The ischuria of paradox. What is urinary retention? Prognostic value of ischuria

Description:

Ischuria - the inability to empty the bladder independently - is one of the most common reasons for emergency hospitalization of patients in a hospital. There are acute and chronic, complete and incomplete urinary retention.

With incomplete urinary retention, a certain amount of urine (more than 20 ml) remains in the bladder after urination. Residual urine can be detected by insertion of a catheter or by X-ray, radioisotope renography and ultrasound. Incomplete urinary retention often becomes complete, especially in patients with adenoma, prostate cancer or stricture of the urethra, as well as in children with various congenital diseases of the vesicourethral segment.

Acute urinary retention occurs suddenly, as if in the midst of complete well-being, for example, when a stone or polyp on a long stalk enters the urethra with a stream of urine.

Symptoms:

Diagnosis of acute urinary retention does not cause difficulties (inability to empty the bladder independently, acute bursting pain in the lower abdomen). On examination, a spherical protrusion above the pubis is detected, especially clearly defined in thin patients and children. Palpation reveals a dense elastic formation above the pubis.

Causes:

Acute retention can be caused by trauma to the urethra or a foreign body. It also develops against the background of chronic urinary retention. The causes of urinary retention can be divided into two groups:

   1. Pathological changes in the urinary organs or their compression:
            1. Traumatic injuries (trauma, crushing, separation of the urethra).
            2. Blockage of the lumen of the urethra:
                     1.at the level of the vesicourethral segment (unilateral or bilateral ureterocele, stone, polyp, bladder, congenital obstruction of the vesicourethral segment);
                     2.at the level of the urethra (valve, diverticulum, foreign body, stone, tumor, post-inflammatory).
            3. Compression of the urethra by pathologically altered organs of the genitourinary system (with adenoma, cancer, cyst, abscess, prostate sclerosis, prostatitis, phimosis, paraphimosis, balanoposthitis).
            4. Compression of the urethra by pathologically altered organs of the pelvic cavity (rectal cancer, uterine tumors, inguinal hernias, hypogastric artery, perineum, etc.).
   2.Diseases nervous system(neurogenic bladder dysfunction).

The causes of disruption of the processes of contraction and relaxation of the detrusor and vesicourethral segment include tumors, inflammatory diseases, spinal cord and brain injuries, spinal cord hernias, and disruption of the peripheral innervation of the bladder after surgery on the pelvic organs. This group of causes also includes reflex retention of urination after surgery, childbirth, or spinal cord. At the same time, it must be remembered that not everyone healthy man may urinate in a horizontal position.
When the urethra is compressed or its lumen is obstructed, urination becomes more frequent and the contractility of the detrusor increases. There is uneven hypertrophy of the bladder muscles, resulting in the so-called trabecular bladder. This is the elevation of individual muscle fibers above the surface of the mucous membrane of the bladder. With detrusor hypertrophy, blood circulation and trophism of the bladder are disrupted, and false and true diverticula can occur. The amount of residual urine increases, and subsequently complete urinary retention occurs. If the cause that disrupts the outflow of urine is not eliminated, paradoxical ischuria occurs. In this case, urine, having overcome the stretched vesicourethral segment, regardless of the will of the patient, is constantly released in drops from the urethra, that is, against the background of complete urinary retention, urination is observed. Bladder rupture is possible in patients who are intoxicated, due to blows to the bladder area, or falls. With complete and incomplete retention of urination, all conditions arise that contribute to the development of the inflammatory process in the bladder -. In the initial stages, the mucous membrane is involved in the inflammatory process, and later - the submucosal, muscular and all layers of the bladder. This development of the inflammatory process is especially often observed in patients with damage to the brain and spinal cord.

In most cases, the reasons that cause urinary retention also cause a violation of the outflow of urine from the kidneys. A good example is patients with prostate adenoma. Hypertrophied paraurethral glands simultaneously compress both the urethra and the orifices of the ureters. The radiograph reveals a narrowed lumen of the elevated distal ureter. It has the shape of a fishhook, and in these cases, the disruption of the outflow of urine from the ureters is caused by the pressure of both the adenomatous nodes themselves and urine, a large amount of which is in the bladder. In patients with prostate adenoma, paradoxically, it may also occur, which is also typical for children with contractures of the vesicourethral segment, hydronephrosis and megadolihoureter.

