URINARY RETENTION AND CATHETERIZATIONNama : Anasti Putri Paramatsari

NIM : 030.10.028

Pembimbing : dr. Bagus, Sp. BU

January, 29th 2015

Kepaniteraan Klinik Bagian Ilmu BedahSub Departement Bedah Urologi

Rumah Sakit Umum Bekasi5 Januari – 14 Maret 2015

TOPIK BAHASAN

TOPIK BAHASAN

Retentio Urine

DefinisiPrevalensi

dan Insidensi

Etiologi

Anatomi dan Fisiologi

Patofisiologi

Manifestasi Klinis

Pemeriksaan Penunjang

Tatalaksana

Kateterisasi Urethral

Komplikasi

DEFINITION

DEFINISI

Urinary retention is the inability to voluntarily urinate.

Acute urinary retention is the sudden and often painful inability to void despite having a full bladder.1

Chronic urinary retention is painless retention associated with an increased volume of residual urine.2

1. Rosenstein D, McAninch JW. Urologic Emergencies. Med Clin North Am. 2004;88(2):495–518.

2. Deane AM, Worth PH. Female chronic urinary retention. Br J Urol. 1985;57(1):24–26.

PREVALENSI AND INCIDENSI

PREVALENSI AND INSIDENSI

Pada pria berusia 43 – 80 tahun, insidensi dari urinary retention 4.5 sampai 6.8 per 1,000 pria.3

Pada pria berusia 70-an, insidensi dari urinary retention meningkat sampai 100 per 1,000 pria. 3

Pada pria berusia 80-an, insidensi dari urinary retention meningkat sampai 300 per 1,000 pria. 3

Urinary retention pada wanita lebih sedikit dibandingkan pria, meskipun juga tidak jarang. 4

3. Sellius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. American Family Physician. 20008;77(5):643-650.

4. Wein Aj, Kavoussi LR, Noviick AC, et al. Campbell—Walsh Urology. 10th ed. Philadelphia: Saunders; 2011 p. 157-8.

ETIOLOGI

ETIOLOGI

Etiologi

Obstruksi

Infeksi dan Peradangan

Farmacologist AgentNeurologis

Lain-lain

Causes Men Women Both

Obstructive

Benign prostatic hyperplasia; meatal stenosis; paraphimosis; penile constricting bands; phimosis; prostate cancer

Organ prolapse (cystocele, rectocele, uterine prolapse); pelvic mass (gynecologic malignancy, uterine fibroid, ovarian cyst); retroverted impacted gravid uterus

Aneurysmal dilation; bladder calculi; bladder neoplasm; fecal impaction; gastrointestinal or retroperitoneal malignancy/mass; urethral strictures, foreign bodies, stones, edema

Infectious and inflammatory

Balanitis; prostatic abscess; prostatitis

Acute vulvovaginitis; vaginal lichen planus; vaginal lichen sclerosis; vaginal pemphigus

Bilharziasis; cystitis; echinococcosis; Guillain-Barré syndrome; herpes simplex virus; Lyme disease; periurethral abscess; transverses myelitis; tubercular cystitis; urethritis; varicella-zoster virus

Other

Penile trauma, fracture, or laceration

Postpartum complication; urethral sphincter dysfunction (Fowler's syndrome)

Disruption of posterior urethra and bladder neck in pelvic trauma; postoperative complication; psychogenic

ETIOLOGI(2)Selected Causes of Urinary Retention1,4, 6-

8

ETIOLOGI(3)

Class Drugs

AntiarrhythmicsDisopyramide (Norpace); procainamide (Pronestyl); quinidine

Anticholinergics (selected)

Atropine (Atreza); belladonna alkaloids; dicyclomine (Bentyl); flavoxate (Urispas); glycopyrrolate (Robinul); hyoscyamine (Levsin); oxybutynin (Ditropan); propantheline (Pro-Banthine*); scopolamine (Transderm Scop)

Antidepressants

Amitriptyline (Elavil*); amoxapine; doxepin (Sinequan*); imipramine (Tofranil); maprotiline (Ludiomil*); nortriptyline (Pamelor)

Antihistamines (selected)

Brompheniramine (Brovex); chlorpheniramine (Chlor-Trimeton); cyproheptadine (Periactin*); diphenhydramine (Benadryl); hydroxyzine (Atarax*)

