritis Xanthogranulomatous pyelonephritis (XPG), Pyonephrosis Papillary necrosis: Ischemic necrosis of the renal papilla or entire pyramid (diabetes, sickle cell disease, analgesic abuse) Renal abscess

Kidney Pain - Cause

Neoplastic Traumatic
Renal injury caused by penetrating or blunt trauma, surgical injury, radiation damage

Ureteral Pain
Ureteral pain
Severe colicky pain (due to renal pelvic and muscle spasm) that radiates from the costovertebral angle down toward the lower anterior abdominal quadrant, along the course of ureter (lateral border of rectus muscle) combined with Back pain from renal capsular distension Referred to bladder, scrotum or testis in men, or into the vulva in women.

Ureteral Pain
Upper ureteric calculi (T11-12)
Pain radiates to the testicle or round ligament

Mid-ureter (T12-L1)
radiates to the low anterior abdominal wall (mimicking appendicitis on the right and diverticulitis or other diseases of the descending or sigmoid colon on the left)

Lower ureter
Referred to the scrotal wall, the testis itself is not hyperesthetic

Stones in the distal ureter: urinary urgency and frequency inflammation and edema of the ureteral orifice

Ureteral Pain - Cause

Obstructive
Urinary lithiasis Congenital Stricture ureter Extrinsic compression: AAA, iliac aneurysm, fibroids, ovarian cysts, diverticulosis, tumors

Pregnancy-related
physiologic hydronephrosis of pregnancy: mechanical and humoral factors

Ureteral Pain
Neoplastic Traumatic
Ureteral injury caused by penetrating or blunt trauma, surgical injury, radiation damage

Suprapubic Pain

Description
Pain in midline of lower abdomen, most often due to genitourinary (GU) disease, occasionally GI or gynecologic causes

Pathophysiology
GU tract pain is usually associated with inflammation or obstruction
inflammatory pain is typically more severe if it involves the parenchyma of the organ

Constant suprapubic pain unrelated to urinary retention is rarely of genitourinary origin Tumors from GU tract malignancies generally do not produce pain unless they cause obstruction or extend into adjacent nerves. Pain is usually a late manifestation.

Pathophysiology
Vesical Pain Prostate Pain Urethral Pain

Pathophysiology
Pain in midline of lower abdomen due to alternate conditions
Large or small bowel
Appendicitis Inflammatory bowel disease Diverticulitis, fecal impaction, malignancy

Gynecologic
Pelvic inflammatory disease, uterine fibroids, ectopic pregnancy, endometriosis

Vesical Pain
Usually produced by overdistention of the bladder secondary to acute urinary obstruction or inflammation Chronic, slowly progressing urinary retention is usually asymtomatic despite large residual volumes. Inflammation of the bladder usually produces intermittent suprapubic discomfort.
Bacterial and interstitial cystitis is most severe when the bladder is full, and symptoms improve when the bladder is empty. Sharp and stabbing pain at the end of micturition Pain can be referred to the distal urethra (S2-3) and is associated with irritative voiding symptoms (urgency, frequency)

Prostatic Pain
Direct pain from the prostate gland is not common. Acute prostatitis
Vague discomfort or fullness in the perineal or rectal area (S2-4). Secondary edema and distention of the prostatic capsule Frequently pain is referred to the suprapubic area. Lumbosacral backache referred (not common) Dysuria, frequency, urgency Severe edema may produce acute urinary retention

Perineal Pain

Description
Perineal pain encompasses symptomatology related to multitude of pathologies Vague, nonspecific, and chronic symptoms may be attributed to nondescript diagnoses, such as prostatodynia Usually found in male patients

Pathophysiology
Since the perineal innervation is crosslinked from L5 to S4 nerve roots, a variety of pathologies could present as perineal pain. Important to distinguish patients who are at risk for a major pathology

Differential Diagnosis
Congenital
Persistent prostatic utricle

Traumatic
Rectal fissures Urethral stricture disease (USD), urethral diverticulum, urethrocutaneous fistula

Neoplastic
Perineal skin cancer Malignant lesions, such as CAP (rare)

Differential Diagnosis
Inflammatory
Prostatitis Urethritis Abscess (Fourniers gangrene, especially in DM) Skin rash, abscess, ... Urinary tract infection

Other
Bladder stones Rarely, lower ureteral stones may present with referred pain in the external genitalia. Post operative (radical prostatectomy, etc.)

