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Acute retention of urine
ACUTE RETENTION OF URINE CLARENCE G. BANDLER, M.D., P.A.C.S. AND ARTHUR Professor of CIinicaI UroIogy
H.
MILBERT,
M.D.
Instructor in UroIogy
New York Post-Graduate MedicaI SchooI and HospitaI, CoIumbia University
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retention of urine represents such instances, micturition is possibIe a highIy significant cIinica1 syn- though curtaiIed in varying degrees. The drome as encountered either by the underIying pathoIogy in both chronic and Internist, surgeon or uroIogist. Inabihty acute urinary retention may be the same. to pass any urine per urethram after re- Sudden shock, overinduIgence in aIcoho1 or peated attempts at voIuntary micturition coitus, exposure to coId, or acute infection may sound a danger signa warranting not may convert a chronic case into an acute mereIy reIief of immediate symptoms but one. careful investigation for underIying pathThe usua1 chnical picture of acute urioIogy. Too often the effect is treated with nary retention is that of a thoroughIy unutter disregard of the cause. Morbidity and comfortabIe patient, with anxious facies mortaIity wouId be markedIy diminished and unabIe to stand stiI1 or Iie quietIy in if cause and effect were reveaIed and suit- bed. WhiIe pain is predominant in the abIe therapy instituted. majority of cases, its absence in no way Any obstructive Iesion of the Iower ahers the acuteness of the condition. An ‘urinary tract, from interna sphincter to individual whose bIadder sensibiIity is impaired or absent due to periphera1 or externa1 urethra1 meatus, may account for compIete interruption of the urinary centra1 nervous system infection or injury .stream. Apart from the dynamic mechanidemands just as much attention as the more animated type. ca1 types, one may encounter adynamic neurogenic Iesions. It wouId be more accuTo compIete and to cIarify our conceprate in defining acute retention of urine tion of ,acute retention, one must excIude anuria, or acute suppression of urine. In to incIude the upper urinary tract. This broader interpretation is expressed as the both instances there occurs an inabiIity inabiIity of the renaI peIvis, ureter or bIad- to pass urine. The former is predicated on the presence of an excessive voIume of der to discharge any of its urinary contents. urine in the bIadder, the Iatter, on renaI One should be mindfu1 of the fact that secretory inhibition. The distended viscus acute inffammation with its attendant may be visibIe, duI1 to percussion and edema, either independent of, or superimpalpabIe. In anuria the bladder cannot be posed upon anomaIy, neopIasm or caIcuIus of the kidney, renal pelvis, ureter or bIad- outIined by percussion or paipation and der, is capabIe of producing acute IocaIized contains IittIe, if any, urine, as confirmed urinary obstruction. Associated with such by catheterization. unilatera1 pathoIogy is the ever-present INCIDENCE danger of reflex inhibition of urine on the InabiIity to void is usuaIIy associated opposite side, or even absence of the kidney, a finding noted in 0.04 to 0.1 per with urethra1 stricture in the youth and cent of a11 individuaIs. For purposes of prostatism in the aged. UndoubtedIy these simpIicity, however, we shaI1 confine our two groups account for many cases of acute retention. However, no age is expresentation to the Iower urinary tract. empt from the incidence of underIying It is aIso beyond the scope of this paper to discuss chronic retention of urine. In Iesions and the precipitation of the cIinica1 162 CUTE
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emergency. Newborn, youth, middle-aged and aged are, as we shah show, victims of the condition. Sex prediIection is of no reaI significance. Acute retention occurs in the femaIe as we11 as in the maIe. True, diseases of the prostate gIand and the greater susceptibiIity of his urethra to gonorrhea1 stricture formation undoubtedIy produces an incidence eIevation in the maIe. Furthermore, the vigorous activity of boys at pIay and the greater number of men at work, make the male more susceptibIe to such injuries which may directly, or indirectIy, produce acute retention. GynecoIogicaI disorders, in turn, cause numerous instances of acute obstruction to the outffow of urine m women. ETIOLOGY
With the exception of isolated cases of hysterica or reff ex (postoperative) retention of urine, carefu1 uroIogic investigation wiI1 reveal a basic cause for the obstruction. Such causes may be cIassified as anomalies, infections, new growths, trauma, neurogenic Iesions, UroIithiasis, foreign bodies, psychic or reflex phenomena, and a misceIIaneous group comprising rarer occurrences. PathoIogicaI entities wiI1 be found to faI1 into certain age groups. Thus, anomaIies frequently manifest themselves in chiIdhood, aIthough occasionaIIy the condition passes unnoticed until superimposed infection precipitates acute obstruction in the adult. The twenty to forty year age group is characterized chieff y by gonorrhea1 strictures in the maIe and pelvic disorders in the female. In the group over fifty years of age, vesica1 neck obstruction due to prostatic disease and gynecoIogica1 maIadies predominate. DIAGNOSIS
The diagnosis of acute retention of urine is usuahy seIf-evident. In most instances pain is an outstanding symptom, and its rehef represents the chief immediate concern of both patient and doctor. History
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of antecedent urinary difficulties, injury, operation, or disease (gonorrhea, syphiIis, uroIithiasis etc.) may be obtained. Such conditions wiI1 be presented in greater detai1 as disease entities are considered. DribbIing of urine shouId make one suspect a condition of “paradoxica1” incontinence due to urinary overffow from an overdistended bIadder. Such instances are usuaIIy associated with neurogenic diseases. An ataxic gait, sensory changes and other neuroIogica1 findings readily identify the tabetic. In true urinary incontinence there is little or no urinary retention. On physica examination, the patient may be extremeIy agitated, perspiring freeIy and tossing about. Inspection of the hypogastric region may revea1 a visibIe midline swelling; the mass is tense and tender to touch, movabIe from side to side (within pain Iimits), with rounded upper contour and merging with the symphysis beIow. Percussion yieIds flatness over the tumor, in contrast to a tympanitic note eIicited IateraIIy and superiorIy. Rectally, a cystic tumefaction may be palpated. During the course of this procedure one may discIose the cause of the condition with the linding of an enIarged or stony hard noduIar prostate gland. Urethra1 catheterization, of course, definiteIy estabIishes the diagnosis of retention of urine. ANOMALIES
MaIformations of the urinary tract account for most obstructive uropathies in infancy. Th e seque1 of obstruction, stasis and infection is aIIied with a state of chronic or acute retention of urine. CompIete or partia1 phimosis, paraphimosis, atresia or constriction of the externa1 meatus, strictures or atresia of the urethra, posterior urethra1 valves, hypertrophy of the verumontanum, and contracture of the vesica1 neck represent such etioIogica1 factors. In the case of complete atresia, an acute emergency exists and Iife-saving measures must be instituted. In other conditions, premonitory signs and symptoms usuaIIy manifest themseIves but
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infection often transforms a chronic struction into an acute one. Complete atresia of the urethra
obis,
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probe or by spreading the bIades of a mosquito clamp inserted through the tiny aperture. If necessary, a dorsal slit of the
2. Hypertrophy of verumontanum as shown by urethrocystography in a four year oId boy with partial urinary obstruction.
FIG.