Antihypertensives Hydralazine; nifedipine (Procardia)

Antiparkinsonian agents

Amantadine (Symmetrel); benztropine (Cogentin); bromocriptine (Parlodel); levodopa (Larodopa*)†; trihexyphenidyl (Artane*)

Pharmacologic Agents Associated with Urinary Retention8

Antipsychotics Chlorpromazine (Thorazine*); fluphenazine (Prolixin*); haloperidol (Haldol); prochlorperazine (Compazine*); thioridazine (Mellaril*); thiothixene (Navane)

Hormonal agents Estrogen; progesterone; testosterone

Muscle relaxants Baclofen (Lioresal); cyclobenzaprine (Flexeril); diazepam (Valium)

Sympathomimetics (alpha-adrenergic agents)

Ephedrine; phenylephrine (Neo-Synephrine); phenylpropanolamine‡; pseudoephedrine (Sudafed)

Sympathomimetics (beta-adrenergic agents)

Isoproterenol (Isuprel); metaproterenol (Alupent); terbutaline (Brethine*)

Miscellaneous Amphetamines; carbamazepine (Tegretol); dopamine (Intropin*); mercurial diuretics; nonsteroidal anti-inflammatory drugs (e.g., indomethacin [Indocin]); opioid analgesics (e.g., morphine [Duramorph]); vincristine (Vincasar PFS)

ETIOLOGI(4)

Pharmacologic Agents… (lanjutan)

8. Choong S, Emberton M. Acute urinary retention. BJU Int. 2000;85(2):186–201.

Lesion Type Causes

Autonomic or peripheral nerve

Autonomic neuropathy; diabetes mellitus; Guillain-Barré syndrome; herpes zoster virus; Lyme disease; pernicious anemia; poliomyelitis; radical pelvic surgery; sacral agenesis; spinal cord trauma; tabes dorsalis

Brain

Cerebrovascular disease; concussion; multiple sclerosis; neoplasm or tumor; normal pressure hydrocephalus; Parkinson's disease; Shy-Drager syndrome

Spinal cord

Dysraphic lesions; invertebral disk disease; meningomyelocele; multiple sclerosis; spina bifida occulta; spinal cord hematoma or abscess; spinal cord trauma; spinal stenosis; spinovascular disease; transverse myelitis; tumors or masses of conus medullaris or cauda equine

ETIOLOGI(5)

Neurologic Causes of Urinary Retention and Voiding Dysfunction9

9. Curtis LA, Dolan TS, Cespedes RD. Acute urinary retention and urinary incontinence. Emerg Med Clin North Am. 2001;19(3):600.

Other CausesPostoperative Complications:Pain; Traumatic instrumentation; Bladder over-distension; Pharmacologic agents; Selective pudendal nerve block.10-14

Pregnancy-Associated Urinary Retention:During pregnancy is usually the result of an impacted retroverted uterus that causes obstruction of the internal urethral meatus, most often at 16 weeks' gestation; 15

Post-partum who received epidural anesthesia were significantly more likely to experience urinary retention.15

Trauma:Acute injury to the urethra, penis, or bladder may cause urinary retention; bladder rupture and urethral disruption can occur with pelvic fracture or traumatic instrumentation.16

ETIOLOGI(5)

ANATOMI DAN FISIOLOGI

ANATOMI

ANATOMI (2)

FISIOLOGI

FISIOLOGI(2)

Bladder filling Bladder emptying Voiding phase

FISIOLOGI(3)

Stage of Micturition

FISIOLOGI(3)

FISIOLOGI(4)

FISIOLOGI(5)

Bladder fills progresively

• Tension bladder wall increase

Initiate a nervous reflex

• Micturition reflex: empties the bladder and causes conscious desire to urinate

• Autonomic spinal cord reflex: inhibited/facilitated by centers in brain stem and cerebral cortex

FISIOLOGI(6)

Steps of micturition(voiding phase)

Sympathetic Nerve

• N. Hypogastricus (L1-L3)• Bladder wall relaxation• M. sphincter urethra interna contraction

Parasympathetic Nerve

• Pelvic nerve (S2-S4)• Bladder wall contraction• M. sphincter urethra interna relaxation

Somatic

• N. Pudenddus (S2-S4)• Acts on sphincter urethra externa

FISIOLOGI(7)

Nerve Supply

FISIOLOGI(7)

MANIFESTASI KLINIS

Acute urinary retention: inability to urinate (anuria) painful, urgent need to urinate (urgency) pain or discomfort in the lower abdomen bloating of the lower abdomen.

