Republic of the Philippines University of Northern Philippines Tamag, Vigan City COLLEGE OF HEALTH SCIENCES

Case Study In

Acute Urinary Retention

In partial fulfilment in the subject

CHW

Submitted by: JONNELL SOLOMON, RM BSN-L III-A Submitted to: Mrs. Rebecca Rios, RN, MAN Clinical Instructor

I.INTRODUCTION
A case study is a tool used to understand well on how a certain disease can occur to a person or human. It gives information such as history or background, pathophysiology of a specific disease, or even the drugs administered to the patient suffering from this disease. This is primarily used by medical students in partial fulfilment of their Related Learning Experience (RLE), but merely it can be used also by an ordinary person to understand well the specific disease. While Im having my duty, a case study was included to be a requirement in our clinical practicum. In the curiosity regarding the Acute Urinary Retention, I have chosen this to be my case study. Urinary retention is a common disorder in elderly males. The most common cause of urinary retention is BPH. This disorder starts around age 50 and symptoms may appear after 10 15 years. BPH is a progressive disorder and narrows the neck of the bladder leading to urinary retention. By the age of 70, almost 10% of males have some degree of BPH and 33% have it by the eighth decade of life. While BPH rarely causes sudden urinary retention, the condition can become acute in the presence of certain medications (blood pressure pills, anti-histamines, antiparkinson medications), after spinal anaesthesia or stroke. In young males, the most common cause of urinary retention is infection of the prostate (acute prostatitis). The infection is acquired during sexual intercourse and presents with low back pain, penile discharge, low grade fever and an inability to pass urine. The exact numbers of individuals with acute prostatitis is unknown, because many do not seek treatment. In the USA, at least 1-3 % of males under the age of 40 develop urinary difficulty as a result of acute prostatitis. Most physicians and other health care professionals are aware of these disorders. Worldwide, both BPH and acute prostatitis have been found in males of all races and ethnic backgrounds. Cancers of the urinary tract can cause urinary obstruction but the process is more gradual. Cancer of the bladder, prostate or ureter scan gradually obstruct urine output. Cancers often present with blood in the urine, weight loss, lower back pain or gradual distension in the flanks. In this case my patient, Mr. Jose Hernandez, ages now 76 years-old, which means he has now the higher risk for developing urinary retention, specifically for the acute type as diagnosed by the attending Physician. As this case study goes on, underlying factors related to urinary retention are explained well to the other parts, especially for the organ involved, the urinary bladder. II. PATIENTS PROFILE Name: Jose Quisisem Hernandez Age: 76 years old Gender: Male Address: Callaguip, Caoayan, Ilocos Sur Civil Status: Married Religion: Roman Catholic Nationality: Filipino

DATE OF ADMISSION: August 28, 2013 TIME OF ADMISSION: 7:48 pm

Attending Physician: Dr. Rafanan

Chief Complaint: Hematuria Dysuria Suprapubic Pain III. HISTORY OF PAST AND PRESENT ILLNESS A. History of Past Illness The patient increased in the frequency of urination. Sometimes, he urinate more than 10 times a day, but most of which, the urine has less in amount. At night, he could not have a better sleep because he woke up several times just to urinate. B. History of Present Illness The patient is very uncomfortable and unable to pass urine even he has the urge to urinate, with tender and distended bladder. The sensation is very painful. Before he admitted to the medical facility, there is presence of blood in the urine.

IV. PHYSICAL ASSESSMENT BODY PARTS Head: Skull No bulging of the Round in shape Hard No signs of tenderness Normal FINDINGS SIGNIFICANCE

Scalp Hair

No lesions No dandruff Straight Smooth Well distributed in the scalp White in color Minimal amount of hair Thin Small in length Properly closed

Normal Normal

Eyebrow Eyelashes Eyelids

Normal Normal Normal

 Eyes

White sclera Moves in every direction No appearance of discharges No sign of nares dilatation No obstruction Pinkish No lesion Pinkish Presence of cavities Pinkish No lesion Fair in complexion No signs of swollen gland Well flexed