Dysuria Painful Urination

discomfort to the suprapubic area or to the end of the penis or urethra in women causes
bacterial infection non bacterial cystitis cancer, stone or FB in bladder or urethra

excess phosphate in urine (phosphaturia)

Dysuria
begins with onset and stops abruptly at the end -> urethra discomfort during urination, but often most severe pain occurs after voiding has ceased -> bladder

Scrotum-Mass and/or Pain (Acute Scrotum)

Description
A lump in the scrotal sac; can be painful or painless May benign or malignant May be associated with structures in the scrotum or independent of them
For example, testicular mass vs. scrotal wall lipoma

Pathophysiology
The mass can result from abnormal growth of tissue or inflammatory causes Etiology varies with age of patient

Differential Diagnosis
Differs between adults and children (i.e., torsion more likely in child/adolescent than in adult) Congenital
In utero testicular torsion Hydrocoele Inguinal hernia Unilateral/bilateral testicular enlargement: associated with Beckwith-Wiedermann syndrome Supernumerary testis Pachyvaginalitis: thickening of the tunica vaginalis around the testicle Epididymal cyst: usually in midline raphe

Differential Diagnosis
Traumatic
Hematoma Fracture testis: more common in penetrating trauma

Inflammatory
Epididymitis/epididymo-orchitis: associated UTI or instrumentation of urethra Scrotal cellulitis Testicular torsion, torsion of testicular appendages can lead to necrosis

Differential Diagnosis
Neoplastic
Scrotal wall lesions Intrascrotal paratesticular lesions Spermatic cord tumors Testicular tumors

Miscellaneous
Varicocoele Spermatocoele: collection of sperm/fluid in epididymis Henoch-Scholein purpura: in up to 15% of patients with the disease Idiopathic fat necrosis of scrotum

History
Age of patient?
Torsion more likely in children

Onset of symptoms?
Associated with trauma or antecedent infection or instrumentation? Acute or insidious onset?
Differentiate acute torsion from mass or infection.

Associated with any pain?

In the absence of trauma, pain suggests infection or torsion. Malignancy is often painless.

Medical history of neoplasm, vasculitis, scrotal surgery, or intranatal trauma?

Physical Examination
Vital signs: fever or tachycardia as sign of infection Skin: signs of Henoch-Scholein purpura or petechiae Abdomen: palpating for hernia defects or inguinal mass Penis: chancre or plaques to indicate infection

Physical Examination
Scrotum
Inspect for lesions, cellulitis, sinus tracts, Blue dot sign with torsion of testicular appendage Palpate testes: normal adult size approximately 3.5 cm, smooth, nontender, nonboggy, firm but not hard, able to seperate epididymis from testis Palpate for mass: intratesticular vs. extratesticular, epididymal or spermatic cord involvement Transilluminate to evaluate for hydrocoele Valsalva maneuver to evaluate for varicocoele in supine and upright positions. Varix should disappear when supine

Physical Examination
Lymph nodes
Palpate inguinal area for enlarged nodes associated with infection

Rectal examination
Evaluate the prostate for evidence of prostatitis, and seminal vesicles for fullness

Hematuria

Descriptions
Normal urine contains a small numbers of RBCs (normal less than 3 RBCs/HPF on an unspun urine). Gross (visible) or microscopic Serious urologic disease is present in 5% to 20% of adults with microscopic hematuria. Gross hematuria has a high incidence of serious urologic disorders.

Pseudohematuria
Other causes of discoloured urine are drugs (eg. Pyridium); vegetables, dyes, or pigments; myoglobin and free hemoglobin (microscopic analysis should be negative); menstrual periods; and dysfuntional uterine bleeding

Types
Epithelial bleeding Glomerular bleeding

History
Age and sex of the patient?
Cancer most commonly seen in men >50. In children, GN is most common cause. GU cancer is greater in males than in females. Females may have vaginal bleeding.

History of trauma?
A large crush injury or burn may result in myoglobinuria. Abdominal or pelvic trauma may cause urinary tract injury.

History
Timing of blood during urinary stream?
Initial hematuria: prostate or anterior urethra pathology Terminal hematuria: posterior urethra, bladder neck, trigone eg. Posterior urethritis, polyps, tumors of the vesical neck. Total hematuria: vesical or upper tract origin

Any associated pain?

