Acute retention of urine is an

indication for emergency

drainage of the bladder

URINARY RETENTION
Acute retention of urine is an indication for
emergency drainage of the bladder.
If the bladder cannot be drained through the urethra,
it requires suprapubic drainage.
Treatment of chronic retention is not urgent. Arrange
to refer patients with chronic urinary retention for
further management.
Emergency drainage
Emergency drainage of the bladder in acute retention
may be undertaken by:
::
::
::

Urethral catheterization
Suprapubic puncture
Suprapubic cystostomy.

Urethral catheterization or bladder puncture is

usually adequate, but cystostomy may become
necessary for the removal of a bladder stone or
foreign body, or for more prolonged drainage, for
example after rupture of the posterior urethra or if
there is a urethral stricture with complications.
If a catheters balloon fails to deflate, inject 3 ml of
ether into the tube leading to the balloon. This will
rupture the balloon. Cut it off and remove it. Prior to
removing the catheter, irrigate the bladder with 30 ml
of saline.
URETHRAL CATHETERIZATION
MALE PATIENT

IN

THE

Technique
1
2

Reassure the patient that catheterization is

atraumatic and usually uncomfortable rather
than painful. Explain the procedure.
Wash the area with soap and water, retracting
the prepuce to clean the furrow between it and
the glans. Put on sterile gloves and, with sterile
swabs, apply a bland antiseptic to the skin of the
genitalia. Isolate the penis with a perforated
sterile towel. Lubricate the catheter with
generous amounts of water soluble gel.
Check the integrity of the Foley catheter balloon
and then lubricate the catheter with sterile liquid
paraffin (mineral oil). If you are right-handed,
stand to the patients right, hold the penis
vertically and slightly stretched
with the left hand, and introduce the Foley
catheter gently with the other
hand (Figure 9.1).
At 1215 cm, the catheter may stick at the

The common causes of acute

retention in the male are
urethral stricture and benign
prostatic hypertrophy
Other causes of acute
retention are urethral trauma
and prostatic cancer
If the bladder cannot be
drained through the urethra,
it requires suprapubic
drainage
In chronic retention of urine,
because the obstruction
develops slowly, the bladder is
distended (stretched) very
gradually over weeks, so pain
is not a feature
The bladder often overfills
and the patient with chronic
retention presents with
dribbling of urine, referred to
as retention with overflow
Treatment of chronic
retention is not urgent, but
drainage of the bladder will
help you to determine the
volume of residual urine and
prevent renal failure, which is
associated with retention.
Arrange to refer
patients with chronic urinary
retention for definitive
management.

junction of the penile and bulbous urethra, in

which case angle it down to allow it to enter the
posterior urethra. A few centimetres further,
there may be resistance caused by the external
bladder sphincter, which can be overcome by a
gentle pressure applied to the catheter for 2030
seconds. Urine escaping through the catheter
confirms entry into the bladder.
Advance the catheter 5 to 10 cm before inflating
the balloon. This prevents the balloon inflating
in the prostatic urethra.

Figure 9.1
4
5

If the catheter fails to pass the bulbous urethra

and the membranous urethra, try a semi-rigid
coud catheter.
Pass a coud catheter in three stages. With one
hand, hold the penis stretched and, with the
other hand, hold the catheter parallel to the fold
of the groin. Introduce the catheter into the
urethra and bring the penis to the midline
against the patients abdomen as the beak of
the catheter approaches the posterior urethra.
Finally, position the penis horizontally between
the patients legs as the catheter passes up the
posterior urethra
over the lip of the bladder neck. At this point,
urine should flow from the catheter.

If you fail to pass a catheter, proceed to

filiforms and followers (Figure 9.2) or use a
Foley catheter with a guide. If these
procedures are unsuccessful, abandon them
in favour of suprapubic puncture. Forcing the
catheter or a metal bougie can create a false
passage, causing urethral bleeding and
intolerable pain, and increasing the risk of
infection.
Fixation of the catheter

Figure 9.2
1

If you are using a Foley catheter, inflate the

balloon with 10 15 ml of sterile water or clean

urine (Figure 9.2). Partially withdraw the

catheter until its balloon abuts on the bladder
neck.
If the catheter has no balloon, knot a ligature
around the catheter just beyond the external
meatus and carry the ends along the body of the
penis, securing them with a spiral of strapping
brought forward over the glans and the knot
(Figures 9.3, 9.4, 9.5).

Figure 9.3

Figure 9.4

Figure 9.5

Aftercare
::

If the catheterization was traumatic, administer

an antibiotic with a gram negative spectrum for 3
days

::
::

Always decompress a chronically distended

bladder slowly
Connect the catheter through a closed system to
a sterile container (Figure 9.6)

Figure 9.6
::

::

Strap the penis and catheter laterally to the

abdominal wall; this will avoid a bend in the
catheter at the penoscrotal angle and help to
prevent compression ulceration
Change the catheter if it becomes blocked or
infected, or as otherwise indicated. Ensure a
generous fluid intake to prevent calculus
formation in recumbent patients, who frequently
have urinary infections, especially
in tropical countries.