Normal

Ears Nose

Normal Normal

Lips Tongue Teeth

Normal Normal Poor hygiene (improper brushing) Normal Normal Normal

Gums Skin

Neck:

Upper extremities: Skin Nails Brown in color No scar Clean Good capillary refill Well flexed Can be easily palpated Normal Normal

Muscle strength and reflex Brachial and radial pulse

Normal Normal

Chest:

No scars Brown in color Moves in regular motion No signs of chest indrawing Heart beat and apical pulse can be easily determine No scoliosis Proper presentation of spinal column No tenderness upon palpation

Normal

Back:

Normal

Abdomen:

Normal

Lower extremities: Skin Toenails Fair in complexion Clean Good capillary refill Well flexed Normal Normal

Muscle strength and reflex

Normal

V. DIAGNOSTIC/LABORATORY PROCEDURE A. Hematology Blood Component/s White Blood Cells (WBC) Red Blood Cells (RBC) Hemoglobin Hematocrit Platelet Result 6.39 x 109 /L 3.66 x 1012 /L 104 g/L 29.5 % 281 x 109 /L Significance NORMAL Indicative of Hypoxemia Decreased O2 saturation in the blood Indicative of Hypoxemia NORMAL

B. Ultrasound
Type of Exam: KUB and Prostate Ultrasound IMPRESSION: Hydronephrosis Bilateral Secondary to Cystitis and Urinary Retention. Urinary Sediments. Moderately Enlarged Prostate Gland with concretions.

VI. ANATOMY AND PHYSIOLOGY OF THE ORGAN INVOLVED

The urinary bladder is a muscular sac in the pelvis, just above and behind the pubic bone. When empty, the bladder is about the size and shape of a pear. This is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible (or elastic) organ, the bladder sits on the pelvic floor. Urine enters the bladder via the ureters and exits via the urethra. The human urinary bladder is derived in embryo from the urogenital sinus and, it is initially continuous with the allantois. In males, the base of the bladder lies between the rectum and the pubic symphysis. It is superior to the prostate, and separated from the rectum by the rectovesical excavation. In females, the bladder sits inferior to the uterus and anterior to the vagina; thus, its maximum capacity is lower than in males. It is separated from the uterus by the vesicouterine excavation. In infants and young children, the urinary bladder is in the abdomen even when empty. The detrusor muscle is a layer of the urinary bladder wall made of smooth muscle fibers arranged in spiral, longitudinal, and circular bundles. When the bladder is stretched, this signals the parasympathetic nervous system to contract the detrusor muscle. This encourages the bladder to expel urine through the urethra. For the urine to exit the bladder, both the autonomically controlled internal sphincter and the voluntarily controlled external sphincter must be opened. Problems with these muscles can lead to incontinence. The urinary bladder usually holds 300-350 ml of urine. As urine accumulates, the rugae flatten and the wall of the bladder thins as it stretches, allowing the bladder to store larger amounts of urine without a significant rise in internal pressure. Since the urinary bladder has a transitional epithelium, it does not produce mucus. The fundus of the bladder is the base of the bladder, formed by the posterior wall. It is lymphatically drained by the external iliac lymph nodes. The peritoneum lies superior to the fundus. Frequent urination can be due to excessive urine production, small bladder capacity, irritability or incomplete empting. Males with an enlarged prostate urinate more frequently. One definition of overactive bladder is when a person urinates more than eight times per day, though there can be other causes of urination frequency. Though both urinary frequency and volumes have been shown to have a circadian rhythm, meaning day and night cycles, it is not entirely clear how these are disturbed in the overactive bladder. The bladder receives motor innervation from both sympathetic fibers, most of which arise from the hypogastric plexuses and nerves, and parasympathetic fibers, which come from the pelvic splanchnic nerves and the inferior hypogastric plexus.