FIG. I. Urogram demonstrating extent of obstructive uropathy caused by posterior urethra1 valves. (Courtesy Dr. S. R. Woodruff.)
fortunateIy, a rare occurrence. Many such cases pass unnoticed in the absence of postmortem examinations of stilIbirths or those dying shortIy after birth. Woodruff and MiIbertl report a case of compIete atresia of the urethra in a chiId who died one hour after birth. Autopsy reveaIed far advanced obstructive uropathy invoIving the posterior urethra, bladder, ureters and kidneys. Even timely intervention in such a case would have been unavailing, but BirdsaI12 performed externa1 urethrotomy on a chiId simiIarIy affected six hours after birth which proved to be a Iife-saving measure. Congenital anomaIies of the prepuce are readiIy amenabIe to treatment. A pinpoint orifice may be bIuntly stretched with a
prepuce or a circumcision can be done. Several cases of obstructive uremia have been reported due to proIonged chronic back pressure produced by extreme phimosis. Strictures of the externa1 meatus represent the most common form of urethra1 narrowing and are especiaIly prone to compIete obstruction when infection with acute inflammation and edema of the gIans supervenes. In the newborn, a vei1 may completeIy occIude the meatus and simpIy nicking the aImost translucent membrane wiI1 resuIt in spontaneous urination and disappearance of a paIpabIe hypogastric mass. Meatal strictures of varying caIibre may be progressiveIy diIated with Hiforms and bougies or subjected to meatotomy, using a No. I I bIade or bistoury. The attending obstetrician shouId assume the responsibiIity of noting any evident pathoIogy of the externa1 genitalia, the correction of which may be of immediate or remote importance. FaiIure of the chiId to void within the first eighteen hours warrants determination of the patency of the urethra. This may be done with a smaI1 bougie or catheter. OccasionalIy such a
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procedure wiI1 separate or perforate membranous adhesions of the urethra1 mucosa. In extreme cases more radicaI surgery is indicated on the urethra or bIadder. Posterior urethra1 vaIves (Fig. I), hypertrophy of the verumontanum (Fig. 2) and contracture of the vesica1 neck may be remedied by using the transurethral cutting or fuIgurating electrotome. INFECTIONS
Non-specific infections are of IittIe significance unIess they give rise to an inff ammatory process engrafted upon an existing point of constriction. PreviousIy mentioned urethra1 anomalies, phimosis and paraphimosis are prone to produce acute obstruction when compIicated by infection. Treatment is usuaIIy expectant and externa Iesions respond to wet dressings of boric acid, potassium permanganate or subacetate of aluminum. Gonorrhea represents a particuIar menace to norma urinary function. CareIessness of the patient or faulty and indiscreet manipuIation by the physician may resuIt in such periurethral edema as to obstruct the urethra1 channe1. PeriurethraI abscess or phIegmon, acute prostatitis, or prostatic abscess may simiIarIy arise and cause acute retention of urine. Treatment of such acute inflammatory obstructions should aIways be conservative. Rest in bed, hot sitz baths, hot recta1 irrigations, sedatives and recta1 suppositories of opium and beIIadonna are prescribed. UsuaIIy this regime resuIts in regression of the acute symptoms. The patient may be advised to attempt micturition whiIe immersed in a warm bath which has a soothing and reIaxing effect upon sphincter spasm and urethra1 congestion. OccasionaIIy radica1 steps are necessary to reIieve the more acute and extensive processes. Suprapubic cystotomy, externa1 urethrotomy or incision and drainage of an abscess may be indicated. In the case of prostatic abscess, intra-urethra1 rupture of the suppurative focus has been effected by bIind manipuIation with a sound. We prefer either the transurethra1 approach under
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vision, using the McCarthy resectoscope with cutting or fulgurating eIectrotomes, or perinea1 incision and drainage. Suprapubic cystotomy, whiIe outwardIy a radica1 step, may be a most conservative and economic measure. By side-tracking the urinary flow temporariIy, the affected area is put at rest with rapid involution of the inflammatory process. Urethra1 instrumentation can then be carried out at a Iater date. To attempt such instrumentation in the acute phase one faces the danger of producing a bIood stream infection,urethraI injury and urinary extravasation, if it is not aIready present. URETHRAL
STRICTURE
Because gonorrhea1 stricture of the urethra accounts for many cases of acute retention we have chosen to dea1 with it separateIy. NegIect, inadequacy of treatment, wiIIfu1 or accidenta use of strong anti-gonorrhea1 urethra1 medication may resuIt in partia1 or compIete constriction of the urethra. Progressive diminution in the urinary stream may be noted with sudden cessation occurring after exposure to coId, overinduIgence in aIcoho1 or coitus, or too vigorous instrumentation. GentIeness is essentia1 in attempting to reIieve such urethra1 obstructions. PIacing the patient in a hot tub bath may resuIt in partia1 reIief of the acute retention. Passage of a smaI1 sized sound or bougie wiI1 indicate the approximate Iocation and degree of the obstruction. SteriIe aIboIene or oIive oi1 may be instiIIed into the urethra as a Iubricant prior to any instrumentation, or instead, a surface anesthetic of one of the various novocaine derivatives or I per cent diothane solution may be used and retained in the urethra with a penis cIamp for ten minutes before instrumentation is attempted. A water-soIubIe Iubricant can then be used. Any form of anesthesia wiI1 cause the operator to take greater Iiberties in instrumentation than necessary, with the ever present danger of further urethral damage. If deIiberation and gentiIity are observed in the passage of Hiforms, bougies
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and other instruments, no anesthesia may be necessary. Passage of a fihform bougie can be a
FIG. 3. Cystogram showing marked intravesica1 prostatic hypertrophy which caused acute retention. Suprapubic cystostomy (tube in place) was performed.
