EMERGENCY UROLOGY
| MANAGING URINARY RETENTION — Lori Lerner, MD, Assistant Professor of Surgery (Urology), Dartmouth
Medical School, Hanover, NH, Dartmouth-Hitchcock Medical Center, Lebanon, NH, and White River Junction Veterans
Affairs Medical Center, White River Junction, VT
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| Definition of urinary retention: acute—painful tense overdistention of bladder; inability to void, although patient
may void in small amounts; chronic—painless, often with history of previous voiding problem that seemed to resolve;
voiding in frequent small volumes; whether acute or chronic, retention secondary to increase in bladder outflow
obstruction or to poor bladder contractility; irritative voiding symptoms—seldom lead to problems of bladder emptying;
American Urological Association (AUA) symptom score assesses voiding in men
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| Acute urinary retention: 4 categories—obstructive; infectious; pharmacologic; neurogenic; most common patients
men, particularly older men, and those who just had surgery
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 | Obstructive: causes—benign prostatic hyperplasia (BPH); prostate cancer (incidence 85% in men 80 yr of age) can
be presenting sign in older men; radiation therapy (prostate seeds and external beam irradiation can cause retention
due to swelling of prostate); nonprostatic obstruction—bladder stone (usually diet-related; kidney stone generally
not big enough to cause obstruction); blood clot; tissue (from bladder tumor; after transurethral resection of prostate
[TURP]); foreign body; congenital urethral valves; urethral strictures (from sexually transmitted diseases [STDs]
and trauma, including instrumentation and surgery); meatal stenosis (circumcised children at higher risk); obstruction
in women—uncommon; causes include abscess in urethra, polyp, and urethral stricture
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| Infectious causes: include prostatitis (acute bacterial), cystitis (including tuberculous), herpes (urethral and zoster of
S3 dermatome), and periurethral abscess
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| Anesthesia: spinal or general
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| Stretch injury: postsurgical; volitional delay in voiding (can occur in children, particularly in girls [Hinman bladder],
and adults)
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| Pharmacologic: anticholinergic drugs—oxybutynin (eg, Ditropan); tolterodine (Detrol); hyoscyamine; narcotics—
especially postsurgical; benzodiazepines—directly inhibit bladder function; antidepressants—particularly tricyclics
because of anticholinergic properties; amitriptyline more anticholinergic, but imipramine also has effects on
urethra (in men, sympathomimetic effect makes urethra tighter); amphetamines; α-agonist drugs—decongestants;
antihistamines; nonsteroidal anti-inflammatory drugs (NSAIDs)—due to inhibition of prostaglandins; alcohol—
causes decreased awareness of need to void and feeling of being able to delay voiding; has diuretic properties
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| Neurogenic: upper motor neuron lesions—above sacral micturition center; stroke or cerebrovascular accident
(CVA); multiple sclerosis; dementia (delayed response time and decreased awareness and sensation of full bladder);
spinal cord lesions, including tumors, injury, and epidural abscess; bladder typically spastic (patients often incontinent),
with decreased storage capacity (leakage better than retention); lower motor neuron lesions—spinal cord
trauma, including surgical trauma; cauda equina syndrome; multiple sclerosis (not uncommon for urinary retention
to be presenting symptom); bladder usually hypotonic or atonic; peripheral nerve lesions—diabetes causes atonic
bladder (urinary retention common; hyperbladder); abdominoperineal resection causes disruption of pelvic nerves
(also hysterectomy); acute bacterial prostatitis—elevation in prostate-specific antigen (PSA) and typically tender
fluctuant prostate
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| Symptoms of acute urinary retention: pain in suprapubic region; poor urinary stream with intermittence and hesitancy;
straining (counterproductive because it tightens pelvic floor, causing sphincter to close); sense of incomplete
voiding; urgency; overflow incontinence common; distention of bladder; hypertension (present in two thirds of patients
with chronic retention)
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| History: perform good urologic review of symptoms, particularly those immediately preceding acute event; neurologic
review of symptoms; history of back pain; acute low back pain and/or increase in chronic pain; previous surgery of
lower urinary tract; previous trauma of lower urinary tract, eg, pelvic fracture
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| Physical examination: palpate for masses and tenderness in suprapubic region; hernias can cause obstruction (eg,
sliding hernia of bladder, inguinal hernia, large hernia); look for incision or other sign of previous surgery; digital rectal
