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An Evidence-Based Approach to Emergency Department Management of Acute Urinary Retention

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An Evidence-Based Approach to Emergency Department Management of Acute Urinary Retention January 2014 An Evidence-Based Approach Volume 16, Number 1 To Emergency Department Authors John R. Marshall, MD Department of Emergency Medicine, Lincoln Medical and Mental Management Of Health Center, Bronx, NY Jordana Haber, MD Department of Emergency Medicine, Maimonides Medical Center, Acute Urinary Retention Brooklyn, NY Elaine B. Josephson, MD, FACEP Assistant Professor of Emergency Medicine in Clinical Medicine, Abstract Weill Cornell Medical College of Cornell University, New York, NY; Emergency Medicine Residency Program Director, Lincoln Medical and Mental Health Center, Bronx, NY Approximately 10% of men in their 70s and 33% of men in their 80s report at least 1 episode of acute urinary retention, and this urologi- Peer Reviewers cal emergency presents unique assessment and treatment challenges William J. Brady, MD Professor of Emergency Medicine and Medicine, Chair, Medical in the emergency department setting. Patients presenting with Emergency Response Committee, Medical Director, Emergency acute urinary retention are often in severe pain and require urgent Management, University of Virginia Medical Center, Charlottesville, VA diagnosis and prompt treatment. The differential diagnosis of acute Joseph D. Toscano, MD urinary retention is vast, with some causes leading to permanent Chairman, Department of Emergency Medicine, San Ramon Regional Medical Center, San Ramon, CA impairment if not dealt with in a timely manner. Quick recogni- tion of the cause and timely bladder decompression are of utmost CME Objectives importance in preventing morbidity and relieving pain. This review Upon completion of this article, you should be able to: analyzes the etiology, key historical and physical findings, differen- 1. Describe the pathophysiology and complications of AUR. 2. Distinguish key physical examination findings, including red flags, tial diagnosis, and diagnostic studies for acute urinary retention in that may help identify patients with AUR. both men and women. Treatment algorithms for men and women, 3. Interpret the treatment algorithms for AUR in men and women. current controversies regarding urinary catheter usage, and recom- Prior to beginning this activity, see “Physician CME Information” on the mendations on criteria for disposition are also presented. back page. Editor-In-Chief of Medicine at Mount Sinai, New Attending Physician, Massachusetts Icahn School of Medicine at Mount Research Editor Andy Jagoda, MD, FACEP York, NY General Hospital, Boston, MA Sinai, New York, NY Michael Guthrie, MD Professor and Chair, Department of Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, Scott Silvers, MD, FACEP Emergency Medicine Residency, Emergency Medicine, Icahn School Professor and Chair, Department FACEP Chair, Department of Emergency Icahn School of Medicine at Mount of Medicine at Mount Sinai, Medical of Emergency Medicine, Carolinas Professor and Chair, Department of Medicine, Mayo Clinic, Jacksonville, FL Sinai, New York, NY Director, Mount Sinai Hospital, New Medical Center, University of North Emergency Medicine, Pennsylvania York, NY Carolina School of Medicine, Chapel Hospital, Perelman School of Corey M. Slovis, MD, FACP, FACEP International Editors Professor and Chair, Department Hill, NC Medicine, University of Pennsylvania, Peter Cameron, MD Associate Editor-In-Chief Philadelphia, PA of Emergency Medicine, Vanderbilt Steven A. Godwin, MD, FACEP University Medical Center; Medical Academic Director, The Alfred Kaushal Shah, MD, FACEP Professor and Chair, Department Michael S. Radeos, MD, MPH Emergency and Trauma Centre, Associate Professor, Department of Director, Nashville Fire Department and of Emergency Medicine, Assistant Assistant Professor of Emergency International Airport, Nashville, TN Monash University, Melbourne, Emergency Medicine, Icahn School Dean, Simulation Education, Medicine, Weill Medical College Australia of Medicine at Mount Sinai, New University of Florida COM- of Cornell University, New York; Stephen H. Thomas, MD, MPH York, NY George Kaiser Family Foundation Giorgio Carbone, MD Jacksonville, Jacksonville, FL Research Director, Department of Chief, Department of Emergency Emergency Medicine, New York Professor & Chair, Department of Gregory L. Henry, MD, FACEP Medicine Ospedale Gradenigo, Editorial Board Hospital Queens, Flushing, NY Emergency Medicine, University of William J. Brady, MD Clinical Professor, Department of Oklahoma School of Community Torino, Italy Professor of Emergency Medicine Emergency Medicine, University Ali S. Raja, MD, MBA, MPH Medicine, Tulsa, OK Amin Antoine Kazzi, MD, FAAEM and Medicine, Chair, Medical of Michigan Medical