VII. PATHOPHYSIOLOGY Urinary retention is the inability to empty the bladder. With chronic urinary retention, you may be able to urinate, but you have trouble starting a stream or emptying your bladder completely. You may urinate frequently; you may feel an urgent need to urinate but have little success when you get to the toilet; or you may feel you still have to go after you've finished urinating. With acute urinary retention, you can't urinate at all, even though you have a full bladder. Acute urinary retention is a medical emergency requiring prompt action. Chronic urinary retention may not seem life threatening, but it can lead to serious problems and should also receive attention from a health professional. Anyone can experience urinary retention, but it is most common in men in their fifties and sixties because of prostate enlargement. A woman may experience urinary retention if her bladder sags or moves out of the normal position, a condition called cystocele. The bladder can also sag or be pulled out of position by a sagging of the lower part of the colon, a condition called rectocele. Some people have urinary retention from rectoceles. People of all ages and both sexes can have nerve disease or nerve damage that interferes with bladder function. Urinary retention can be caused by an obstruction in the urinary tract or by nerve problems that interfere with signals between the brain and the bladder. If the nerves aren't working properly, the brain may not get the message that the bladder is full. Even if you know that your bladder is full, the bladder muscle that squeezes urine out may not get the signal that it is time to push, or the sphincter muscles may not get the signal that it is time to relax. A weak bladder muscle can also cause retention. There are several causes of which the urinary retention occurs. The primary reason is the BPH (Benign Prostatic Hyperplasia). Men have the higher risk to develop this certain kind of disease. As a man ages, his prostate gland may enlarge. Doctors call the condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. As a result, the bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so urine remains in the bladder. Other causes include: Infection Infections cause swelling and irritation, or inflammation. A urinary tract infection (UTI) may cause retention if the urethra becomes inflamed and swells shut. Surgery During surgery, anaesthesia is often administered to block pain signals, and fluid is given intravenously to compensate for possible blood loss. The combination may result in a full bladder with impaired nerve function. Consequently, many patients have urinary retention after surgery. Medication Many medicines work by calming overactive nerve signals. Various classes of drugs that block various signals may be used to treat allergies, stomach cramps, muscle spasms, anxiety, or depression. Some medicines are used to treat urinary incontinence and overactive bladder. The drugs that may cause urinary retention include antihistamines to treat allergies o fexofenadine (Allegra) o diphenhydramine (Benadryl) o chlorpheniramine (Chlor-Trimeton) o cetirizine (Zyrtec)

anticholinergics/antispasmodics to treat stomach cramps, muscle spasms, and urinary incontinence o hyoscyamine (Levbid, Cystospaz, Anaspaz, Gastrosed) o oxybutynin (Ditropan, Ditropan XL, Oxytrol) o tolterodine (Detrol, Detrol LA) o propantheline (Pro-Banthine) tricyclic antidepressants to treat anxiety and depression o imipramine (Tofranil) o amitriptyline (Elavil, Endep) o nortriptyline (Aventyl, Pamelor) o doxepin (Novo-Doxepin, Sinequan)

Bladder Stone A stone formed anywhere in the urinary tract may become lodged in the bladder. If the stone is large enough, it can block the opening to the urethra like a bathtub plug. Cystocele and Rectocele A cystocele occurs when the wall between a woman's bladder and her vagina weakens and allows the bladder to droop into the vagina. The abnormal position of the bladder may cause urine to remain trapped. In a rectocele, the rectum droops into the back wall of the vagina. Cystocele and rectocele are often the results of a dropping of the pelvic support floor for the bladder. This sagging can pull the bladder out of position and cause urinary problems such as incontinence or urinary retention.