Impaired urine outflow from the kidneys, vesicoureteral, and subsequently renal pelvic reflux disrupt microcirculation, reduce the level of glomerular filtration and tubular reabsorption and create conditions for the penetration of ascending infection and the occurrence of pyelonephritis. Moreover, under these conditions, serous quickly turns into purulent (apostematosis, carbunculosis) and leads to kidney death, urosepsis and renal failure.

Patients with prostate adenoma already in the 1st stage (when the person is practically healthy) have pyelonephritis and latent. Patients with long-term untreated urinary retention usually die from renal failure and urosepsis.

Treatment:

Treatment of patients with urinary retention includes two aspects. This is the removal of urine from the bladder and the elimination of the causes that caused urinary retention. Patients with acute urinary retention and those suffering from incomplete urinary retention for a long time, weakened chronic pyelonephritis And renal failure, require immediate removal of urine from the bladder. Emptying the bladder can be accomplished by catheterization, suprapubic capillary puncture, trocar cystostomy, and epicystostomy.

The most common method of excreting urine is. It is carried out under aseptic conditions. In order to prevent inflammatory processes and urethral fever, antibiotics are prescribed. For catheterization of the bladder, metal and rubber catheters are used. Position the patient on his back, preferably in a gynecological chair. The doctor stands near the couch or chair on the right side. With three fingers of the left hand he takes the penis by the head, with his right hand he inserts the catheter into the urethra, pulling the latter onto the instrument to the external sphincter of the bladder. Then the penis, together with the catheter, is brought to the anterior abdominal wall and gradually lowered down towards the scrotum. At this moment, overcoming the slight resistance of the vesicourethral segment, the catheter enters the bladder. The use of a metal catheter, especially in the absence of skills, does not eliminate the danger of the formation of false passages in the urethra and prostate gland, which can lead to the development of urethral fever, orchiepididymitis, and urinary leakage. It is safer to insert Nelaton and Timan rubber catheters into the urethra. The latter has a beak-like bend at the distal end and passes better along the posterior wall of the urethra into the bladder. The advantage of rubber catheters is that they can be left in the urethra for 2-3 days, and sometimes up to 2 weeks. The presence of mucus, blood, pus, and salts in the urine makes it difficult to drain the bladder with a catheter, especially when left in place for a long time.

Complications of catheterization. Even with a single catheterization, infection of the lower urinary tract (urethritis, cystitis), microtrauma of the mucous membrane of the urethra is possible, which can lead to the development of pyelonephritis and urosepsis. Catheterization, especially metal catheter, can cause urethrorrhagia, which forces you to abandon the attempt to empty the bladder.

Contraindications to catheterization: trauma to the urethra, acute.

The second way to remove urine from the bladder during urinary retention is capillary puncture of the bladder, which is performed by patients in cases where insertion of a catheter is impossible or contraindicated. It is advisable to carry out capillary puncture of the bladder in patients with stage 2 prostate adenoma (complete urinary retention) for the purpose of examining and deciding on the advisability of performing a simultaneous adenomectomy. The bladder is punctured above the pubis, 1-2 cm away from the midline. The puncture can be performed 2-3 times a day.

Complications of capillary puncture. According to many authors, during capillary puncture, extensive urinary leaks are observed, especially in patients with a thin bladder wall. Capillary puncture is difficult in overweight individuals. It is ineffective if there are blood clots, pus, salts, etc. in the urine.

Suprapubic epicystostomy. The operation has been used for a long time and the technique for performing it is well known. A suprapubic vesical fistula is formed, providing sufficient drainage of the bladder using a Petzer, Foley catheter, and rubber drains. Being relatively small in volume and less traumatic, cystostomy is nevertheless difficult to tolerate in weakened and elderly patients, who often have concomitant diseases.

Noteworthy is drainage of the bladder by suprapubic puncture with a trocar leaving a rubber catheter. The puncture technique is simple, painless, low-traumatic and does not require special conditions. It can be performed in the dressing room or ward. Anesthesia is administered along the midline of the abdomen 2 cm above the palpable symphysis pubis, the skin is incised and a trocar is inserted from front to back and slightly downwards. The small diameter of the tube and significant contraction of the bladder with displacement lead to the bladder sliding off the drainage. The tube may be bent, salts may be deposited in it, which interferes with the flow of urine. Urinary leakage and paracystitis occur. Currently, one- and two-way trocars are produced, which are used to fix the bladder and simultaneously wash it. A detachable tube-trocar (two half-tubes up to 130 mm long and 8 mm in diameter) has been developed. When a trocar is inserted, these half-tubes are moved apart, after which a Petzer catheter is inserted. The advantages of this method are the following: the catheter itself is held in the bladder, it is elastic, its lumen has a larger diameter, which creates more favorable conditions for drainage of the bladder.