examination (DRE)—assessment of prostate size and consistency and rectal tone; check urethral meatus for stricture;
check penis for signs of previous surgery
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| Focused neurologic examination: look for—evidence of spinal cord lesion, spastic leg weakness, sensory loss,
tenderness in spinal column (in presence of fever, suggestive of epidural abscess), evidence of cauda equina lesion,
and flaccid leg weakness
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| Diagnostic tests: blood pressure (BP); bladder scan; catheter urine for urinalysis and culture; PSA—draw before catheterization
(irritation of prostate causes elevation); may be artificially elevated secondary to retention; white blood cell
count to evaluate for infection; hemoglobin for anemia if clot retention found; if worried about renal failure, check serum
urea nitrogen (BUN), creatinine, and potassium; if potassium elevated, perform electrocardiography (ECG) and correct
potassium
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| Catheterization: to drain bladder (may need to drain kidneys too)
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| Indwelling: urethral—standard Foley with 5-mL balloon most common (2-way); coudé tipped Foley; 3-way Foley
(ports for irrigation, drainage, and balloon); suprapubic—used if pelvic trauma or severe infection present
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| Medication: if BPH suspected, start patient on α-blocker (eg, terazosin [Hytrin], doxazosin [Cardura], tamsulosin
[Flomax], alfuzosin [Uroxatral]); 5-α reductase inhibitor (finasteride [eg, Proscar]) shrinks prostate by ≈20% (takes
6 mo to 1 yr for maximum reduction)
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| Surgery: includes cystoscopy, urethral dilation, TURP, and laser reduction
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| Urojet device: lidocaine gel syringe; facilitates catheter placement; injects lubrication into pendulous urethra; dilates
urethra, enabling catheter to get past prostate
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| Bladder drainage: not necessary to clamp Foley catheter; concern with hematuria from stretching of bladder; hypotension
probably from vagal response, but significant hypotension not proven; bladder not injured by draining too
fast
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| Benign prostatic hyperplasia: typically, patients have prolonged history of decreased stream; dribbling common
and hesitancy present; may have extreme discomfort; may have overflow incontinence and start wearing pads; can
cause bleeding and clot retention (especially patients who have been anticoagulated and strain during bowel movement
or voiding); bladder often palpable and frequently contains >1 L of urine; no correlation between size of prostate
and degree of obstruction; treat with bladder decompression, ideally urethral Foley catheter; may need coudé catheter;
refer to urologist for further management; patient usually sent home with catheter (to resolve stretch injury) and α-
blocker
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| Advanced prostate cancer: can invade urethra and cause obstruction of bladder neck and kidneys; also can cause
hematuria; on DRE, prostate hard, usually one side more than other; may lose border of prostate; serum PSA elevated,
and patient may have other signs of systemic disease (eg, bone pain, weight loss); treat with catheter placement and
send home; refer to urologist or oncologist
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| Acute prostatitis: patients usually sick at presentation, with fever, dysuria, and perineal pain (usually when sitting);
tender prostate on examination; avoid aggressive prostate examination; send urine culture and PSA before catheterization;
start on antibiotics; some patients need hospital admission for intravenous (IV) antibiotics; need lipophilic
antibiotics (eg, ciprofloxacin); speaker recommends IV antibiotics before patient leaves hospital; if patient has urinary
retention, small or suprapubic catheter preferred
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| Management of clot retention: use 6-sided catheter; if having problems or not getting enough clots back, use syringe
with 10 to 15 mL of air (causes turbulence to break up clots); hold anticoagulation if possible; correct supratherapeutic
anticoagulation; may need trip to operating room (OR)
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| Postobstructive diuresis: generally defined as 200 mL of urine output in 1 hr; important to determine orthostatic
BPs; replace 0.5 mL per 1 mL lost; can propagate diuresis by replacing mL per mL
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| Conclusion: acute urinary retention is a urologic emergency; correct problems and rule out other causes
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| TESTING AND TORSION —Dennis Heon, MD, Assistant Professor of Clinical Pediatrics and Emergency Medicine,
New York University School of Medicine, Bellevue Hospital Center, New York, NY