simpIe or very tedious performance. Patience is a prerequisite to success, for it may take haIf an hour and repeated attempts with one or more fiIiforms before the point of obstruction is passed. The use of muItipIe filiforms passed paraIIe1 to one another heIps to IocaIize an eccentricaIIy pIaced passage through the strictured area. The PhiIips whip fiIiform and foIIower or the LeFort type are especiaIIy desirabIe. A smaIIcaIibered uretera catheter may serve the twofoId_ purpose of passing a point of constriction asrweI1 as effecting sIow drainage. FoIlowing successfu1 passage of a IiIiform, it may be Ieft indweIIing in the urethra and fastened with thread or adhesive to prevent its disIodgement. The instrument acts as a spIint for the passage of urine aIong side of it through the edematous cana1. After tweIve to twenty-four hours the inffammatory process wiI1 have so subsided as to permit the passage of graduated foIIowers of the PhiIips type or of ordinary bougies. In cases where the patient is seen after repeated unsuccessfu1 attempts have been made by others, a period of rest and sedation shouId be given before resuming further instrumentation. RareIy is it necessary to perform suprapubic cystotomy or externa1 urethrotomy for the reIief of acute retention. Such procedures, together with
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interna urethrotomy or diIatation, may be appIicabIe in the subacute or chronic stages. NEW
GROWTHS
Prostatic obstruction due to benign hypertrophy or maIignancy is the most common source of acute retention in eIderIy maIes (Fig. 3). A history of frequency, nocturia, dysuria, urgency and diminution of stream often is cIimaxed by acute retention. The immediate precipitating factor may be an upper respiratory infection, automobiIe ride, exposure to cold, aIcoho1 or sexua1 excitement. It may aIso foIIow diagnostic or therapeutic measures such as cystoscopy, passage of a sound or prostatic massage. Success in catheterizing such individuals depends upon possession of a suitabIe suppIy of catheters. An ordinary NitIaton soft rubber catheter may be sufficient. Depending upon the degree of edema, the tortuosity or distortion of the posterior urethra and the degree of eIevation of the sphincter Aoor, one may try, in turn, a soft rubber coude, natura1 curve, coudi: or bi-coudi: woven siIk, or a soft rubber catheter threaded on a curved wire styIet to obviate “buckling” of the ffexibIe tube. SteeI catheters shouId be used onIy in extreme cases and then with caution. The smaIIest sized catheters shouId be used wherever possibIe to minimize trauma. As emphasized in the treatment of urethra1 stricture, gentIeness is paramount. Repeated unsuccessful attempts shouId be punctuated by a rest period both for patient and doctor. Sedation and IocaI anesthesia can be given the patient in the meantime. A I per cent soIution of diothane instiIIed into the urethra1 cana and retained by a penis chp wiII often bring gratifying resuIts. Having catheterized the eIderIy prostatic patient, gradual decompression of the chronicaIIy distended bIadder shouId be effected. This may be carried out by drawing off four ounces of urine at one to two hour intervaIs or by attaching a Murphy drip tube to the catheter and reguIating
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the ffow by a screw clamp to sixty drops a minute. Creevy,3 in analyzing 6g deaths following catheter treatment of retention, could find no proof that sudden decompression was the cause. However, shock, collapse, renaI or vesical hemorrhage and anuria have been reported by others as direct results of sudden tota evacuation of acutely distended bladders. Nothing is lost and much gained by observing precautionary measures. If too much urine has been withdrawn inadvertently, a safe procedure is to replace the fluid volume in part by sterile saline, boric acid or other antiseptic solution. In addition to prostatism, vesical neck obstruction may be produced by benign or malignant bladder tumors at or about the interna sphincter. Just as a middle Iobe may produce a bail-valve obstruction so can a pedunculated bladder tumor engage itseIf in the interna sphincter and lead to acute retention of urine. Inffammatory edema in prostatic or vesical malignancies can completely occlude the sphincteric lumen. Recently we encountered a case of acute retention of urine in a patient undergoing deep x-ray therapy for prostatic carcinoma. He had voided freeIy prior to the exposure to roentgen rays. Catheter drainage affords immediate relief in the mentioned conditions. Their subsequent treatment, other than immediate symptomatic rehef, is not germaine to our subject.
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Direct injury to the urethra or pelvis may cause a protective reflex retention of urine. Rupture of the urethra is best treated by suprapubic diversion of the urinary stream to offset any extensive extravasation at the site of injury. In selective cases and in expert hands, passage of a catheter along the roof of the urethra may be attempted. Injuries to the spina cord with resultant compression fractures, transverse myehtis or localized nerve tissue injury result in disturbed function of the sacral and sympathetic innervation to the bladder.
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Diminished or absent sensibility of the bIadder to urinary distention results in acute, painless retention of urine. Dribbling occurs as an overflow phenomenon and is referred to as “paradoxica1” incontinence. Catheterization of patients suffering from spinal cord injuries should not be done without specific indication. The patient may go days or weeks without voluntary micturition but a state of automatic bladder contraction will develop sooner or later. Massage, stroking the thighs or appIication of the Credit maneuver to the distended bladder will facilitate its emptying. Infection subsequent to catheterization in such cases is especiahy common and for this reason it should be avoided entirely or when done, strictest asepsis observed. Either as a result of external trauma or urethral or vesical instrumentation, hemorrhage from the bIadder wall or prostate may occur. Formation of large clots in the bIadder may produce complete obstruction to the outffow of urine until they are evacuated. This may be effected through a Iarge catheter or cystoscopic sheath and application of suction. Irrigation with a solution of boric acid and alum (I 3 grains to the ounce) is an effective hemostatic. In exceptional cases, transurethral or suprapubic fulguration of the bleeding points may be necessary. NEUROGENIC
TRAUMA
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LESIONS
Intrinsic centra1 nervous system diseases, apart from those resulting from trauma, cause retention of urine. Cord tumors, syringomyeha, myelitis and tabes dorsalis are frequentIy complicated by urinary retention. Recent advances have been made in demonstrating altered intravesica1 pressure and muscle tonus in such conditions by cystometric determinations. In tabes, one must take into account the fact that the patient is also in the age group characterized by prostatic hypertrophy. Both conditions may be present and for this reason catheterization, with judicious emptying of the bladder and use
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of antiseptic astringent irrigating soIutions, is permissible. POSTOPERATIVE
RETENTION
Postoperative retention represents the most common form of reflex inhibition of urination. IndividuaIs upon whom IocaI anesthesia is used are seIdom if ever troubIed. In contrast, however, spina or inhaIation anesthesia is CharacteristicaIIy foIIowed by acute retention in from IO to 50 per cent of a11 cases. Butureanu and BurgheIe4 report a IO per cent incidence of acute retention after 573 spina anesthesias, one-third of which were for Iower abdomina1 or peIvic surgery. Jordan,6 surveying a group of postoperative cases at the University HospitaI, PhiIadeIphia, notes an incidence of 19.3 per cent with retention foIIowing spina1, 12.5 per cent after ether, and 27 per cent after nitrous oxide-ether anesthesia. ApparentIy, impuIses which normaIIy initiate the act of micturition are nuII&ed by the anesthetic, resuIting in interruption in the coordinated cycIe of rhythmic bIadder muscuIature contraction and subsequent reIaxation of the sphincter. The failure of the bIadder to heed Nature’s caI1 with subsequent retention is simiIar to the production of constipation when the desire to defecate is repeatedIy denied. Barrett? has made the interesting cIinica1 observation that if catheterization is done before the patient is unduIy distended or at the first compIaint of discomfort, two-thirds of such cases wiI1 be reIieved without subsequent discomfort or danger. Routine postoperative catheterization shouId be avoided except in certain gynecoIogica1 operations upon the vagina or perineum, where straining and pressure is contraindicated and where residua1 urine commonIy predisposes to acute infection. Time honored conservative measures incIude heat to the hypogastrium in the form of an eIectric pad, hot water bottIe or stupes; the sound of running water; ora administration of strychnine or beIIadonna; subcutaneous injections of pituitrin, ergot
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or physostigmine; and methenamine intravenously in 30 to 60 grain doses. Potassium acetate, 15 grains every haIf hour for eight doses, has been advocated by Jordan to reIieve interna sphincter spasm. A warm enema may frequentIy initiate micturition. The average patient who has been subjected to surgery can easily go tweIve to fourteen hours without catheterization. Some surgeons favor early and repeated catheterization whiIe others absoIuteIy forbid it. Hard and fast ruIes cannot be Iaid down but the patient shouId not be aIIowed to suffer unduly. In the absence of pain, catheterization is not indicated unIess one fears anuria, and wishes to confirm such an impression. If strictest asepsis is observed, the procedure is innocuous. Curtis7 reports on 1595 major operations in women, 34 per cent of whom required catheterization. In 275 instances where the procedure was done once or twice, none were infected; of 269 requiring reIief of retention three times or more, I 2 developed cystitis. Jordan’s statistics are Iess impressive, with g of 37 cases catheterized deveIoping cystitis and one an epididymitis. Cases of severe fata urosepsis have been reported by others foIlowing simpIe postoperative catheterization. As a prophylaxis against postcatheterization cystitis, germicida1 soIutions of siIver nitrate, argyro1, protargo1, neosiIvo1 or acriffavine shouId be instiIIed into the bladder and urethra as the catheter is being withdrawn. We have found that if patients are urged to void whiIe the catheter is in the bIadder, they may force it out and continue with the urinary stream naturaIIy. One may modify this technique by sIowIy withdrawing the catheter as the patient is toId to void with similar gratifying results. The vicious inhibiting mechanism is thus broken and further mechanica withdrawa of urine is rendered unnecessary. OTHER
REFLEX
PHENOMENA
Apart from reflex inhibition of urination after genera1 or spina anesthesia and from operations on the urethra, perineum or
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rectum, essential sphincterospasm occurs in individuaIs with vegetative imbaIance or psychic conflicts. The desire to void
FIG. 4. Cystogram depicting the distended viscus which contained 2500 c c. of urine. (Courtesy Dr. S. R. Woodruff.)