With constant and prolonged drainage of the bladder, the stretch reflex is impaired. The bladder detrains and irreversible changes develop in its intramural nervous system, which causes a decrease and even complete loss of the functional ability of the detrusor.

The presence of infection and prolonged unimpeded outflow of urine causes the formation of a small, wrinkled bladder, which loses the elasticity so necessary for its normal functioning. Therefore, the bladder must be constantly washed with antiseptics, periodically filled and retained in it. In 1935, Monroe and Guy proposed an automatic bladder filling and emptying device.

Urinary retention or ischuria is not a disease. This is a symptom complex caused by the inability to urinate. The accumulation of urine in the bladder reaches a liter or more. The person experiences strong urges and pain, but cannot urinate on his own.

The situation occurs more often in men, in women - much less often. It is impossible to cope with it on your own. The administration of antispasmodic drugs is ineffective. The greatest difficulties in diagnosis are caused by paradoxical ischuria. It is manifested by bladder overflow and spontaneous urine leakage. Residual urine creates a feeling of incomplete emptying.

What types of ischuria do doctors take into account?

Types of ischuria differ according to the clinic. Based on the remaining ability to urinate, the following are distinguished:

complete ischuria - the patient, even with the help of the abdominal muscles and straining, cannot excrete urine; excretion is possible only with a catheter;
incomplete – there is partial outflow, but a large volume of residual urine (up to a liter) always remains.

By length of delay:

acute – occurs against the background of normal urination, suddenly, in the form of an attack;
chronic – occurs unnoticed by the patient and is detected only when signs of complications caused by prolonged stagnation appear (cystitis, pyelonephritis).

Based on the totality of these manifestations, the following clinical course options are observed in practice. Acute complete ischuria is characterized by a sudden development, the outflow of urine is stopped. The patient has complaints:

to paroxysmal acute pain above the pubis;
strong urge to urinate.

Upon examination, a roller-like protrusion in the lower abdomen and pain in the bladder area are revealed. The condition should not be confused with anuria, in which there is no urine in the bladder due to impaired filtration function of the kidneys. Therefore, there is no painful urge to urinate.

Acute incomplete – also develops quickly, but urine is excreted in small portions and complete emptying does not occur. Patients constantly have heaviness in the lower abdomen, periodically turning into severe pain. Chronic complete – as a consequence of a long-term disease, it develops over a month or several years. Urine is removed only by a catheter.

The most common cause of chronic ischuria in men is prostatic hyperplasia

Chronic incomplete - emptying occurs at 20% of the required volume. The remaining urine must be removed with a catheter. Acute forms often come under the influence of urologists. Paroxysmal pain forces patients to consult a doctor. Urine excretion and subsequent diagnosis make it possible to find out the cause, apply the optimal treatment method and prevent complications.

Unfortunately, in chronic forms, the diagnosis is made in an advanced state, against the background of severe inflammation, kidney damage, and sepsis.

Causes and mechanism of occurrence

The factors that provoked ischuria are very diverse. Mechanical – for diseases that compress the urinary tract or become a barrier to the flow of urine:

prostate adenoma in men;
neoplasms;
polyps;
blockage of the urethral canal by blood clots due to injuries, hematuria;
urethral adhesions;
phimosis and paraphimosis;
stones in the neck of the bladder.

Possible compression due to neighboring organs (tumor growth, abscesses); in children, outflow disturbance due to congenital anomalies.

Neurogenic – include diseases of the nervous system:

brain tumors;
consequences of stroke;
myelitis;
traumatic injury to the spinal cord.

Functional and reflex – these include:

postoperative complications in the form of innervation disturbances;
emotional arousal;
consequences of difficult childbirth in women;
conditions associated with prolonged bed rest, uncomfortable posture for urination;
toxic effect of sleeping pills, alcohol, drugs, atropine compounds, a group of ganglion blockers;
reaction to pain, shock;
effects of anesthesia;
mental changes (hysteria) with spastic contraction of the urethral muscles.