Chronic urinary retention: urinary frequency (urination eight or more times a day) trouble beginning a urine stream a weak or an interrupted urine stream an urgent need to urinate with little success when trying

to urinate feeling the need to urinate after finishing urination mild and constant discomfort in the lower abdomen and

urinary tract.

SYMPTOMS

PEMERIKSAAN FISIK

Umumnya keadaan umum dan tanda vital dalam batas normal. Dapat terjadi perubahan akibat adanya nyeri hebat.

Abdomen: Inspeksi: tidak tampak kelainan, terlihat tegang atau

menonjol di regio suprapubik. Auskultasi: tidak tampak kelainan Palpasi: teraba masa di regio suprapubik, bentuk bulat,

tepi tidak tegas, permukaan rata, konsistensi kenyal, tidak dapat digerakkan, nyeri tekan dapat +; palpasi bimanual ginjal dapat teraba masa.

Perkusi: nyeri ketok + Pemeriksaan genitalia eksterna Rectal toucher dan pemeriksaan bimanual vesika

urinaria. Pemeriksaan neurologi

Possible Etiology of Urinary Retention Based on History and Physical Examination Findings17-20

17.Curtis LA, Dolan TS, Cespedes RD. Acute urinary retention and urinary incontinence. Emerg Med Clin North Am. 2001;19(3):591–619.18. Ellerkmann RM, McBride A. Management of obstructive voiding dysfunction. Drugs Today (Barc). 2003;39(7):513–540.19. Dorflinger A, Monga A. Voiding dysfunction. Curr Opin Obstet Gynecol. 2001;13(5):507–512.20. Stohrer M, Goepel M, Kondo A, et al. The standardization of terminology in neurogenic lower urinary tract dysfunction: with suggestions for diagnostic procedures. International Continence Society Standardization

Committee. Neurourol Urodyn . 1999;18(2):139–158.

PEMERIKSAAN PENUNJANG

PEMERIKSAAN PENUNJANG17-20

• Urinalysis: evaluate for infection, hematuria, proteinuria, glucosuria• Serum BUN, creatinine, electrolytes: evaluate for renal failure from lower

UTI• Serum blood glucose: evaluate for undiagnosed or uncontrolled DM in

neurogenic bladder.• Prostate-specific antigen: elevated in prostate cancer, may be elevated in

BPH, prostatitis, and in the setting of AUR

Laboratory

• Renal and bladder USG: measure postvoid residual urine; evaluate for bladder and urethral stones, hydronephrosis, and upper urinary tract disease.

• Pelvic USG, CT of abdomen and pelvic: evaluate for suspected pelvic, abdominal or retroperitoneal mass or malignancy causing extrinsic bladder neck compression.

• MRI or CT of brain: evaluate for intracranial lesion, including tumor, stroke, multiple sclerosis (MRI preferred in MS)

• MRI of spine: evaluate for lumbosacral disk herniation, cauda eqquina syndrome, spinal tumors, spinal cord compression, MS.

Imaging Studies

• Cystoscopy, retrograde cystourethrography: evaluate for suspected bladder tumor and bladder or urethral stones or strictures.

• Urodynamic studies (e.g., uroflowmetry, cystometry, electromyography, urethral pressure profile): evaluate bladder function (detrusoor muscle and sphincter) in patiens with neurogenic ladder to help guide management.

Other

TATALAKSANA

TATALAKSANA Urinary retention:

bladder drainage urethral dilatation causal treatment, e.g., prostate medication Surgery Administered consultation

Acute urinary retention: immediate and complete decompression of the bladder through

catheterization, if catheter placement is not successful, a suprapubic tube should be placed approximately two finger breadths above the pubic symphysis.

For BPH: a coude (French for curved) catheter is helpful in negotiating past the angulation in the prostatic urethra. The curved portion (which is angled in line with the balloon port) is maintained at the 12 o'clock position as it is passed through the urethra.22

For stricture: using a 12F or 14F catheter often will allow the passage of the catheter into the bladder. 22

TATALAKSANA

KATETERISASI URETHA

DEFINISI

Kateter adalah sebuah alat berbentuk pipa yang dimasukkan ke dalam kandung kemih dengan tujuan untuk mengeluarkan urine yang terdapat di dalamnya.

