Acute urinary retention (core) | Risk factors: - History of BPH, elderly, male, post-op patients, infection - Uncontrolled pain, opioids, fluid overload, decreased mobility - Spinal, pelvic, perineal, and inguinal procedures are highest risk Symptoms: inability to void, bladder fullness, pelvic pain, increased urinary frequency with low-volume voids, overflow incontinence May have suprapubic fullness/tenderness to palpation | Bladder U/S with >400-mL volume Consider UA and urine culture, if cause is unclear | Can try intermittent catheterization initially, with Foley placement if patient continues to retain - If unable to place regular Foley, can try Coudé tip catheter and/or or larger sized catheter - If discharged with Foley in place, usually see back in clinic in 5-7 d for void trial If drainage with Foley not possible, may need suprapubic catheter placement - If no prior pelvic or abdominal surgery, prevesical space should be clear → percutaneous cystostomy - In patients with a history of pelvic surgery (ie, radical prostatectomy, TEPP), this space has been violated and may contain bowel → open cystostomy Can start alpha-blocker (tamsulosin) or 5-alpha reductase inhibitor (finasteride) for men with urinary retention due to BPH | Percutaneous cystostomy placement (core): - If patient had prior procedure that dissected prevesical space, use intra-op U/S to visualize the bladder and look for overlying bowel - If able, perform cystoscopy or place a catheter to distend the bladder with saline - Make a 2-cm transverse incision directly cephalad to pubic symphysis - Using Seldinger technique, insert a 22-gauge spinal needle through the incision until bladder access is obtained, distend bladder by filling through spinal needle - Pass guidewire into bladder - Exchange needle with percutaneous dilator system over wire, upsize dilators until 20 Fr dilator and sheath are in place - Place a 16 Fr Foley catheter through peel-away sheath - Inflate Foley balloon and secure catheter to skin with nonabsorbable suture Open cystostomy placement: - Place Foley catheter and use it to fill the bladder, if able - Make 4 cm lower midline abdominal incision and enter the space of Retzius - Place full thickness stay sutures in anterior bladder wall and make small incision into bladder - Place a 16 Fr Foley catheter through the incision into the bladder - Inflate balloon and secure the catheter to the bladder wall with purse string sutures - Bring the Foley out through a separate skin incision, close ... |