School; CEO, Director of Network Operations and Ron M. Walls, MD Associate Professor and Vice Chair, Emergency Response Committee, Medical Practice Risk Assessment, Business Development, Department Professor and Chair, Department of Department of Emergency Medicine, Medical Director, Emergency Inc., Ann Arbor, MI of Emergency Medicine, Brigham University of California, Irvine; and Women’s Hospital; Assistant Emergency Medicine, Brigham and Management, University of Virginia John M. Howell, MD, FACEP American University, Beirut, Lebanon Professor, Harvard Medical School, Women’s Hospital, Harvard Medical Medical Center, Charlottesville, VA Clinical Professor of Emergency Boston, MA School, Boston, MA Hugo Peralta, MD Peter DeBlieux, MD Medicine, George Washington Scott D. Weingart, MD, FCCM Chair of Emergency Services, Professor of Clinical Medicine, University, Washington, DC; Director Robert L. Rogers, MD, FACEP, Associate Professor of Emergency Hospital Italiano, Buenos Aires, Interim Public Hospital Director of Academic Affairs, Best Practices, FAAEM, FACP Medicine, Director, Division of Argentina of Emergency Medicine Services, Inc, Inova Fairfax Hospital, Falls Assistant Professor of Emergency ED Critical Care, Icahn School of Dhanadol Rojanasarntikul, MD Louisiana State University Health Church, VA Medicine, The University of Maryland School of Medicine, Medicine at Mount Sinai, New Attending Physician, Emergency Science Center, New Orleans, LA Shkelzen Hoxhaj, MD, MPH, MBA Baltimore, MD York, NY Medicine, King Chulalongkorn Francis M. Fesmire, MD, FACEP Chief of Emergency Medicine, Baylor Memorial Hospital, Thai Red Cross, Professor and Director of Clinical College of Medicine, Houston, TX Alfred Sacchetti, MD, FACEP Senior Research Editors Thailand; Faculty of Medicine, Assistant Clinical Professor, Research, Department of Emergency Eric Legome, MD Chulalongkorn University, Thailand Medicine, UT College of Medicine, Department of Emergency Medicine, James Damilini, PharmD, BCPS Chief of Emergency Medicine, Clinical Pharmacist, Emergency Suzanne Peeters, MD Chattanooga; Director of Chest Pain Thomas Jefferson University, King’s County Hospital; Professor of Room, St. Joseph’s Hospital and Emergency Medicine Residency Center, Erlanger Medical Center, Philadelphia, PA Clinical Emergency Medicine, SUNY Medical Center, Phoenix, AZ Director, Haga Hospital, The Hague, Chattanooga, TN Downstate College of Medicine, Robert Schiller, MD The Netherlands Brooklyn, NY Chair, Department of Family Joseph D. Toscano, MD Nicholas Genes, MD, PhD Medicine, Beth Israel Medical Chairman, Department of Emergency Assistant Professor, Department of Keith A. Marill, MD Center; Senior Faculty, Family Medicine, San Ramon Regional Assistant Professor, Harvard Medical Emergency Medicine, Icahn School Medicine and Community Health, Medical Center, San Ramon, CA School; Emergency Department Case Presentations often leads to inconsistent and suboptimal recogni- tion and management of female patients. It’s a typically busy morning in your community ED. This issue of Emergency Medicine Practice pres- The average wait time to be seen is 1 hour when a ents a systematic review of the latest evidence 66-year-old man with hypertension and high cholesterol regarding the pathophysiology, diagnosis, and states that he has been unable to urinate for a few days treatment of AUR, with a focus on controversies and and now has suprapubic pain and constipation. He denies advances in care. fever and chills. He also notes that, in the past, he was diagnosed with benign prostatic hypertrophy and has re- Critical Appraisal Of The Literature quired Foley placement. It seems simple enough, and you anticipate he will be out as soon as the Foley and leg bag An initial search utilizing the PubMed® database are in place. You wonder if a rectal exam is needed and from 1960 to 2013 was performed using the search how fast his bladder can be emptied... term management of acute urinary retention, with It’s 2:00 PM and you are about to finally grab some a total of 385 results produced. Full texts for 122 lunch, but in comes a 72-year-old man with a history of articles were reviewed, of which 69 are cited in this large cell lymphoma for the past 15 years. He complains of review. Two Federal Aviation Administration (FAA) dribbling urinary frequency, which has worsened over 1 guideline appendices studying the treatment of day after being prescribed an antibiotic by his doctor for a AUR in airplane flight as well as a website on flight UTI. The nurse asks him to walk to another stretcher, and safety were also reviewed. In addition, the Cochrane as he gets up, he stumbles and catches himself with his Database of Systematic Reviews was searched with hands. As you prepare to do the bladder ultrasound, you regard to the treatment of AUR. In 1994, A BPH wonder why he stumbled... guidelines
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