which has been denied by circumstance in a perfectly healthy individual may be foIlowed by acute retention of urine. Hysteria, most often evident in women, may account for single or frequent attacks of retention. No organic pathology can be found in such cases even after thorough urologic investigation. Woodruffs recently saw a middle-aged woman with acute retention of over two liters of urine which could onIy be explained on the basis of hysteria (Figs. 4 and 5). Psychotherapy resulted in no further disturbance. A similar instance was seen by us in a woman who was considerabIy agitated by business and famiIia1 probIems. MISCELLANEOUS
DISORDERS
G_ynecological conditions may occasionally produce acute retention. Uterine fibroid,
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ovarian cyst or retroverted gravid uterus impacted “in the pelvis have been reported as causes of compIete urinary obstruction.
FIG. 3. LateraI view of patient in the acute retention due to hysteria showing marked abdominal protuberance. An abdominal tumor had been suspected prior to catheterization. (Courtesy Dr. S. R. Woodruff.)
Hematocolpos behind an imperforate hymen, pelvic abscess, extreme procidentia, inflammatory edema of an urethral caruncIe or even excessive vaginal packing have led to complete mechanical obstruction of urinary flow. Treatment is directed at correction of the cause: catheterization merely alleviating acute drstress. Vesical or urethral calculi, by impinging upon the internal or external sphincters or becoming impacted in the urethra can completely block the outflow of urine (Figs. 6 and 7). Urethral caIcuIi may be crushed and removed by foreign body forceps through the panendoscope or pushed back into the bIadder and converted into vesical caIcuIi. OccasionaIly the stone may become so impacted and imbedded in
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inflammatory tissue as to warrant externa1 urethrotomy. VesicaI caIcuIi may be removed by cystoscopy, IithoIopaxy or suprapubic cystotomy.
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such offenders are behadonna, opium, and cantharides. VaIentine and Fitzgerald9 presented instances of the deIeterious effect of ephedrin when used in eIderIy asthmatics.
FIG. 6. Roentgenogram showing shadow of Iarge calculus. (Bandler and Hyams. Am. Jour. Surg., 8: 836-841, 1930.)
Rectal lesions are an indirect source of urinary dysfunction. ReA ex inhibition has aIready been cited. Tumefaction or abscess formation in or about the Iower recta1 segment can produce sufficient pressure upon the urethra to compIeteIy obstruct it. In radica1 abdominoperinea1 surgery, sympathetic or sacral nerve roots may be so damaged as to cause persistent urinary retention for weeks or months. Foreign bodies represent an infrequent source of urinary obstruction. Insertion of objects into the urethra for purposes of masturbation may resuIt in their impaction in the channe1. Rings, bands, or Iigatures may be pIayfuIIy pIaced about the penis onIy to produce edema, constriction, and in extreme cases, actua1 obstruction. Treatment depends on the nature of the offending agent and the mechanica probIem at hand. Drugs have been heId accountabIe for a few cases of acute retention of urine. Among
FIG. 7. CompIete urographic study resuking from vesicorena1 reflux of 6 per cent sodium iodide solution. This picture was made prior to complete remova of obstruction at internal vesical sphincter. (Bandler and Hyams. Am. Jour. Surg., 8: 836-841, 1930.)
Sphincter spasm, pain and a desire to void out of a11 proportion to the quantity of urine in the bIadder was noted, in addition to red bIood ceIIs, albumin and an increased number of epitheIia1 ceIIs in the urine. Ephedrin stimuIates the sympathetic innervation to the sphincter. Systemic signs of toxicity are palpitation, restIessness, gastric pains and giddiness. RemovaI of the drug is foIIowed by subsidence of symptoms, whiIe its resumption in sensitive cases causes exacerbation. Respect for such individua1 drug idiosyncrasies represents idea1 therapeusis. CONCLUSION
WhiIe acute retention of urine and its attendant discomfort represents the imme-
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diate concern of both patient and physician, the Iatter’s responsibihty does not end after effecting symptomatic rehef. One wouId be faiIing in his duty if he did not undertake the task of determining etiologica1 factors involved. In some instances, the cause is readiIy apparent and needs no further study. On the other hand, urinary disturbance may represent the initia1 sign of potentia1 or actua1 pathoIogy. No attempt has been made to exhaustively enumerate the causes of retention, although the more common and some of the Iess common etiologic factors have been presented. Many of the therapeutic steps outIined may be carried out in o&e practice but in some instances hospitaIization is desirable, if not imperative.
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REFERENCES I. WOODRUFF, S. R.
and MILBERT, A. H. Congenital atresia of the urethra. Presented before Section on Urology N. Y. Academy of Medicine (Nov.) 1935. 2. BIRDSALL, J. C. CongenitaI obstruction of the urethra. Jour. Ural., 22. 438, rg2g. 3. CREEVY, C. D. Sudden decompression of chronically distended urinary btadder. Arch. Surg., 25: 356, 1932. 4. BUTUREANU, W.
and BURGHELE, T. Presse
MU.
35: 1414, 1927. 5. JORDAN, C.
6. 7.
8. g.
G. Postoperative urinary retention. Ann. Surg., 98: 125, 1933. BARRETT, N. R. Treatment of postoperative retention of urine. Lancet, 227: 104, 1934. CURTIS, A. H. Management of femaIe bladder after operation and during pregnancy. J. A. M. A., 80: 1126, 1923. WOODRUFF, S. R. Persona1 communication. VALENTINE, J. J. AND FITZGERALD, J. S. Retention of urine due to ephedrin. Jour. Ural., 34: 314, 1935.