The main role in the mechanism of development of ischuria is played by:

increased resistance to urine flow;
decreased contractility of the bladder expulsion muscle (detrusor).

Resistance increases against the background of mechanical obstruction to outflow. An increase in pressure inside the bladder leads to its overstretching, subsequent dystrophic changes and the replacement of muscle fibers with connective tissue.

Neurogenic disorders cause a decrease in detrusor tone when the sphincters of the bladder neck and urethra are activated.

Paradoxical ischuria often develops with prolonged chronic course diseases. IN in this case there is a combination of loss of detrusor and urethral sphincter tone. Therefore, urine is “passed” through the canal in drops.

How is diagnosis carried out?

To confirm the fact of ischuria, it is necessary to find out from the patient or his relatives how the pathology developed, whether there are any diseases of the urinary organs, ask about previous injuries, diseases of the nervous system or mental disorders.

Protrusion of the bladder is visible when examining the abdomen

The upper border protrudes above the womb. A soft, tense formation is palpated. Due to the constant urge, patients are very restless and complain of pain. It is necessary to assist the patient and remove urine with a catheter. To prevent increased urethral spasm, antispasmodic drugs (Atropine, Platyphylline) are administered before the procedure. It is rarely necessary to use puncture and suction with a syringe.

The next step is to find out the cause of ischuria. To do this, the patient must undergo a complete examination by a urologist. Women are required to consult a gynecologist with bimanual palpation of the uterus and appendages. Men are examined through the rectum by a urologist and the prostate is palpated.

List of necessary studies:

A urine test will reveal the inflammatory process and its causative agents. In case of bacteriuria, a study using the tank method is prescribed. sowing
A blood test can indirectly judge the activity of the inflammatory process; biochemical tests for residual nitrogen, protein, and electrolytes help establish initial stage renal failure.
Cystoscopy is a method of viewing the inner surface of the bladder. The urologist examines the orifices of the ureters, neck, and triangle area. Polyps and tumors are most often localized in them. If malignant growth is suspected, material is taken for a biopsy.
Contrast research methods involve the injection into a vein (excretory) or into the bladder (retrograde) of a dye that is visible on subsequent x-rays. In this way, developmental anomalies, tumor growth, and dysfunction are detected.
Ultrasound abdominal cavity helps check neighboring organs.
TRUS is a necessary method to determine the size of the prostate gland in men.

May need long-term conservative treatment or surgery to remove a tumor, adenoma, congenital anomaly, or other mechanical obstruction.

Stagnation of urine in the bladder spreads higher, the ureters and pelvis expand

What are the possible complications?

The patient’s refusal to undergo examination is fraught with a recurrence of the attack of acute delay or transition to a chronic course. Serious consequences of missing treatment can be:

the development of chronic inflammatory diseases of the urinary organs (pyelonephritis, glomerulonephritis, cystitis) due to the high probability of infection of residual urine and reflux into higher structures;
significant expansion of the renal pelvis (hydronephrosis) with compression of the parenchymal tissue of the kidney;
accelerated formation of stones from salt sediment with attacks of urolithiasis, blood in the urine;
chronic failure kidney

Ishuria can be eliminated without a trace initial stage. Due to complications, ongoing treatment will be required chronic diseases, and urinary retention will have to be dealt with only by catheterization or surgery.

ISHURIA (ischuria; Greek, ischo retain + uron urine; syn.: urischesis, retentio urinae) - urinary retention, inability to empty the bladder; a symptom of a wide variety of diseases. More common in men, less common in women and children.

There are the following types of I.: 1) acute complete, occurring suddenly and accompanied by pain and the urge to urinate; 2) acute incomplete, when urine is released in drops from a full bladder (paradoxical I.); 3) chronic complete, when urination is impossible and urine is released with a catheter; 4) chronic incomplete, when the patient urinates, but the bladder does not empty completely.

Acute forms of I. are extremely painful for the patient, quickly bring him to the doctor and are therefore less dangerous than chronic forms, which often proceed unnoticed, do not attract the patient’s attention and are detected at an advanced stage, when urinary intoxication occurs. At first, I. is not accompanied by a urinary tract infection, but it soon follows, especially after catheterization. The infection aggravates the course of I., its elimination is possible only after the complete restoration of urination.