Painless gross hematuria is the hallmark of bladder cancer. Flank pain with gross hematuria and an abdominal mass is pathognomonic of RCC. Ureteral colic is usually caused by calculi, but can also be due to a tumor or blood clot.

History
Symptoms of urinary tract infection or prostatitis?
Infection can cause hematuria.

Lower tract symptoms present (frequency, urgency, nocturia)?

BPH may cause hematuria. Incomplete bladder emptying predisposes to infection and/or stones.

History
Hematuria associated with any activity?
Exercise-induced or trauma should be sought.

History of recent upper respiratory tract infection?

Associated with GN or IgA nephropathy.

Current medications?
Drugs can cause hematuria.

History of tobacco use?

Associated with TCC.

History
Significant medical or surgical history?
A history of renal or urologic disease or surgery must be sought Sexually transmitted diseases or urethral instrumentation (including catheterization) can cause stricture. A history of tuberculosis, pelvic irradiation and bleeding diatheses.

Menstrual history?
Vaginal bleeding (normal or dysfunctional) can be mistaken for hematuria.

History
Family history?
Conditions such as benign familial hematuria, Alport syndrome, sickle cell disease or trait, polycystic kidney disease, coagulation abnormalities, familial hypertension, nephrolithiasis, cancer (prostate, renal), or chronic renal failure may be relevant.

Occupational risk factors?

Exposure to naphthylamine, benzidine, and 4aminobiphenyl, often in rubber, dye petroleum, industries, predispose to TCC.

Physical Examination
Hypertension
Renal parenchymal disease, renal failure, renal cystic disease, or renal vascular disease.

Pallor
Anemia is associated with several abnormalities: hemolytic anemia, SLE, and renal failure.

Rashes
Henoch-Shonlein purpura and SLE

Physical Examination
Generalized edema
Nephrotic syndrome or renal failure

Hearing loss
Alport syndrome

Heart murmurs
Subacute bacterial endocarditis

Palpable abdominal or flank masses

Hydronephrosis, renal cystic disease, renal tumors, renal vein thrombosis, and distened bladder

Physical Examination
Flank tenderness
Pyelonephritis or urolithiasis

Flank lacerations, contusions, or rib fractures

Underlying renal injury

Urethral prolapse, meatitis, or meatal stenosis

May cause hematuria in children

Physical Examination
Digital rectal examination
Boggy, tender, warm prostate with acute prostatitis Nodularity suggests cancer Floating prostate suggests urethral disruption in the presence of pelvic fracture

Pelvic examination findings

Urethral caruncle or vaginal prolapse Vaginal bleeding

Urine analysis
Color
Bright red with urologic/anatomic causes Browned or tea-colored urine suggests GN or old clots

Specific gravity
Poorly concentrated urine (low specific gravity) suggests hydronephrosis with renal impairment or intrinsic renal disease

Proteinuria
If heavy (3-4+) suggests GN

Leukocyte esterase or nitrite positive; pyruria

Suggests infection

Urine analysis
Red cell casts
Pathognomonic of a glomerular source of bleeding

Crystalluria
Suggests urolithiasis

Urine culture
If UA suggestive of infection

Urine cytology
Detects high-grade TCC Less effective with well-differentiated TCC (renal or prostate are not diagnosed by cytology). Atypical cells can be seen with calculi of inflammation.

Special studies
Phase contrast microscopy of urinary sediment: differentiate glomerular and nonglomerular bleeding based on the presence of distorted RBCs in glomerular bleeding; sensitivity of 95% and specificity 100% Urinary RBC acanthocytosis: ring-formed cells with one or more protrusions. If >5% of total RBC, glomerular disease likely

Excretory urography
May detect renal masses Collecting system filling defects may signify tumors or stones. Rough estimation of kidney function and bladder emptying Contraindicated if creatinine is >2 mg/dL

Abdominal ultrasonography
More sensitive for renal masses than EXU. Poor in diagnosing filling defects in upper tract unless due to stones. Useful in children and when contrast is contraindicated.

Abdominal CT or MRI
Usually if US or ExU suggests mass. Spiral CT in rapid evaluation of suspected urolithiasis

Cystoscopy
Identifies lower urinary pathology (ie. Neoplasm, stricture)
Bleeding site often visualized (ie. Bladder tumor) Retrograde pyelograms used in case of contrast allergy Ureteroscopy as needed to evaluate upper tracts

Initial management
The standard urologic evaluation of hematuria (gross and microscopic) has been urine analysis, ExU, cystoscopy, and cytology. Additional testing based on clinical findings (ie. Urine culture with pyuria) Always consider medical causes of hematuria (eg. GN, IgAN) based on presentation, lab data, or if evaluation for anatomic lesion is negative.