SUPRAPUBIC PUNCTURE
Bladder puncture may become necessary if urethral
catheterization fails. It is essential that the bladder is
palpable if a suprapubic puncture is to be performed.
Technique
1
2

Assess the extent of bladder distension by

inspection and palpation.
If you are proceeding to suprapubic puncture
immediately after catheterization has failed,
remove the perforated sheet that was used to
isolate the penis and centre the opening of a new
sheet over the midline above the pubis.
Make a simple puncture 2 cm above the
symphysis pubis in the midline with a wide-bore
needle connected to a 50 ml syringe. This will
afford the patient immediate relief, but the
puncture must be made again after some hours if

the patient does not pass urine.

It is preferable to perform a suprapubic puncture
with a trochar and cannula, and subsequently to
insert a catheter. Raise a weal of local
anaesthetic in the midline, 2 cm above the
symphysis pubis, and then
continue with deeper infiltration (Figure 9.7).
Once anaesthesia is accomplished, make a
simple puncture 2 cm above the symphysis pubis
in the midline with a wide bore needle.
Introduce the trochar and cannula and advance
them vertically with care (Figure 9.8). After
meeting some resistance, they will pass easily
into the cavity of the bladder, as confirmed by
the flow of urine when the trochar is withdrawn
from the cannula.

Figure 9.7

Figure 9.8
5

Introduce the catheter well into the bladder

(Figure 9.9). Once urine flows freely from the
catheter, withdraw the cannula (Figure 9.10).

Figure 9.9

Figure 9.10
6

Fix the catheter to the skin with the stitch used

to close the wound and connect it to a bag or
bottle. Take care that the catheter does not
become blocked, especially if the bladder is
grossly distended. If necessary, clear the catheter
by syringing with saline.

This type of drainage allows later investigation of the

lower
urinary
tract,
for
example
by
urethrocystography, to determine the nature of any
obstruction.
SUPRAPUBIC CYSTOSTOMY
The purpose of suprapubic cystostomy is:
::
::
::

To expose and, if necessary, allow exploration of

the bladder
To permit insertion of a large drainage tube,
usually a self-retaining
catheter
To allow suprapubic drainage of a non-palpable
bladder.

Technique
1

If the patient is in poor condition, use a local

anaesthetic, for example, 0.5% to 1% lidocaine
with epinephrine (adrenaline) for layer-by-layer
infiltration of the tissues. Otherwise, general
anaesthesia is preferable. See page 14 4 for
dose calculation.
Place the patient supine. Centre a midline
suprapubic incision 2 cm above the symphysis
pubis (Figure 9.11) and divide the subcutaneous
tissues. Achieve haemostasis by pressure and
ligation

Figure 9.11
3

Open the rectus sheath, starting in the upper

part of the wound. Continue dissection with
scissors to expose the gap between the muscles
(Figure 9.12). In the lower part of the incision,
the pyramidalis muscles will obscure
this gap. Finally, expose the extraperitoneal fat.

Figure 9.12
4

Carry the incision in the linea alba down to the

pubis, splitting the pyramidalis muscles. With a
finger, break through the prevesical fascia
behind the pubis; then sweep the fascia and
peritoneum upwards from the bladder surface
(Figure 9.13). Take care not to open the
peritoneum.
The distended bladder can be recognized by its
pale pink colour and the longitudinal veins on its
surface. On palpation, it has the resistance of a
distended sac. Insert a self-retaining retractor to
hold this exposure.

Figure 9.13
5

Insert stay sutures of No. 1 absorbable suture

into the upper part of the bladder on either side
of the midline (Figure 9.14). Puncture the
bladder between the sutures and empty it by
suction (Figure 9.15). Explore the
interior of the bladder with a finger to identify
any calculus or tumour (Figure 9.16). Note the
state of the internal meatus, which may be
narrowed by a prostatic adenoma or a fibrous
ring.

Figure 9.14

Figure 9.15

Figure 9.16
6

If the bladder opening must be enlarged to allow

you to remove a loose stone, open it 12 cm,
inserting a haemostatic stitch of 2/0 absorbable
suture in the cut edge, if necessary. Close the
extended incision partially with one or two
stitches of No. 1 absorbable suture, picking up
only the
bladder muscle. Inspect the interior of the
bladder for retained swabs before you introduce
the catheter.

For insertion of the catheter, hold the edges of

the incision with two pairs of tissue forceps,
making sure that the mucosa is included so that
the catheter does not slip beneath the mucosa
(Figure 9.17):
If you are using a de Pezzer catheter, stretch its
head with forceps and introduce the catheter
into the bladder between the two pairs of tissue
forceps
If you are using a Foley catheter, introduce it
into the bladder and inflate the balloon.

Figure 9.17
8

Insert a purse-string 2/0 absorbable suture in

the bladder muscle to ensure a watertight
closure around the tube or, if you have made an
extended incision in the bladder, secure the
catheter with the final stitch needed to
close the incision (Figure 9.18).

Figure 9.18
9

If drainage is to be continued for a long period,

fix the bladder to the abdominal wall so that the
catheter can be changed. Otherwise, omit this
step to allow more rapid healing of the bladder
wound. To fix the bladder, pass the traction
stitches in the bladder wall out through the
rectus sheath
(Figure 9.19). Tie them together after closing this
layer.

Figure 9.19
10 Close the linea alba with 0 absorbable suture and
the skin with 2/0 nonabsorbable suture (Figure
9.20). Connect the tube to a sterile, closed
drainage system. Dress the wound every second
day until it is healed.

Figure 9.20