 Constipation A hard stool in the rectum may push against the bladder and urethra, causing the urethra to be pinched shut, especially if a rectocele is present. Urethral Stricture A stricture is a narrowing or closure of a tube. Men may have a narrowing of the urethra, usually caused by scarring after a trauma to the penis. Infection is a less common cause of scarring and closure in the urethra. Acute urinary retention causes great discomfort, and even pain. You feel an urgent need to urinate but you simply can't. The lower belly is bloated. Chronic urinary retention, by comparison, causes mild but constant discomfort. You have difficulty starting a stream of urine. Once started, the flow is weak. You may need to go frequently, and once you finish, you still feel the need to urinate. You may dribble between trips to the toilet because your bladder is constantly full, a condition called overflow incontinence. Urinary retention is characterised by poor urinary stream with intermittent flow, straining, a sense of incomplete voiding, and hesitancy (a delay between trying to urinate and the flow actually beginning). As the bladder remains full, it may lead to incontinence, nocturia (need to urinate at night), and high frequency. Acute retention causing complete anuria is a medical emergency, as the bladder can stretch to enormous sizes and possibly tear if not dealt with quickly. If the bladder distends enough it becomes painful. The increase in bladder pressure can also prevent urine from entering the ureters or even cause urine to pass back up the ureters and get into the kidneys, causing hydronephrosis, and possibly pyonephrosis, kidney failure, and sepsis. The acute urinary retention is treated by placement of a urinary catheter (small thin flexible tube) into the bladder. This can be either an intermittent catheter or a Foley catheter that is emplaced with a small inflatable bulb that holds the catheter in place. Intermittent catheterization can be done by a health care professional (nurse/ doctor) or by the patient himself/herself (clean intermittent self-catheterization). Intermittent catheterization performed at the hospital is a sterile technique performed by nurses or doctors. Patients can be taught to use a self-catheterization technique in one simple demonstration, and that reduces the rate of infection from long-term Foley catheters. Selfcatheterization requires doing the procedure every 3 or 4 hours 4-6 times a day. The chronic form of urinary retention may require some type of surgical procedure. While both procedures are relatively safe, complications can occur. For acute urinary retention, treatment requires urgent placement of a urinary catheter (tube) through the urethra and into the bladder. These catheters are usually inserted by health care professionals. However, if the procedure is not done in a sterile fashion, it can introduce bacteria into the bladder. This can result in an infection of the entire urinary tract. Therefore, sterile technique is a must when inserting a Foley catheter. Careful washing of hands, meatus, and reusable catheters are also necessary with clean self-catheterization techniques. A permanent urinary catheter may cause discomfort and pain that can last several days. The urinary catheter must be placed into the bladder and not near the prostate gland. Placement of the catheter near the prostate can lead to significant irritation and some bleeding. In most patients with benign prostate hyperplasia (BPH), a procedure known as transurethral resection of the prostate (TURP) is performed to relieve bladder obstruction.

The surgeon performs the procedure with a small lighted instrument inserted into the urethra under anaesthesia. The surgeon can core out the enlarged prostate and relieve obstruction. However, the procedure has risks. There are risks of anaesthesia which may include allergy to medications or low blood pressure from spinal anaesthesia. When placement of a urethral catheter is contraindicated or unsuccessful, percutaneous suprapubic urinary bladder catheterization is a commonly performed procedure to relieve urinary retention. This allows bladder drainage by inserting a catheter or tube into the bladder through a suprapubic incision or puncture. It may be a temporary measure to divert the flow of urine from the urethra when the urethral route is impassable, after gynecologic or other abdominal surgery when bladder dysfunction is likely to occur, and occasionally after pelvic fractures. For insertion of the suprapubic catheter, the patient is placed in a supine position and the bladder distended by administering oral or intravenous fluids or by instilling sterile saline solution into the bladder through a urethral catheter. These measures make it easier to locate the bladder. The suprapubic area is prepared as for surgery and the puncture site located about 5cm (2inches) above the symphysis pubis. The bladder is entered through an incision or through a puncture made by a small trocar (pointed instrument). The catheter or suprapubic drainage tube is threaded into the bladder and secured with sutures or tape; the area around the catheter is covered with a sterile dressing. The catheter is connected to a sterile closed drainage system and the tubing is secured to prevent tension of the catheter. ALGORITHM

Prostatic Hyperplasia

Blockage to the urethral passage

Accumulation of Large amount of urine in the bladder

Wall of the bladder becomes stretch (to accomodate the urine)

Overstretching of the wall

Wall becomes thicker and irritable

Presence of the Signs and Syptoms: Bladder begins to contract (even when it contains a small amount of urine) *Dysuria Bladder weakens and loses the ability to empty itself

*Bladder Distention
*Decreased Urine Output *Frequent Urination