Initial management
Gross hematuria
Usually requires urgent evaluation to prevent/treat clot retention

Patients with clots and retention

Place three-way Foley catheter (24Fr-26Fr) and continuous bladder irrigation. Irrigate clots from bladder; a large-bore, two-way Foley catheter is sometimes more effective than a three-way to clear clots (larger lumen). For difficulty clots, a cystoscope sheath may help. Renal Bx may be urgently needed in gross hematuria and renal failure;

Anuria and Oliguria

Definition
Anuria: no urine output Oliguria: urine output < 0.5 cc/kg/h

Causes
Prerenal
Most common cause in hospitalized patients Absolute decrease in intravascular volume
Hemorrhage: postoperative, trauma Dehydration: GI losses, inadequate fluid replacement

Relative decrease in intravascular volume

Septic shock Decrease venous tone Spinal shock; autonomic neuropathy

Causes
Prerenal (cont.)
Myocardial failure
Ischemic heart disease Cardiomyopathy Valvular heart disease Pericardial tamponade/ constriction

Renal/ glomerular
Acute glomerulonephritis Vasculitis Goodpasture syndrome Tubulointerstitial (acute interstitial nephritis, acute tubular necrosis)

Causes
Renal/ Glomerular
Vascular
Renal artery occlusion Renal vein thrombosis Vasculitis

Causes
Postrenal
Upper urinary tract obstruction
Nephrolithiasis External compression of ureter: retroperitineal fibrosis

Lower urinary tract obstruction

Prostatic enlargement Poorly functioning bladder Urethral stricture

Laboratory Testing
BUN/Cr > 20 suggests prerenal azotemia There can be multiple electrolyte abnormalities associated with renal failure (hyperkalemia, hypocalcemia, hyperphosphatemia, and hypermagnesemia)

Laboratory Testing
Urinalysis
Urine specific gravity > 1.030 and/or urine osmolality > 500 mOsmol/kg/h Urine sediment
Prerenal failure may exhibit hyaline and fine granular casts. Intrinsic renal failure: brown granular casts and tubular epithelial casts cells are present in 80% of patients.

Laboratory Testing
Urine electrolytes (spot urine sodium) Prerenal
Urinary sodium conc. (mmol/L) Fractional excretion of Na (%) Ratio of urinary to plasma cr. Ratio of urinary to plasma osmolarity

Renal > 40 >1 < 20 < 1.1

< 20 <1 > 40 > 1.5

Imaging
Renal / bladder ultrasound
Help to differentiate an obstructive phenomenon, such as hydronephrosis, from parenchymal renal disease. Hydronephrosis: may be able to visualize stone as cause of obstruction, and level may be noted secondary to level of ureteral dilatation; can be used in all patients because there is no radiation exposure.

Initial Management
Diagnosing the cause of oliguria/anuria in a patient is the most important step, because this determines the proper treatment. Serum electrolytes should be checked and abnormalities corrected.

Initial Management
All patients with oliguria/anuria should have a Foley catheter placed to accurately monitor urine output. Catheter placement also rules out lower tract obstruction as a cause. If a catheter is already in place, check to ensure that it is functioning properly (i.e. not obstructed) and irrigates easily

Initial Management
If a prerenal cause has been diagnosed, this may treated with crystalloid/colloids/ blood product, vasoactive drugs, or cardiotropic drugs, depending on the exact cause. In the case of intrinsic renal failure secondary to acute tubular necrosis, two strategies may employed:

Initial Management
High-dose loop diuretics (1-3 g/d) may convert oliguric to nonoliguric ATN, which may have a more favorable prognosis. Low-dose dopamine (0.5-2.0 ug/kg/min) can be used to increase renal blood.

Initial Management
If the cause is post renal, then the obstruction must be relieved. This can be performed most quickly via percutaneous nephrostomy placement, ureteral stent placement, or Foley catheter insertion, depending on the level of obstruction and the overall condition of the patient.