Kateterisasi urethra adalah tindakan memasukkan selang karet atau plastik melalui uretra ke dalam kandung kemih untuk mengeluarkan urine

INDIKASI

• Memperoleh contoh urin pada wanita guna pemeriksaan kultur urin.

• Mengukur residual urin pada pembesaran prostat.• Memasukkan bahan kontras pemeriksaan seperti pada

sistogram.• Mengukur tekanan tekanan buli-buli seperti pada sindrom

kompartemen abdomen.• Mengukur produksi urin yang merupakan cerminan keadaan

perfusi ginjal pada penderita shock• Mengetahui perbaikan atau perburukan pada trauma ginjal.

Diagnostik

• Mengeluarkan urin pada retensio urinae• Membilas / irigasi buli-buli setelah operasi batu buli-buli, tumor

buli atau prostat• Sebagai splint setelah operasi uretra seperti pada hipospadia• Untuk memasukkan obat ke buli-buli, misalnya pada carcinoma

buli-buli.

Terapeutik

KONTRAINDIKASI

• Rupture urethraAbsolut

e

• Striktur uretra• Pembedahan uretra atau

bladder,• Pada pasien yang tidak

kooperatif

Relative

JENIS KATETER

Kateter Nelathon/ kateter straight/ kateter sementara• kateter urin yang berguna untuk mengeluarkan urin

sementara

Kateter balon/kateter Folley, Kateter Indwelling/ Kateter Tetap• digunakan untuk mengeluarkan urin dalam sistem tertutup,

dapat digunakan untuk waktu lebih lama (±6-7 hari).

Curved or Coude• Catheters have a rounded curved tip (elbowed) used in older

male patients with enlarged prostates

3-way Foley catheter• Retention catheter, they have 2 or 3 lumens that encircle the

body of the cath

UKURAN KATETER

Diameters: 5Fr, 6fr, 8fr 10fr, 12fr, 14fr, 16fr, 18fr, 20fr, 22fr, 24fr, 26fr.

The higher the number the larger the diameter of the catheter.

1Fr. = 3mm (e.g. a 24fr. catheter is 8mm in diameter)

Wanita dewasa : no 14/16 Laki-laki dewasa : no 18/20 Anak-anak : no 8/10

ALAT-ALAT

Set catheter• Catheter Folley• Urin bag• Selang

Handschoen Steril Spuit dissposible 10cc Xylocain gel

Duk KertasKlem/Pinset Kasa steril Aquadest

Povidone iodine Micropore/plester Nierbeckhen

TINDAKAN PELAKSANAAN1. Identifikasi pasien 2. Jelaskan prosedur kepada pasien 3. Tarik tirai tempat tidur dan atur posisi

a. Pasien anak/pasien sadar butuh bantuan b. Pasien dewasa/wanita : posisi dorsal recumbent dengan lutut fleksi c. Pasien dewasa/ laki-laki: Posisi supine dan kaki abduksi

4. Pasang urin bag 5. Pasang perlak atau alas pada klien 6. Tuangkan cairan antiseptic 7. Sediakan spuit isi aquadest 8. Cuci tangan dengan cara furbringer 9. Pasang sarung tangan 10. Lakukan vulva/perineum hygiene 11. Buka set kateter dan berikan jelly di ujung kateter 12. Masukkan kateter sampai urin mengalir 13. Ketika urin mengalir, pindahkan tangan yang tidak dominant dari labia atau dari penis ke kateter. 14. Jika menggunakan indwelling kateter, isi balon kemudian tarik kateter ± 2,5 cm 15. Fiksasi kateter 16. Bantu pasien pada posisi yang nyaman 17. Kumpulkan dan buang alat-alat yang sekali pakai, bersihkan alat-alat yang bukan sekali pakai 18. Cuci tangan.