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| Differential diagnosis: patient typically presents with red swollen scrotum and painful testicle; differentiate into painful
and painless lesions; if painful—testicular torsion; torsion of testicular appendage (appendix testis, appendix epididymis)
mimics testicular torsion; epididymitis; orchitis (infectious etiology); Henoch-Schönlein purpura (disease
largely of children, with purpuric rash on lower extremities; consider renal or gastrointestinal involvement; 2%-40% of
patients have scrotal involvement; typically peaks at 4-10 yr of age; often bilateral; onset within 10 days of disease;
usually lasts ≈1 wk then resolves); trauma (eg, hematoma, testicular rupture; can mimic torsion); if painless—
hydrocele; hernia; varicocele (some patients report pain); tumor (affects adolescents and patients in their 20s; any painful
or nonpainful hard mass in testicle tumor until proven otherwise; if germ cell tumor, teratocarcinoma or seminoma;
if no germ cell tumor, leukemia or rhabdomyosarcoma); acute idiopathic scrotal edema (typically affects boys 2-10 yr
of age; severe edema; often red and inflamed; painless; edema confined to skin and dartos muscle; typically unilateral;
usually resolves without therapy in 1 wk); antenatal testicular torsion
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| Etiology of acute scrotum: large percentage testicular torsion; one third due to torsion of appendix testis (“great
mimicker”); 12% due to epididymitis and orchitis combined; remainder due to acute idiopathic scrotal edema and others
(eg, hernias, traumatic hematocele)
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| Testicular torsion: typically, in OR, urologist exposes testis, untwists cord, and hopes blood flow returns; in
speaker’s opinion, ultrasonography (US) has reduced number of cases taken to surgery
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| Epidemiology: 1 in 4000 males <25 yr of age; left side more common than right (spermatic cord slightly longer on
left); peak incidence first months of life (extravaginal) and onset of puberty (intravaginal); most idiopathic, with remainder
related to trauma, sexual activity, and athletic activity
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| History: sudden severe scrotal pain; many have several brief episodes (average 4 episodes) of less severe testicular
pain within preceding few days; nausea, vomiting, and abdominal pain seen in one fourth to one third of patients; fever
uncommon; patient may concoct spurious history of minor trauma, so high index of suspicion for torsion required
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| Physical examination: diffuse tenderness of testicle; erythema and swelling of scrotum; horizontal lie—testicle appears
sideways in scrotum; highly correlated with bell-clapper deformity (BCD; indicates high-riding tunica vaginalis);
causes increased risk for torsion; autopsy studies show 12% incidence of BCD; absence of cremasteric
reflex—most sensitive finding; seen in almost 100% of cases of torsion; also found in torsion of appendix testis
(0%-20%) and epididymitis (15%-20%); ≈50% of newborns have cremasteric reflex, 100% by 30 mo of age;
Prehn’s sign—elevating testicle makes pain worse in torsion and better in epididymitis; unreliable in children; no
published data; not useful predictor of torsion
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| Manual detorsion: Sessions et al—20-yr review of 200 patients; 120 testicles salvaged; two thirds turned medially;
group with salvaged testicles had pain for less time (≈5 hr) and 360° of twist; in nonsalvaged group, duration of pain
≈2.2 days and 540° of twist (further contributed to loss of blood flow); successful detorsion in 67%; 32% residual
torsion; of those successfully detorted, 25% had subsequent testicular atrophy
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| Testicular US: gold standard; Blask—prospective study of 50 patients; every patient had US and testicular scan ≤30
min apart; final accuracy of US 91%, 87% for testicular scan; both tests had false negatives; disadvantages of testicular
scan—2-hr waiting period; limited availability; involves radiation to scrotum; Baker—study of 130 pediatric
patients; operated on 20; observed ≈110 patients; lost several to follow-up; of 85 followed, 2 had testicular
atrophy; of 20 who had surgery, 1 torsion of appendix testis; advantages of US—fast (can be performed at bedside);
reliable; readily available; sensitivity and specificity partly operator-dependent; can provide alternative diagnosis;
in emergency department (ED)—commonly used; limited published data; study by Blaivas showed that ED
physician agreed with confirmatory study in 35 of 36 cases; 15 of cases normal; only few had testicular torsion; one
missed case of epididymitis
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| Salvage rate: testicular torsion time-sensitive diagnosis; depends on duration of torsion and number and tightness of
twists; >80% if surgery performed within 8 hr; 20% within 12 to 24 hr; salvage rate near 0% after 24 hr
