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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

Monday, June 4, 2018

Acute Urinary Retention

Acute urinary retention (AUR) is commonly encountered condition in the emergency department. It is the inability to void voluntarily despite a distended bladder that often leads to agitation or altered mental status in the elderly who are on several medications. Classical patient with AUR is an elderly man with BPH. 


Hypertension or tachycardia may be transient and may resolve after bladder decompression. 



Higher Centres and Receptors involved in Micturation
Micturition involves coordination of high cortical neurologic (sympathetic, parasympathetic, and somatic) and muscular (detrusor and sphincter smooth muscle) functions.







Urinary Retention requires both relaxation of the detrusor muscle (through β-adrenergic stimulation and parasympathetic inhibition) and contraction of the bladder neck and internal sphincter (through α-adrenergic stimulation). In contrast, Urination requires contraction of bladder detrusor muscle (by cholinergic muscarinic receptors) and relaxation of both the internal sphincter of the bladder neck and the urethral sphincter (throughα-adrenergic inhibition). 

Common Causes of Urinary Retention

  • BPH
  • Prostate Cancer, Phimosis, Paraphimosis
  • Meatal Stenosis
  • Prostatitis
  • Medications (Anticholinergics, Antihistaminics, Antipsychotics, BZDs etc.)

Females presenting with AUR should undergo neurologic examination and a pelvic examination to detect possible inflammatory lesions or pelvic masses. 

AUR is a clinical diagnosis but bedside US can be used as an adjunct. Prolonged obstruction may result in impaired renal function and electrolyte imbalance. Thus, renal function studies and Potassium should be checked for those with prolonged retention. Formal abdominal imaging and urodynamic studies can be deferred as an out-patient if the patient appears clinically well. 

A thorough history is required to find the cause/precipitant of Urinary Retention

ED management is limited to bladder decompression with urethral catheterization or suprapubic catheterization (if urethral cath fails). Alpha-blockers can be prescribed during discharge to relax the uretheral muscles. 


Disposition and Indications for admission

Admit in case of:
  • Significant Post Renal Failure
  • Post Obstructive Diuresis
  • Frank Hematuria
  • Clot Retention 
  • Sepsis
Majority of patients with AUR are discharged home after bladder decompression and Urology Clinic review. It is paramount to educate them about catheter care to avoid accidental displacement/removal of the catheter leading to urethral injury. Reg flags include - fever, abdominal pain, catheter blockage, or penile pain. Tho who complain of a sense of urgency despite being on foleys can be treated with oxybutynin, 2.5 milligrams twice/thrice daily. 

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic


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