Acute Urinary

retention &
hematuria
Dr.NOURA Alshahrani
PGY1,SBEM At ACH
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 Acute urinary retension

01
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 ACUTE URINARY
RETENTION
● Sudden inability to pass urine voluntarily from the bladder.
● Life time risk with age, 10% of men in their 70s and in 33% in
their 80s.
● Men> women
● The most common cause seen in ED is obstruction of urinary tract
distal to the bladder: - In Men BPH
-women pelvis mass or pelvic organ prolapse
– congenital posterior urethral valve in peds.
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 Pathophysiology
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 Causes of AUR
1) Obstructive: BPH, phimosis , paraphymosis, tumors, FB, calculus, stricture, hematoma.
2) Infectious , inflammatory M.C is acute prostatitis, followed by urethritis and vulvovaginitis.
3) Neurogenic either Motor :spinal shock, spinal cord syndromes
or sensory tabes dorsalis , syringomyelia ,DM, MS, herpes zoster.
4) Drugs: anticholinergic, antihistamine, antispasmodic ,TCA, amphetamines.
5) Psycogenic bladder: lazy bladder syndrome
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 History & Examination
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 Diagnostic testing?
Labs Radiology & others

● US provide visualization of postvoid

● CBC. residual ,obstruction ,hydronephrosis.

● CT for masses or malignancy.

● RFT ? & Electrolytes.

● MRI Of SPINE.
● Urinalysis.
● Cystoscopy & Retrograde
urethrography as OPD procedure.
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● PSA??
 Clinical Case 1
A 65-year-old male with a history of HTN, BPH, IDDM, and
lumbar spinal stenosis presented to the ED with low back
pain and lower extremity weakness. He denied fever,
abdominal pain, and dysuria. He reports that he is able to
urinate but unable to state if his urinary frequency has
increased beyond “my normal prostate issues.” He notes he
has fallen twice because “my legs just seem to give out on
me.” On physical exam, he demonstrates 4+/5 bilateral LE
strength, mild distal sensory loss, and absent patellar and
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Achilles reflexes. His rectal tone was equivocal.

 bedside POCUS was used to measure his
post-void residual bladder volume:
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Step 1 :A cross-sectional view of the bladder Step 2:A sagittal view of the bladder with
with AP and transverse measurements cranial-caudal measurement
 Step 3 : Calculation of bladder volume using the ellipsoid method (L x W x H x 0.52 = mL)
5.37 x 5.15 x 7.09 = 102 ml

Findings concerning for Cauda Equina were all present in this patient’s history, physical exam, and
workup. Current literature defines normal post-void bladder volume in adults as < 50 mL in patients
under 65 years of age, and < 100 mL in those older than 65. Two hundred milliliters or greater is
generally regarded as the threshold for retention.1 In this case, the patient was just on the cusp of
normal vs abnormal post-void urinary volume, but with his other clinical signs and symptoms,
warranted emergency spine consultation and MRI. Imaging eventually showed severe compression
of the spinal nerve roots by discs at the L2-3 and 3-4 levels, necessitating emergent decompression.
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 Myths vs Evidence based management

• Gradual bladder decompression has been

recommended to prevent post obstruction
diuresis, hypotension, and hematuria. such
problems believed to be related to rapid
decompression

• Early removal of the catheter is recommended.

• D/C patient on prophylactic antibiotics.

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 02 Hematuria
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 Introduction

• Prevelance of hematuria in general population is 9-18%

• In prospective study analysis of 1930 patients enrolled from hematuria clinic,61% had no definite
etiology of hematuria.

• Blood in urine can be microscopic or gross.

• Microscopic is defined by the AUA as 3 or more RBC/HPF.
• Macroscopic hematuria is 4 times more likely to indicate malignancy.

• Hematuria causes may be systemic/hematologic,renal (glomerular) or post renal (non glomerular).