H.
MILBERT,
M.D.
Instructor in UroIogy
New York Post-Graduate MedicaI SchooI and HospitaI, CoIumbia University
A
NEW
YORK
retention of urine represents such instances, micturition is possibIe a highIy significant cIinica1 syn- though curtaiIed in varying degrees. The drome as encountered either by the underIying pathoIogy in both chronic and Internist, surgeon or uroIogist. Inabihty acute urinary retention may be the same. to pass any urine per urethram after re- Sudden shock, overinduIgence in aIcoho1 or peated attempts at voIuntary micturition coitus, exposure to coId, or acute infection may sound a danger signa warranting not may convert a chronic case into an acute mereIy reIief of immediate symptoms but one. careful investigation for underIying pathThe usua1 chnical picture of acute urioIogy. Too often the effect is treated with nary retention is that of a thoroughIy unutter disregard of the cause. Morbidity and comfortabIe patient, with anxious facies mortaIity wouId be markedIy diminished and unabIe to stand stiI1 or Iie quietIy in if cause and effect were reveaIed and suit- bed. WhiIe pain is predominant in the abIe therapy instituted. majority of cases, its absence in no way Any obstructive Iesion of the Iower ahers the acuteness of the condition. An ‘urinary tract, from interna sphincter to individual whose bIadder sensibiIity is impaired or absent due to periphera1 or externa1 urethra1 meatus, may account for compIete interruption of the urinary centra1 nervous system infection or injury .stream. Apart from the dynamic mechanidemands just as much attention as the more animated type. ca1 types, one may encounter adynamic neurogenic Iesions. It wouId be more accuTo compIete and to cIarify our conceprate in defining acute retention of urine tion of ,acute retention, one must excIude anuria, or acute suppression of urine. In to incIude the upper urinary tract. This broader interpretation is expressed as the both instances there occurs an inabiIity inabiIity of the renaI peIvis, ureter or bIad- to pass urine. The former is predicated on the presence of an excessive voIume of der to discharge any of its urinary contents. urine in the bIadder, the Iatter, on renaI One should be mindfu1 of the fact that secretory inhibition. The distended viscus acute inffammation with its attendant may be visibIe, duI1 to percussion and edema, either independent of, or superimpalpabIe. In anuria the bladder cannot be posed upon anomaIy, neopIasm or caIcuIus of the kidney, renal pelvis, ureter or bIad- outIined by percussion or paipation and der, is capabIe of producing acute IocaIized contains IittIe, if any, urine, as confirmed urinary obstruction. Associated with such by catheterization. unilatera1 pathoIogy is the ever-present INCIDENCE danger of reflex inhibition of urine on the InabiIity to void is usuaIIy associated opposite side, or even absence of the kidney, a finding noted in 0.04 to 0.1 per with urethra1 stricture in the youth and cent of a11 individuaIs. For purposes of prostatism in the aged. UndoubtedIy these simpIicity, however, we shaI1 confine our two groups account for many cases of acute retention. However, no age is expresentation to the Iower urinary tract. empt from the incidence of underIying It is aIso beyond the scope of this paper to discuss chronic retention of urine. In Iesions and the precipitation of the cIinica1 162 CUTE
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emergency. Newborn, youth, middle-aged and aged are, as we shah show, victims of the condition. Sex prediIection is of no reaI significance. Acute retention occurs in the femaIe as we11 as in the maIe. True, diseases of the prostate gIand and the greater susceptibiIity of his urethra to gonorrhea1 stricture formation undoubtedIy produces an incidence eIevation in the maIe. Furthermore, the vigorous activity of boys at pIay and the greater number of men at work, make the male more susceptibIe to such injuries which may directly, or indirectIy, produce acute retention. GynecoIogicaI disorders, in turn, cause numerous instances of acute obstruction to the outffow of urine m women. ETIOLOGY
With the exception of isolated cases of hysterica or reff ex (postoperative) retention of urine, carefu1 uroIogic investigation wiI1 reveal a basic cause for the obstruction. Such causes may be cIassified as anomalies, infections, new growths, trauma, neurogenic Iesions, UroIithiasis, foreign bodies, psychic or reflex phenomena, and a misceIIaneous group comprising rarer occurrences. PathoIogicaI entities wiI1 be found to faI1 into certain age groups. Thus, anomaIies frequently manifest themselves in chiIdhood, aIthough occasionaIIy the condition passes unnoticed until superimposed infection precipitates acute obstruction in the adult. The twenty to forty year age group is characterized chieff y by gonorrhea1 strictures in the maIe and pelvic disorders in the female. In the group over fifty years of age, vesica1 neck obstruction due to prostatic disease and gynecoIogica1 maIadies predominate. DIAGNOSIS
The diagnosis of acute retention of urine is usuahy seIf-evident. In most instances pain is an outstanding symptom, and its rehef represents the chief immediate concern of both patient and doctor. History
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of antecedent urinary difficulties, injury, operation, or disease (gonorrhea, syphiIis, uroIithiasis etc.) may be obtained. Such conditions wiI1 be presented in greater detai1 as disease entities are considered. DribbIing of urine shouId make one suspect a condition of “paradoxica1” incontinence due to urinary overffow from an overdistended bIadder. Such instances are usuaIIy associated with neurogenic diseases. An ataxic gait, sensory changes and other neuroIogica1 findings readily identify the tabetic. In true urinary incontinence there is little or no urinary retention. On physica examination, the patient may be extremeIy agitated, perspiring freeIy and tossing about. Inspection of the hypogastric region may revea1 a visibIe midline swelling; the mass is tense and tender to touch, movabIe from side to side (within pain Iimits), with rounded upper contour and merging with the symphysis beIow. Percussion yieIds flatness over the tumor, in contrast to a tympanitic note eIicited IateraIIy and superiorIy. Rectally, a cystic tumefaction may be palpated. During the course of this procedure one may discIose the cause of the condition with the linding of an enIarged or stony hard noduIar prostate gland. Urethra1 catheterization, of course, definiteIy estabIishes the diagnosis of retention of urine. ANOMALIES
MaIformations of the urinary tract account for most obstructive uropathies in infancy. Th e seque1 of obstruction, stasis and infection is aIIied with a state of chronic or acute retention of urine. CompIete or partia1 phimosis, paraphimosis, atresia or constriction of the externa1 meatus, strictures or atresia of the urethra, posterior urethra1 valves, hypertrophy of the verumontanum, and contracture of the vesica1 neck represent such etioIogica1 factors. In the case of complete atresia, an acute emergency exists and Iife-saving measures must be instituted. In other conditions, premonitory signs and symptoms usuaIIy manifest themseIves but
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infection often transforms a chronic struction into an acute one. Complete atresia of the urethra
obis,
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probe or by spreading the bIades of a mosquito clamp inserted through the tiny aperture. If necessary, a dorsal slit of the
2. Hypertrophy of verumontanum as shown by urethrocystography in a four year oId boy with partial urinary obstruction.
FIG.