KOMPLIKASI DARI KATETERISASI URINE

Complications of catheter use include:21

Allergy or sensitivity to latex Bladder stones Blood infections (septicemia) Blood in the urine (hematuria) Kidney damage (usually only with long-term,

indwelling catheter use) Urethral injury Urinary tract or kidney infections

21. Moy ML, Wein AJ. Additional therapies for storage and emptying failure. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 70.22. Wierbicky J, Nesathurai S. Spinal cord injury (thoracic). In: Frontera WR, Silver JK, Rizzo TD Jr, eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 147.23. Resnick NM. Incontinence. In: Goldman L, Ausiello D, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 25

KOMPLIKASI

KOMPLIKASI

Complications of urinary retention and its treatment: UTIs bladder damage kidney damage urinary incontinence after surgery

DAFTAR PUSTAKA

DAFTAR PUSTAKA1. Rosenstein D, McAninch JW. Urologic Emergencies. Med Clin North Am.

2004;88(2):495–518.

2. Deane AM, Worth PH. Female chronic urinary retention. Br J Urol. 1985;57(1):24–26.

3. Sellius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. American Family Physician. 20008;77(5):643-650.

4. Wein Aj, Kavoussi LR, Noviick AC, et al. Campbell—Walsh Urology. 10th ed. Philadelphia: Saunders; 2011 p. 157-8.

5. Meigs JB, Barry MJ, Giovannucci E, Rimm EB, Stampfer MJ, Kawachi I. Incidence rates and risk factors for acute urinary retention: the health professionals follow up study. J Urol. 1999;162(2):376–382.

6. Curtis LA, Dolan TS, Cespedes RD. Acute urinary retention and urinary incontinence. Emerg Med Clin North Am. 2001;19(3):591–619.

7. Ellerkmann RM, McBride A. Management of obstructive voiding dysfunction. Drugs Today (Barc). 2003;39(7):513–540.

8. Choong S, Emberton M. Acute urinary retention. BJU Int. 2000;85(2):186–201.

9. Curtis LA, Dolan TS, Cespedes RD. Acute urinary retention and urinary incontinence. Emerg Med Clin North Am. 2001;19(3):600.

10. Kim J, Lee DS, Jang SM, Shim MC, Jee DL. The effect of pudendal block on voiding after hemorrhoidectomy. Dis Colon Rectum. 2005;48(3):518–523.

11. Iorio R, Whang W, Healy WL, Patch DA, Najibi S, Appleby D. The utility of bladder catheterization in total hip arthroplasty. Clin Orthop Relat Res . 2005;(432):148–152.

12. Hershberger JM, Milad MP. A randomized clinical trial of lorazepam for the reduction of postoperative urinary retention. Obstet Gynecol. 2003;102(2):311–316.

13. Gonullu NN, Dulger M, Utkan NZ, Canturk NZ, Alponat A. Prevention of postherniorrhaphy urinary retention with prazosin. Am Surg . 1999;65(1):55–58.

14. Cardozo L, Cutner A. Lower urinary tract symptoms in pregnancy. Br J Urol. 1997;80(suppl 1):14–23.

15. Glavind K, Bjork J. Incidence and treatment of urinary retention post-partum. Int Urogynecol J Pelvic Floor Dysfunct . 2003;14(2):119–121.

16. Yip SK, Sahota D, Pang MW, Day L. Postpartum urinary retention. Obstet Gynecol. 2005;106(3):602–606.

17. Curtis LA, Dolan TS, Cespedes RD. Acute urinary retention and urinary incontinence. Emerg Med Clin North Am . 2001;19(3):591–619.

18. Ellerkmann RM, McBride A. Management of obstructive voiding dysfunction. Drugs Today (Barc). 2003;39(7):513–540.

19. Dorflinger A, Monga A. Voiding dysfunction. Curr Opin Obstet Gynecol. 2001;13(5):507–512.

20. Stohrer M, Goepel M, Kondo A, et al. The standardization of terminology in neurogenic lower urinary tract dysfunction: with suggestions for diagnostic procedures. International Continence Society Standardization Committee. Neurourol Urodyn . 1999;18(2):139–158.

21. Moy ML, Wein AJ. Additional therapies for storage and emptying failure. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 70.

22. Wierbicky J, Nesathurai S. Spinal cord injury (thoracic). In: Frontera WR, Silver JK, Rizzo TD Jr, eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 147.

23. Resnick NM. Incontinence. In: Goldman L, Ausiello D, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 25

DAFTAR PUSTAKA

TERIMA KASIH