• One of the life threatening differential of hematuria is AAA with aortocaval fistula occurs in 3-6% of
ruptured AAA cases, with mortality of 7-20%.
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Aortocaval fistula
 History
 The pattern and character of hematuria can localize the anatomical etiology.
occurs with the onset of voiding: Likely urethral.
Last few drops: Prostate or bladder neck.
Present throughout: Bladder, ureter, or kidney source.
Cyclic hematuria: Consider menses or endometriosis of the bladder/ureter.
 The color and consistency of the urine can determine the source .
Brown or smokey: Renal source.
Bright red with or without clots: Non-glomerular, renal, or lower genitourinary (GU) source.
 Painful hematuria : Calculus ,Infarction ,Obstruction, Infection
 Medications can cause papillary necrosis, and hemorrhagic cystitis: Phenazopyridine ,Rifampin,
Nitrofurantoin ,Chloroquine Hydroxychloroquine ,Iodine bromide
 Approximately 15-20% of people develop hematuria after strenuous exercise, although the
mechanism is currently unknown.
 Certain foods can mimic hematuria, including beets, berries, rhubarb, and food coloring.
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 Con. History
 Consider the following:
1. Trauma
2. Infectious symptoms: Fever, dysuria, frequency, abdominal/flank pain
3. Recent illness: Sore throat, skin infection, diarrhea
4. Concern for vasculitis: Abdominal pain, joint pain, rash (suggestive of HUS)
5. Propensity for bleeding: Prolonged bleeding with trauma, heavy menses, hemarthrosis, easy and
frequent bruising, gum bleeding
6. Family history: Sickle cell, hemophilias, polycystic kidney disease, nephrolithiasis, other family
members with history of hematuria or nephropathies.
7. Travel history: Schistosoma haematobium, which is the primary cause of hematuria worldwide.
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 Physical examination
 Vitals
•Hypertension can be concerning for hypertensive emergency vs. glomerulonephritis.
•Tachycardia and irregular cardiac rhythms may be indicative of atrial fibrillation,
which can cause renal infarcts secondary to embolic events.
•Cardiac: Findings consistent with high output heart failure can be concerning for a
vascular etiology of hematuria.
•Abdominal: Suprapubic vs. costovertebral angle (CVA) tenderness or bruising may
help localize origin of hematuria.
•Gynecologic: Pelvic exam to evaluate for external trauma or a vaginal source of
hematuria.
•GU: External genital exam and prostate exam to localize the source of hematuria.
•Extremities/musculoskeletal: Edema, skin lesions, arthritis in the presence of HTN is
suggestive of glomerulonephritis.
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 Laboratory Evaluation
Urinalysis
•Urine dipstick is 91-100% sensitive for blood.

•There is no threshold for RBC/HPF in microscopic hematuria that identifies patients at

higher risk of urinary tract malignancies; however high-grade hematuria (>50 RBC/HPF) or
gross hematuria is a significant risk factor for malignancy

•UA positive for blood without RBCs on microscopy is concerning for myoglobinuria or
hemoglobinuria.. Check the CK if there is concern for rhabdomyolysis.

•Uncomplicated urinary catheterization should generally not produce significant hematuria,

not more 3 RBC/HPF
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 •In some patients, further tests such as complement studies, Antistreptolysin O (ASO) titer, and anti-
DNase may be helpful for immune complex disease but are rarely part of the ED work-up.

•Extensive electrolyte and coagulopathy testing is rarely necessary.

•CBC: Evaluate for anemia and thrombocytopenia.

•Serum BUN/creatinine: Evaluate for azotemia and renal insufficiency.

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 Management and Disposition
● Imaging is not beneficial in patients with a recent history of infection, strenuous exercise, or
urological procedure or recent menstruation.

● Outpatient urology evaluation for asymptomatic microhematuria: which include RFT,

Calculated GFR & CTU if risk factors for urinary tract malignancy are present.

● The following patient population requires further work-up.

• 35 y or older (American Urological Association recommendations)
• Cigarette smoking
• Occupational exposure
• Analgesic abuse
• Persistent hematuria
• Irritative voiding symptoms or urologic disorder
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• Pelvic irradiation
 • Patient with gross hematuria require a thorough evaluation before discharge
from the ED. Renal function should be assessed to rule out the development of
renal insufficiency. If the initial assessment fails to identify a benign cause for the
hematuria, a CT scan with contrast or renal ultrasound study should be
performed.

• CT is appropriate imaging modality for traumatic hematuria, the exact level of

hematuria that trigger imaging is unclear.
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 Thank you!
Do you have any questions?
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