Etiology

Acute incomplete I. is observed in diseases and damage to the nervous system (cerebral hemorrhages, fractures and gunshot wounds spine with spinal cord damage), tuberculous spondylitis, tabesa, hysteria and multiple sclerosis; can develop during severe diseases, including infectious diseases (typhoid, malaria), during inflammatory processes, for example. for peritonitis, inflammation of hemorrhoids, adnexitis, for neoplasms located in the pelvis along the urethra. Acute complete I. is the main symptom of injury to the urethra or bladder. With gonorrheal and traumatic strictures of the urethra, I. is observed periodically, in attacks, which are usually associated with sexual intercourse or the introduction of a bougie. In the latter case, I. occurs several hours after bougienage due to swelling of the mucous membrane at the site of narrowing. When the urethra is blocked by a foreign body or stone, acute complete I. is possible.

I. most often occurs in men with diseases of the prostate gland (adenoma, cancer). Acute complete I. with prostate adenoma can be the first symptom of the disease, appearing suddenly, without any warning signs. In the chronic version of the disease, the patient complains for a long time about difficulty urinating (chronic incomplete 11. .

Sometimes I. develops after surgery or childbirth. The ethnology of this form of I. is diverse and is determined by the nature and localization of the operation: on the perineum, rectum, in the abdominal cavity, large and small pelvis, and on the genitals. Postoperative I. is also associated with the nature of pain relief, appearing more often after spinal anesthesia. The main cause of I. after childbirth is detrusor atony, which developed due to injury to the bladder during delivery, and labor pain, as well as injury to the hypogastric nerves during the passage of the fetal head through the birth canal.

Clinical manifestations

In case of acute complete urinary retention due to diseases of the prostate gland (abscess, adenoma, cancer), as well as in case of I. due to stricture or injury, patients are restless, do not find rest, experience pain in the suprapubic region with frequent strong urges, and try unsuccessfully to release urine , taking various positions. In the suprapubic region, examination reveals a bulge associated with an overfilled bladder (Fig. 1).

With urinary retention due to c. n. With. the urge to urinate is either absent or weakly expressed; the patient is completely calm, despite significant overflow of the bladder. During the examination, one or another neurol syndrome is revealed. There may be paresis, both spastic and flaccid, with a corresponding increase or decrease in tendon reflexes and muscle tone, as well as a sensitivity disorder of a predominantly conductive nature. I. in diseases of the nervous system is accompanied by simultaneous difficulty in bowel movement.

Diagnosis

Complete acute and complete chronic, urinary retention is easily diagnosed. It is more difficult to identify incomplete I. It is necessary to determine the cause of the delay, since the choice of method depends on this emergency care.

Incomplete urinary retention can be recognized by the presence of a significant amount of residual urine (more than 300 ml), as determined by catheterization performed immediately after urination. Residual urine is also determined by administering radioisotope drugs, which are excreted by the kidneys and remain in the bladder along with residual urine after urination.

In all forms of hron, urinary retention, the muscular wall of the bladder hypertrophies compensatoryly, which leads to the formation of trabecularity visible during cystoscopy, and sometimes diverticulosis. In cases of atony of the bladder, atrophy of its mucous membrane and muscle layer usually develops (Fig. 2).

Differential diagnosis should be carried out with anuria (see), when there is no urge to urinate, percussion examination of the suprapubic region and catheterization in the bladder does not detect urine. Tumors in the suprapubic region may simulate a full bladder; in these cases, the issue is resolved after emptying the bladder with a catheter.

Treatment

Emergency assistance for various types I. consists of removing urine with a catheter, using a suprapubic puncture or applying a suprapubic fistula (see Cystostomy). The method of emptying the bladder depends on the disease that caused I.

When treating postpartum and postoperative I., the main task is to remove urine without resorting to catheterization. Sometimes the urge to urinate is caused by the sound of water flowing from a tap; Irrigation of the external genitalia with a stream of warm water is also used. Subcutaneous administration of proserin (1 ml of 0.05% solution) has a good effect. Catheterization (see) should be carried out aseptically; indicated when these remedies do not lead to a positive result. If repeated catheterization is necessary, the bladder cavity should be rinsed with a disinfectant solution (rivanol solution 1:2000 or Furacilin solution 1:5000). At the same time, chloramphenicol, nitrofuran derivatives (furadonin, furagin, furazolidone) or negro are prescribed orally to prevent cystitis and pyelonephritis.

Prognostic value of ischuria

Chron. I. is accompanied by changes in urodynamics in the upper urinary tract, impaired renal function and can lead to the development of urosepsis.