FIG. I. Urogram demonstrating extent of obstructive uropathy caused by posterior urethra1 valves. (Courtesy Dr. S. R. Woodruff.)
fortunateIy, a rare occurrence. Many such cases pass unnoticed in the absence of postmortem examinations of stilIbirths or those dying shortIy after birth. Woodruff and MiIbertl report a case of compIete atresia of the urethra in a chiId who died one hour after birth. Autopsy reveaIed far advanced obstructive uropathy invoIving the posterior urethra, bladder, ureters and kidneys. Even timely intervention in such a case would have been unavailing, but BirdsaI12 performed externa1 urethrotomy on a chiId simiIarIy affected six hours after birth which proved to be a Iife-saving measure. Congenital anomaIies of the prepuce are readiIy amenabIe to treatment. A pinpoint orifice may be bIuntly stretched with a
prepuce or a circumcision can be done. Several cases of obstructive uremia have been reported due to proIonged chronic back pressure produced by extreme phimosis. Strictures of the externa1 meatus represent the most common form of urethra1 narrowing and are especiaIly prone to compIete obstruction when infection with acute inflammation and edema of the gIans supervenes. In the newborn, a vei1 may completeIy occIude the meatus and simpIy nicking the aImost translucent membrane wiI1 resuIt in spontaneous urination and disappearance of a paIpabIe hypogastric mass. Meatal strictures of varying caIibre may be progressiveIy diIated with Hiforms and bougies or subjected to meatotomy, using a No. I I bIade or bistoury. The attending obstetrician shouId assume the responsibiIity of noting any evident pathoIogy of the externa1 genitalia, the correction of which may be of immediate or remote importance. FaiIure of the chiId to void within the first eighteen hours warrants determination of the patency of the urethra. This may be done with a smaI1 bougie or catheter. OccasionalIy such a
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procedure wiI1 separate or perforate membranous adhesions of the urethra1 mucosa. In extreme cases more radicaI surgery is indicated on the urethra or bIadder. Posterior urethra1 vaIves (Fig. I), hypertrophy of the verumontanum (Fig. 2) and contracture of the vesica1 neck may be remedied by using the transurethral cutting or fuIgurating electrotome. INFECTIONS
Non-specific infections are of IittIe significance unIess they give rise to an inff ammatory process engrafted upon an existing point of constriction. PreviousIy mentioned urethra1 anomalies, phimosis and paraphimosis are prone to produce acute obstruction when compIicated by infection. Treatment is usuaIIy expectant and externa Iesions respond to wet dressings of boric acid, potassium permanganate or subacetate of aluminum. Gonorrhea represents a particuIar menace to norma urinary function. CareIessness of the patient or faulty and indiscreet manipuIation by the physician may resuIt in such periurethral edema as to obstruct the urethra1 channe1. PeriurethraI abscess or phIegmon, acute prostatitis, or prostatic abscess may simiIarIy arise and cause acute retention of urine. Treatment of such acute inflammatory obstructions should aIways be conservative. Rest in bed, hot sitz baths, hot recta1 irrigations, sedatives and recta1 suppositories of opium and beIIadonna are prescribed. UsuaIIy this regime resuIts in regression of the acute symptoms. The patient may be advised to attempt micturition whiIe immersed in a warm bath which has a soothing and reIaxing effect upon sphincter spasm and urethra1 congestion. OccasionaIIy radica1 steps are necessary to reIieve the more acute and extensive processes. Suprapubic cystotomy, externa1 urethrotomy or incision and drainage of an abscess may be indicated. In the case of prostatic abscess, intra-urethra1 rupture of the suppurative focus has been effected by bIind manipuIation with a sound. We prefer either the transurethra1 approach under
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vision, using the McCarthy resectoscope with cutting or fulgurating eIectrotomes, or perinea1 incision and drainage. Suprapubic cystotomy, whiIe outwardIy a radica1 step, may be a most conservative and economic measure. By side-tracking the urinary flow temporariIy, the affected area is put at rest with rapid involution of the inflammatory process. Urethra1 instrumentation can then be carried out at a Iater date. To attempt such instrumentation in the acute phase one faces the danger of producing a bIood stream infection,urethraI injury and urinary extravasation, if it is not aIready present. URETHRAL
STRICTURE
Because gonorrhea1 stricture of the urethra accounts for many cases of acute retention we have chosen to dea1 with it separateIy. NegIect, inadequacy of treatment, wiIIfu1 or accidenta use of strong anti-gonorrhea1 urethra1 medication may resuIt in partia1 or compIete constriction of the urethra. Progressive diminution in the urinary stream may be noted with sudden cessation occurring after exposure to coId, overinduIgence in aIcoho1 or coitus, or too vigorous instrumentation. GentIeness is essentia1 in attempting to reIieve such urethra1 obstructions. PIacing the patient in a hot tub bath may resuIt in partia1 reIief of the acute retention. Passage of a smaI1 sized sound or bougie wiI1 indicate the approximate Iocation and degree of the obstruction. SteriIe aIboIene or oIive oi1 may be instiIIed into the urethra as a Iubricant prior to any instrumentation, or instead, a surface anesthetic of one of the various novocaine derivatives or I per cent diothane solution may be used and retained in the urethra with a penis cIamp for ten minutes before instrumentation is attempted. A water-soIubIe Iubricant can then be used. Any form of anesthesia wiI1 cause the operator to take greater Iiberties in instrumentation than necessary, with the ever present danger of further urethral damage. If deIiberation and gentiIity are observed in the passage of Hiforms, bougies
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and other instruments, no anesthesia may be necessary. Passage of a fihform bougie can be a
FIG. 3. Cystogram showing marked intravesica1 prostatic hypertrophy which caused acute retention. Suprapubic cystostomy (tube in place) was performed.
