Lynda Kirkwood, RN, is continence adviser, Weston General Hospital, Weston Super Mare, Somerset.
Peter Brian is a 69-year-old man who has been feeling a bit under the weather. He had been having problems sleeping and it seemed as if he was continuously getting up and going to the toilet all night. He had woken his wife on several occasions during the past few weeks and she was now really grumpy.
He decided to go to the pub with his friend and had a couple of pints of bitter. When he got home, his wife had gone to bed. The sitting room was cosy and soon he had drifted off to sleep in his favourite armchair.
Mr Brian woke up at 3am and felt like he needed to pass urine. He went to the toilet but, although he had the urge to urinate, he couldn’t start. He sat on the toilet and turned on the tap, but still nothing happened. By 4.45am Mr Brian was sweating and the pain in his abdomen was terrible. He felt as if he was going to explode. His wife was worried about him and decided to call the emergency GP.
The GP asked about Mr Brian’s symptoms and advised that they should go to the A&E department straight away. He telephoned the department to let them know the patient was on his way.
On arrival Mr Brian was introduced to the surgical on-call doctor, who asked him about what had happened to him and then examined his abdomen. He quickly came to the conclusion that Mr Brian had acute urinary retention and would need to have a catheter inserted. Mr Brian had no idea what a catheter was, but he really didn’t care what the doctor did to him as long as the awful feeling of a full bladder was relieved.
Urinary retention can be acute or chronic, and the symptoms are distinct (Box 1). A distended bladder is a serious medical condition, and immediate intervention is required to drain urine and improve patient comfort. The presence of suprapubic pain distinguishes acute urinary retention from chronic retention (Osborne, 2000).
The doctor took a full medical history that included details of Mr Brian’s current symptoms. As urinary retention has a diverse number of causes, including obstruction, neurological causes and side-effects of certain drugs, it is important that the patient has a full medical assessment.
Blood samples should also be taken to assess renal function and, if cancer of the prostate is suspected, prostate-specific antigen should be checked with the patient’s consent.
Treatment to relieve retention
The doctor explained that he was going to insert a suprapubic catheter so that he could drain Mr Brian’s bladder in a way that would help with his future treatment. The doctor introduced the suprapubic catheter and, although the procedure was uncomfortable, Mr Brian felt instant relief as urine drained through the tube into a drainage bag.
When a patient experiences acute urinary retention the bladder can be decompressed, using a urethral or suprapubic catheter. Both have advantages and disadvantages. There is evidence to suggest that there are fewer complications associated with bladder decompression using a suprapubic catheter (Horgan et al, 1992).
Once Mr Brian was comfortable, the doctor explained that it was possible that his prostate gland might be at the root of his retention problem.
When questioned, Mr Brian said he had noticed increased frequency and urgency and had taken longer to empty his bladder over the past six months. The doctor assessed his prostate size by undertaking a digital rectal examination. This confirmed a large smooth prostate. The doctor suggested that Mr Brian should start taking alpha blockers to relax the prostate and allow a better flow. Providing he had a good response, the catheter could be removed in the outpatients clinic.
Alpha blockers (alfuzosin, tamsulosin, indoramin) have been demonstrated to be effective in the long-term treatment of patients with uncomplicated benign prostatic hypertrophy (Brewster et al, 2001).
Another drug used to treat benign prostatic hypertrophy is finasteride, which shrinks the prostate over a six-month period.
Mr Brian was shown how to empty his catheter valve, instructed not to leave more than four hours between voids and told to try to pass urine normally via his urethra. After each try he should open the valve and let any residual urine in his bladder drain out.
Mr Brian was asked to keep a record of how much he was able to void and how much residual urine he drained from his suprapubic catheter. He was asked to bring this information to the trial-without-catheter (TWOC) clinic run by the urology team who would be following him up. The community nurses were notified that Mr Brian had been discharged with a suprapubic catheter so that he had additional support at home. He could contact the district nurse if he had any problems - for example, if the catheter blocked.
Armed with his first supply of alpha blocker tablets, Mr Brian was sent home feeling a lot more comfortable. Evidence suggests that, although patients may experience some catheter- related problems at home, it is an effective use of resources to discharge patients following an episode of acute retention of urine and following them up in outpatient clinics (Khoubehi et al, 2000). However, such service developments are not available throughout the country.
Mr Brian attended the TWOC clinic after four weeks with his catheter. He successfully passed a good volume of urine, with a slightly reduced flow rate, and he was found to have a small residual volume - 50ml - of urine in his bladder.
The suprapubic catheter was removed and he was given an appointment to attend the urology outpatients department in six months’ time to have a flow test and post-void residual measurement before reassessment by the doctor.