Initial Management
Treatment for patients, in acute renal failure in which initial treatment is unsuccessful is hemodialysis.
Indications for hemodialysis are
Severe hyperkalemia; symptomatic uremia Severe volume overload resulting in pulmonary edema or severe hypertension Refractory metabolic acidosis; uremic pericarditis

Urinary Retention

Definition
Acute urinary retention:
distress associated with an uncomfortable distended bladder and the inability to void more than small volumes of urine

Chronic urinary retention:

frequency, weak stream, and incomplete voiding; individuals experience little discomfort from their distended bladder, even though post-void residuals can be large.

Pathophysiology
Most commonly occurs in patients with preexisting bladder outlet obstruction. Infection, bleeding, or overdistention usually is the precipitating event. Identifying the underlying condition or precipitating event that contributed to retention, espectially neurogenic etiologies. Catheter drainage results in prompt symptomatic relief.

Causes
Generally either bladder outlet obstruction or bladder dysfunction Anatomic
Penis: phimosis, paraphimosis, meatal stenosis, foreign-body constriction Urethra: tumor, foreign body, calculus, urethritis, stricture, clot retention, meatal stenosis (female), hematoma Prostate: BPH, prostate cancer, bladder neck contracture, prostitis, prostatic infarction

Causes
Neurologic
Motor paralytic: spinal shock, spinal cord syndromes (eg. spina bifida, meningomyelocoele) Sensory paralytic: tabes dorsalis, DM, multiple sclerosis, pernicious anemia Syringomyelia Herpes zoster, poliovirus Herniated discs

Causes
Drugs
Antihistamines Anticholinergics: atropine, belladonna, benztropine mesylate, cyclic antidepressants, phenothiazines, ipratropium bromide Antispasmodics Tricyclic antidepressants

Causes
Drugs
Alpha-agonists (induce bladder neck hypertonicity):
cold preparations ephedrine derivatives amphetamines

Narcotics: morphine, meperidine Detrusor muscle relaxants: flavoxate, dicyclomine, oxybutynin

Causes

Anticholinergic Ganglionic blocker Calcium channel blocker Antihistamine Bronchodilator Phenothiazine Tricyclic antidepressant

Detrusor muscle relaxants: flavoxate, dicyclomine, oxybutynin

Causes
bladder neck and urethra
Alpha adrenergic agonist L-dopa amphetamine tricyclic antidepressant anticholinergic antihistamine

Causes of urinary retention in female

(Urethral obstruction) (Detrusor failure) (Neuropathic bladder dysfunction)
sacrum

(Psychogenic retention)
Schizophrenia, depression, habitual

History
Symptoms of bladder outlet obstruction (weak stream, hesitancy, incomplete voiding, dribbling)?
BPH is the most common cause in men > 50 Other causes of obstruction in men
prostate cancer urethra stricture bladder cancer neurogenic bladder

History
Symptoms of irritative voiding (frequency, urgercy, dysuria, nocturia)?
These symptoms may suggest infection or BPH

History of urologic procedures or instrumentation? History of sexually transmitted disease or strictures? Medications, especially cold medications?

History
History of pain?
Bone pain and weight loss suggest prostate cancer

History of spinal cord injury or pelvic trauma? History of recent surgery, especially in those with spinal or epidural anesthesia?

Physical Examination
Palpable abdominal mass
A bladder with > 150 mL of urine should be palpable or percussible, depending on the size of the patient.

Digital rectal examination (DRE)

Symmetrically enlarged prostate with BPH Nodularity suggests cancer Boggy, tender, warm prostate suggests prostatitis

Physical Examination
Cystocoele, Procidentia uteri Imperforated hymen -> hematocolpos -> urethra

Physical Examination
Neurologic examination
Complete neurologic examination if suspicion for a neurologic etiology exists A directed examination would include testing the anal, bulbocavernosal, knee, and ankle reflexs Anal tone (S2) and levator muscle tone (S3) Check sensation over the penis (S2), perianal area (S2-S3), outside the foot (S2), sole of the foot (S2-S3), and large toe (S3)

Physical Examination
Neurologic examination (cont.)
Muscle stretch reflexs and the Babinski reflex are useful in differentiating an upper motor neuron lesion from a lower motor neuron lesion When extremity findings do not parallel perineum findings (ie., absent sensation and tone in the feet but partial tone or sensation in the perineum), suspect spina bifida or meningomyelocoele