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| Risk for cancer: Chilvers (1987) looked at patients with testicular tumors; testicular torsion 3 times higher than
expected statistically; subsequently found that torsion and tumor in opposite testicles ≈50% of time (unclear
whether tumor causative); poor awareness of risk among young males; survey of ≈1000 junior high school, high
school, and college athletes found that 15% unaware that painless testicular swelling possibly cancer; only 38%
realized they are highest risk group for testicular cancer; ≈50% did not use genital protection when competing;
34% would delay care if they had painful swollen testicle
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| Exocrine and endocrine function: exocrine function affected, while endocrine function normal; Thomas (Lancet)—
study found that 4 yr after torsion, almost 90% of patients had decrease in sperm count but had normal testosterone,
follicle-stimulating hormone, and luteinizing hormone levels; antisperm antibodies—first described by Bartsch in
1980; study by Visser in 2003 found occurrence in 10% of patients; even after 24 hr of torsion when testicle obviously
dead, remove it anyway so as not to create antisperm antibodies that affect contralateral testicle; speculated
mechanism release of cytokines, with damage to contralateral germinal epithelium
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Suggested Reading
Anderson JB et al: Impaired spermatogenesis in testes at risk of torsion. Br J Surg 73:847, 1986; Baker LA et al:
An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics 105:604,
2000; Gehrich AP et al: Chronic urinary retention and pelvic floor hypertonicity after surgery for endometriosis: a
case series. Am J Obstet Gynecol 193:2133, 2005; Gruenenfelder J et al: Acute urinary retention associated with
the use of cyclooxygenase-2 inhibitors. J Urol 168:1106, 2002; Kadish HA et al: A retrospective review of pediatric
patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics 102:73, 1998; Keita H et
al: Predictive factors of early postoperative urinary retention in the postanesthesia care unit. Anesth Analg 101:592,
2005; Marks LS et al: Prevention of benign prostatic hyperplasia disease. J Urol 176:1299, 2006; McVary KT:
Non-steroidal anti-inflammatory drugs and urinary retention. Lancet 367:195, 2006; Moog FP et al: The catheter and
its use from Hippocrates to Galen. J Urol 174:1196, 2005; Nasrallah P et al: Testicular health awareness in pubertal
males. J Urol 164:1115, 2000; Paltiel HJ et al: Acute scrotal symptoms in boys with an indeterminate clinical presentation:
comparison of color Doppler sonography and scintigraphy. Radiology 207:223, 1998; Pike MC et al: Effect of
age at orchidopexy on risk of testicular cancer. Lancet 1:1246, 1986; Rosenstein D et al: Urologic emergencies. Med
Clin North Am 88:495, 2004; Sami AR et al: Recurrent torsion of the testis. Br J Surg 77:1193, 1990; Sessions AE
et al: Testicular torsion: direction, degree, duration and disinformation. J Urol 169:663, 2003; Shalaby-Rana E et
al: Imaging in pediatric urology. Pediatr Clin North Am 44:1065, 1997; Verhamme KM et al: Nonsteroidal anti-inflammatory
drugs and increased risk of acute urinary retention. Arch Intern Med 165:1547, 2005; Williamson RC:
The continuing conundrum of testicular torsion. Br J Surg 72:509, 1985; Williamson RC: Torsion of the testis and allied
conditions. Br J Surg 63:465, 1976; Yucel S et al: Can alpha-blocker therapy be an alternative to biofeedback for
dysfunctional voiding and urinary retention? A prospective study. J Urol 174:1612, 2005.
Educational Objectives
| The goal of this program is to improve the management of urinary retention and testicular torsion. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Recognize the 4 categories of acute urinary retention based on etiology.
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| 2. Employ catheterization in the treatment of urinary retention.
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| 3. Distinguish benign prostatic hyperplasia from prostate cancer and acute prostatitis.
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| 4. Describe the physical examination findings in testicular torsion.
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| 5. Discuss the salvage rate and risk for cancer in testicular torsion.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the following has been disclosed: Dr. Lerner is a preceptor and consultant for Lumenis,
Inc.
Acknowledgements
Dr. Lerner was recorded at Managing Medical Emergencies, held May 15, 2006, in Lebanon, NH, and sponsored by
the Dartmouth-Hitchcock Medical Center in cooperation with the New Hampshire Center of the American College of
Emergency Physicians. Dr. Heon was recorded at Contemporary Concepts in Clinical Emergency Medicine, held
June 7-9, 2006, in New York, NY, and sponsored by the Department of Emergency Medicine, New York University
School of Medicine, and New York University Postgraduate Medical School. The Audio-Digest Foundation thanks
the speakers and the sponsors for their cooperation in the production of this program.
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