simpIe or very tedious performance. Patience is a prerequisite to success, for it may take haIf an hour and repeated attempts with one or more fiIiforms before the point of obstruction is passed. The use of muItipIe filiforms passed paraIIe1 to one another heIps to IocaIize an eccentricaIIy pIaced passage through the strictured area. The PhiIips whip fiIiform and foIIower or the LeFort type are especiaIIy desirabIe. A smaIIcaIibered uretera catheter may serve the twofoId_ purpose of passing a point of constriction asrweI1 as effecting sIow drainage. FoIlowing successfu1 passage of a IiIiform, it may be Ieft indweIIing in the urethra and fastened with thread or adhesive to prevent its disIodgement. The instrument acts as a spIint for the passage of urine aIong side of it through the edematous cana1. After tweIve to twenty-four hours the inffammatory process wiI1 have so subsided as to permit the passage of graduated foIIowers of the PhiIips type or of ordinary bougies. In cases where the patient is seen after repeated unsuccessfu1 attempts have been made by others, a period of rest and sedation shouId be given before resuming further instrumentation. RareIy is it necessary to perform suprapubic cystotomy or externa1 urethrotomy for the reIief of acute retention. Such procedures, together with
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interna urethrotomy or diIatation, may be appIicabIe in the subacute or chronic stages. NEW
GROWTHS
Prostatic obstruction due to benign hypertrophy or maIignancy is the most common source of acute retention in eIderIy maIes (Fig. 3). A history of frequency, nocturia, dysuria, urgency and diminution of stream often is cIimaxed by acute retention. The immediate precipitating factor may be an upper respiratory infection, automobiIe ride, exposure to cold, aIcoho1 or sexua1 excitement. It may aIso foIIow diagnostic or therapeutic measures such as cystoscopy, passage of a sound or prostatic massage. Success in catheterizing such individuals depends upon possession of a suitabIe suppIy of catheters. An ordinary NitIaton soft rubber catheter may be sufficient. Depending upon the degree of edema, the tortuosity or distortion of the posterior urethra and the degree of eIevation of the sphincter Aoor, one may try, in turn, a soft rubber coude, natura1 curve, coudi: or bi-coudi: woven siIk, or a soft rubber catheter threaded on a curved wire styIet to obviate “buckling” of the ffexibIe tube. SteeI catheters shouId be used onIy in extreme cases and then with caution. The smaIIest sized catheters shouId be used wherever possibIe to minimize trauma. As emphasized in the treatment of urethra1 stricture, gentIeness is paramount. Repeated unsuccessful attempts shouId be punctuated by a rest period both for patient and doctor. Sedation and IocaI anesthesia can be given the patient in the meantime. A I per cent soIution of diothane instiIIed into the urethra1 cana and retained by a penis chp wiII often bring gratifying resuIts. Having catheterized the eIderIy prostatic patient, gradual decompression of the chronicaIIy distended bIadder shouId be effected. This may be carried out by drawing off four ounces of urine at one to two hour intervaIs or by attaching a Murphy drip tube to the catheter and reguIating
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the ffow by a screw clamp to sixty drops a minute. Creevy,3 in analyzing 6g deaths following catheter treatment of retention, could find no proof that sudden decompression was the cause. However, shock, collapse, renaI or vesical hemorrhage and anuria have been reported by others as direct results of sudden tota evacuation of acutely distended bladders. Nothing is lost and much gained by observing precautionary measures. If too much urine has been withdrawn inadvertently, a safe procedure is to replace the fluid volume in part by sterile saline, boric acid or other antiseptic solution. In addition to prostatism, vesical neck obstruction may be produced by benign or malignant bladder tumors at or about the interna sphincter. Just as a middle Iobe may produce a bail-valve obstruction so can a pedunculated bladder tumor engage itseIf in the interna sphincter and lead to acute retention of urine. Inffammatory edema in prostatic or vesical malignancies can completely occlude the sphincteric lumen. Recently we encountered a case of acute retention of urine in a patient undergoing deep x-ray therapy for prostatic carcinoma. He had voided freeIy prior to the exposure to roentgen rays. Catheter drainage affords immediate relief in the mentioned conditions. Their subsequent treatment, other than immediate symptomatic rehef, is not germaine to our subject.
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Direct injury to the urethra or pelvis may cause a protective reflex retention of urine. Rupture of the urethra is best treated by suprapubic diversion of the urinary stream to offset any extensive extravasation at the site of injury. In selective cases and in expert hands, passage of a catheter along the roof of the urethra may be attempted. Injuries to the spina cord with resultant compression fractures, transverse myehtis or localized nerve tissue injury result in disturbed function of the sacral and sympathetic innervation to the bladder.
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Diminished or absent sensibility of the bIadder to urinary distention results in acute, painless retention of urine. Dribbling occurs as an overflow phenomenon and is referred to as “paradoxica1” incontinence. Catheterization of patients suffering from spinal cord injuries should not be done without specific indication. The patient may go days or weeks without voluntary micturition but a state of automatic bladder contraction will develop sooner or later. Massage, stroking the thighs or appIication of the Credit maneuver to the distended bladder will facilitate its emptying. Infection subsequent to catheterization in such cases is especiahy common and for this reason it should be avoided entirely or when done, strictest asepsis observed. Either as a result of external trauma or urethral or vesical instrumentation, hemorrhage from the bIadder wall or prostate may occur. Formation of large clots in the bIadder may produce complete obstruction to the outffow of urine until they are evacuated. This may be effected through a Iarge catheter or cystoscopic sheath and application of suction. Irrigation with a solution of boric acid and alum (I 3 grains to the ounce) is an effective hemostatic. In exceptional cases, transurethral or suprapubic fulguration of the bleeding points may be necessary. NEUROGENIC
TRAUMA
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LESIONS
Intrinsic centra1 nervous system diseases, apart from those resulting from trauma, cause retention of urine. Cord tumors, syringomyeha, myelitis and tabes dorsalis are frequentIy complicated by urinary retention. Recent advances have been made in demonstrating altered intravesica1 pressure and muscle tonus in such conditions by cystometric determinations. In tabes, one must take into account the fact that the patient is also in the age group characterized by prostatic hypertrophy. Both conditions may be present and for this reason catheterization, with judicious emptying of the bladder and use
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of antiseptic astringent irrigating soIutions, is permissible. POSTOPERATIVE
RETENTION
Postoperative retention represents the most common form of reflex inhibition of urination. IndividuaIs upon whom IocaI anesthesia is used are seIdom if ever troubIed. In contrast, however, spina or inhaIation anesthesia is CharacteristicaIIy foIIowed by acute retention in from IO to 50 per cent of a11 cases. Butureanu and BurgheIe4 report a IO per cent incidence of acute retention after 573 spina anesthesias, one-third of which were for Iower abdomina1 or peIvic surgery. Jordan,6 surveying a group of postoperative cases at the University HospitaI, PhiIadeIphia, notes an incidence of 19.3 per cent with retention foIIowing spina1, 12.5 per cent after ether, and 27 per cent after nitrous oxide-ether anesthesia. ApparentIy, impuIses which normaIIy initiate the act of micturition are nuII&ed by the anesthetic, resuIting in interruption in the coordinated cycIe of rhythmic bIadder muscuIature contraction and subsequent reIaxation of the sphincter. The failure of the bIadder to heed Nature’s caI1 with subsequent retention is simiIar to the production of constipation when the desire to defecate is repeatedIy denied. Barrett? has made the interesting cIinica1 observation that if catheterization is done before the patient is unduIy distended or at the first compIaint of discomfort, two-thirds of such cases wiI1 be reIieved without subsequent discomfort or danger. Routine postoperative catheterization shouId be avoided except in certain gynecoIogica1 operations upon the vagina or perineum, where straining and pressure is contraindicated and where residua1 urine commonIy predisposes to acute infection. Time honored conservative measures incIude heat to the hypogastrium in the form of an eIectric pad, hot water bottIe or stupes; the sound of running water; ora administration of strychnine or beIIadonna; subcutaneous injections of pituitrin, ergot
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or physostigmine; and methenamine intravenously in 30 to 60 grain doses. Potassium acetate, 15 grains every haIf hour for eight doses, has been advocated by Jordan to reIieve interna sphincter spasm. A warm enema may frequentIy initiate micturition. The average patient who has been subjected to surgery can easily go tweIve to fourteen hours without catheterization. Some surgeons favor early and repeated catheterization whiIe others absoIuteIy forbid it. Hard and fast ruIes cannot be Iaid down but the patient shouId not be aIIowed to suffer unduly. In the absence of pain, catheterization is not indicated unIess one fears anuria, and wishes to confirm such an impression. If strictest asepsis is observed, the procedure is innocuous. Curtis7 reports on 1595 major operations in women, 34 per cent of whom required catheterization. In 275 instances where the procedure was done once or twice, none were infected; of 269 requiring reIief of retention three times or more, I 2 developed cystitis. Jordan’s statistics are Iess impressive, with g of 37 cases catheterized deveIoping cystitis and one an epididymitis. Cases of severe fata urosepsis have been reported by others foIlowing simpIe postoperative catheterization. As a prophylaxis against postcatheterization cystitis, germicida1 soIutions of siIver nitrate, argyro1, protargo1, neosiIvo1 or acriffavine shouId be instiIIed into the bladder and urethra as the catheter is being withdrawn. We have found that if patients are urged to void whiIe the catheter is in the bIadder, they may force it out and continue with the urinary stream naturaIIy. One may modify this technique by sIowIy withdrawing the catheter as the patient is toId to void with similar gratifying results. The vicious inhibiting mechanism is thus broken and further mechanica withdrawa of urine is rendered unnecessary. OTHER
REFLEX
PHENOMENA
Apart from reflex inhibition of urination after genera1 or spina anesthesia and from operations on the urethra, perineum or
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rectum, essential sphincterospasm occurs in individuaIs with vegetative imbaIance or psychic conflicts. The desire to void
FIG. 4. Cystogram depicting the distended viscus which contained 2500 c c. of urine. (Courtesy Dr. S. R. Woodruff.)