Diagnostic Studies
BUN and creatinine elevated in retention if hydronephrosis present With postrenal obstruction, the BUN/Cr ratio will be increased. Urinalysis
Pyuria infection Hematuria infection, tumor, calculi

Urine culture if UA suggestive of infection Ultrasonography hydronephrosis, stone, residual urine

Diagnostic Studies
IVP or CT
Identifies upper tract pathology from chronic retention (rarely needed)

Cystoscopy: identifies lower urinary tract pathology (urethral stricture, prostatic hypertrophy, bladder malignancy) Uroflow: Measuring peak urine flow rate is useful in objectively documenting severity of bladder outlet obstruction. Post-void residual should be determined at the time of initial uroflow

Diagnostic Studies
Urodynamics: In spinal shock, urodynamics should be done at least 8 weeks after spinal cord injury and then periodically

Initial Management
Determine if retention is present by catheterization or ultrasound
Normal residual immediately after voiding to completion is generally <30 mL in adults, but can vary slightly

Initial management is to provide urinary drainage by the least invasive technique available

Initial Management
Urethral catheter
Standard urethral catheter (for men, 16-18 Fr) Men with BPH may need a larger caliber catheter to help seperate hypertrophied lateral lobes; a curved-tip Coude catheter may facilitate negotiating the median lobe of the prostate If catheter is successfully passed, the bladder should be decompressed slowly (approximally 300 mL/h) to minimize urothelial bleeding

Initial Management
More than 1000 cc should not be drained from the bladder at once because of the possibility of a vasovagal reaction. After draining 1000 cc, simply clamp the catheter for a few minutes before allowing the remainder to drain.

Initial Management
Percutaneous suprapubic tube
Generally placed when a urethral catheter cannot be passed or in cases of acute bacterial cystoprostatitis in men Relative contraindications:
previous lower abdominal surgery small, contracted neurogenic bladder coagulopathy known bladder tumor

Initial Management
Insertion requires at least 200-300 cc urine in an easily percussible bladder; if percussion is difficult, use bladder ultrasound

Cystourethroscopy
The filiform can be passed through a stricture under direct vision using a cystoscope

Monitoring
Patients may require monitoring and fluid replacement for postobstructive diuresis (>200 mL/h), especially after chronic or prolonged retention and when BUN and Cr are significantly elevated. Relief of chronic or prolonged obstruction may result in major hemorrhage secondary to bladder mucosal disruption

Monitoring
Significant hypotension may occur secondary to a vasovagal response Patients with signs of serious infection or decreased renal function should be admitted.

Prevention
Chronic retention may be managed with clean intermittent catheterization Work-up of the underlying cause or precipitating event should be done

Symptoms Related to The Act of Urination

Functional features of the bladder

Normal capicity of 400-500 mL Sensation of fullness Ability to accommodate various volumes without a change in intraluminal pressure Ability to initiate and sustain a contraction until the bladder is empty Normal voiding pressures in the bladder should not rise above 30 cm water Voluntary initiation or inhibition of voiding despite the involuntary nature of the organ

Symptoms related to the act of urination

Frequency Urgency Nocturia

Frequency
Decreases the functional capacity of the bladder
Residual urine Inflammation
Pain resulting from even mild stretching of the bladder Loss of bladder compliance resulting from inflammatory edema

Frequency
Fibrosis of the bladder
Tuberculosis, radiation cystitis, interstitial cystitis, schistosomiasis

Stones or foreign bodies causes vesical irritability Very low or very high urine pH can irritate the bladder

Urgency
A strong sudden desire to urinate. Causes by hyperactivity and irritability of the bladder, resulting from obstruction, inflammation, or neuropathic bladder disease.

Nocturia
Decrease in the functioning renal parenchyma with loss of concentrating power. Drink excessive amounts of fluid in the late evening. Some fluid retention may develop secondary to mild heart failure or varicose vein.

Symptoms of Bladder Outlet Obstruction

Symptoms of Bladder Outlet Obstruction

Obstructive Symptoms Irritative Symptoms

Obstructive Symptoms
Hesitancy detrusor takes a longer time to generate the initial increased pressure to overcome urethral resistance Decrease in force and Caliber of the stream urethral compression Intermittency detrusor is unable to sustain the increased pressure until the end of voiding Terminal dribbling Incomplete emptying (Sense of residual urine)

Irritative Symptoms
Frequency Urgerncy a strong, sudden desire to urinate Nocturia