which has been denied by circumstance in a perfectly healthy individual may be foIlowed by acute retention of urine. Hysteria, most often evident in women, may account for single or frequent attacks of retention. No organic pathology can be found in such cases even after thorough urologic investigation. Woodruffs recently saw a middle-aged woman with acute retention of over two liters of urine which could onIy be explained on the basis of hysteria (Figs. 4 and 5). Psychotherapy resulted in no further disturbance. A similar instance was seen by us in a woman who was considerabIy agitated by business and famiIia1 probIems. MISCELLANEOUS
DISORDERS
G_ynecological conditions may occasionally produce acute retention. Uterine fibroid,
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ovarian cyst or retroverted gravid uterus impacted “in the pelvis have been reported as causes of compIete urinary obstruction.
FIG. 3. LateraI view of patient in the acute retention due to hysteria showing marked abdominal protuberance. An abdominal tumor had been suspected prior to catheterization. (Courtesy Dr. S. R. Woodruff.)
Hematocolpos behind an imperforate hymen, pelvic abscess, extreme procidentia, inflammatory edema of an urethral caruncIe or even excessive vaginal packing have led to complete mechanical obstruction of urinary flow. Treatment is directed at correction of the cause: catheterization merely alleviating acute drstress. Vesical or urethral calculi, by impinging upon the internal or external sphincters or becoming impacted in the urethra can completely block the outflow of urine (Figs. 6 and 7). Urethral caIcuIi may be crushed and removed by foreign body forceps through the panendoscope or pushed back into the bIadder and converted into vesical caIcuIi. OccasionaIly the stone may become so impacted and imbedded in
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inflammatory tissue as to warrant externa1 urethrotomy. VesicaI caIcuIi may be removed by cystoscopy, IithoIopaxy or suprapubic cystotomy.
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such offenders are behadonna, opium, and cantharides. VaIentine and Fitzgerald9 presented instances of the deIeterious effect of ephedrin when used in eIderIy asthmatics.
FIG. 6. Roentgenogram showing shadow of Iarge calculus. (Bandler and Hyams. Am. Jour. Surg., 8: 836-841, 1930.)
Rectal lesions are an indirect source of urinary dysfunction. ReA ex inhibition has aIready been cited. Tumefaction or abscess formation in or about the Iower recta1 segment can produce sufficient pressure upon the urethra to compIeteIy obstruct it. In radica1 abdominoperinea1 surgery, sympathetic or sacral nerve roots may be so damaged as to cause persistent urinary retention for weeks or months. Foreign bodies represent an infrequent source of urinary obstruction. Insertion of objects into the urethra for purposes of masturbation may resuIt in their impaction in the channe1. Rings, bands, or Iigatures may be pIayfuIIy pIaced about the penis onIy to produce edema, constriction, and in extreme cases, actua1 obstruction. Treatment depends on the nature of the offending agent and the mechanica probIem at hand. Drugs have been heId accountabIe for a few cases of acute retention of urine. Among
FIG. 7. CompIete urographic study resuking from vesicorena1 reflux of 6 per cent sodium iodide solution. This picture was made prior to complete remova of obstruction at internal vesical sphincter. (Bandler and Hyams. Am. Jour. Surg., 8: 836-841, 1930.)
Sphincter spasm, pain and a desire to void out of a11 proportion to the quantity of urine in the bIadder was noted, in addition to red bIood ceIIs, albumin and an increased number of epitheIia1 ceIIs in the urine. Ephedrin stimuIates the sympathetic innervation to the sphincter. Systemic signs of toxicity are palpitation, restIessness, gastric pains and giddiness. RemovaI of the drug is foIIowed by subsidence of symptoms, whiIe its resumption in sensitive cases causes exacerbation. Respect for such individua1 drug idiosyncrasies represents idea1 therapeusis. CONCLUSION
WhiIe acute retention of urine and its attendant discomfort represents the imme-
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diate concern of both patient and physician, the Iatter’s responsibihty does not end after effecting symptomatic rehef. One wouId be faiIing in his duty if he did not undertake the task of determining etiologica1 factors involved. In some instances, the cause is readiIy apparent and needs no further study. On the other hand, urinary disturbance may represent the initia1 sign of potentia1 or actua1 pathoIogy. No attempt has been made to exhaustively enumerate the causes of retention, although the more common and some of the Iess common etiologic factors have been presented. Many of the therapeutic steps outIined may be carried out in o&e practice but in some instances hospitaIization is desirable, if not imperative.
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REFERENCES I. WOODRUFF, S. R.
and MILBERT, A. H. Congenital atresia of the urethra. Presented before Section on Urology N. Y. Academy of Medicine (Nov.) 1935. 2. BIRDSALL, J. C. CongenitaI obstruction of the urethra. Jour. Ural., 22. 438, rg2g. 3. CREEVY, C. D. Sudden decompression of chronically distended urinary btadder. Arch. Surg., 25: 356, 1932. 4. BUTUREANU, W.
and BURGHELE, T. Presse
MU.
35: 1414, 1927. 5. JORDAN, C.
6. 7.
8. g.
G. Postoperative urinary retention. Ann. Surg., 98: 125, 1933. BARRETT, N. R. Treatment of postoperative retention of urine. Lancet, 227: 104, 1934. CURTIS, A. H. Management of femaIe bladder after operation and during pregnancy. J. A. M. A., 80: 1126, 1923. WOODRUFF, S. R. Persona1 communication. VALENTINE, J. J. AND FITZGERALD, J. S. Retention of urine due to ephedrin. Jour. Ural., 34: 314, 1935.