Table “The most common causes of urinary retention, their nature, associated clinical signs and therapeutic measures”

Cause of urinary retention	The nature of urinary retention	Associated clinical signs	Therapeutic measures
Urinary retention due to developmental defects, injuries and diseases of the genitourinary system
Malformations (at-resia, valves and strictures of the urethra, phimosis)	Acute or chronic, characterized by absence of urination or dribbling of urine	Restless behavior of the newborn, fluctuating swelling in the suprapubic region, with phimosis - narrowing of the foreskin	For urethral atresia - epicystostomy (imposition of a suprapubic fistula), for phimosis - dissection of the foreskin, for congenital urethral valves - catheterization of the bladder followed by transurethral electroresection or electrocoagulation of the valves, for narrowing of the external opening of the urethra - meatotomy (dissection), for strictures and obliteration of the urethra in a small area - bougienage and tunnelization using a permanent catheter; for extended strictures - plastic surgery
Trauma to the urethra (as a result of damage to the pelvic bones, a fall on a hard object)		Discharge of blood from the urethra, perineal hematoma. With retrography, radiopaque substance flows beyond the urethra	Epicystostomy, with a fresh injury and satisfactory general condition of the victim - primary urethro-urethroanastomosis or primary urethral suture. As an emergency (before hospitalization), capillary puncture of the bladder or trocar epicystostomy may be required
Strictures of the urethra of traumatic or inflammatory origin	Chronic (against its background, acute urinary retention may occur or paradoxical ischuria may develop - involuntary dropwise release of urine from a full bladder)	Scars in the area of the urethra, as well as outside it and above the pubis, an obstacle to the passage of the catheter. With urethrography - single or multiple narrowing of the urethra	Bougienage; for strictures that are not passable for bougies - epicystostomy and plastic surgery on the urethra
Stones, foreign bodies of the urethra	Acute (with a sudden interruption of the stream during urination)	In case of urolithiasis, urinary retention is preceded by renal colic and dysuria. Hematuria is noted after exercise; purulent or serous-bloody discharge from the urethra. Sometimes a stone or foreign body can be felt through the wall of the urethra; they can also be detected with plain and contrast cystography	If stones are located in the scaphoid fossa - meatotomy; stones and foreign bodies of the posterior urethra can be pushed with a bougie into the bladder, crushed using a cystolithotripter and removed piece by piece; if the stone is in the perineal urethra for a long time - epicystostomy
Malignant tumors urethra	Chronic (difficulty urinating with a gradual thinning of the stream)	Bloody issues from the urethra; upon palpation - compaction along the urethra. Urethrography shows a filling defect; biopsy shows signs of a tumor.	On early stages- resection of the urethra followed by radiation therapy, in case of common processes - extended operations in combination with radiation therapy, in inoperable cases - epicystostomy
Acute prostatitis and prostate abscess		Pain in the perineum, anus. With a rectal digital examination, the entire prostate gland or one of its lobes is enlarged; with an abscess, there are areas of compaction and fluctuation; its palpation is extremely painful. There is an increase in temperature (sometimes hectic type)	Trocar or capillary cystostomy* anti-inflammatory therapy
Prostate adenoma	Acute or chronic. With chronic retention, frequent, difficult urination in a thin sluggish stream, nocturia are noted, and paradoxical ischuria may develop	A rectal digital examination reveals an enlarged, rounded prostate gland with a smoothed groove, smooth surface, clear boundaries, and elastic consistency; Pneumocystography reveals the shadow of an adenoma protruding into the lumen of the bladder	In case of acute urinary retention - catheterization of the bladder with a rubber catheter (preferably a Thiemann catheter), if there is difficulty - with an elastic catheter made of a harder material or a metal catheter; if catheterization is ineffective - suprapubic puncture or trocar cystostomy. In case of acute urinary retention and absence of independent urination for 5-7 days - epicystostomy. For chronic urinary retention - adenomectomy
Prostate cancer	Chronic, with gradually increasing difficulty urinating and thinning of the urine stream, leading to paradoxical ischuria; rarely - acute	A rectal digital examination reveals uneven enlargement, dense consistency, lumpy surface, unclear boundaries of the prostate gland, infiltration of surrounding tissue and seminal vesicles	Epicystostomy followed by radical combined treatment of the tumor or transurethral electroresection of the prostate gland
Contracture (sclerosis) of the bladder neck	Chronic, with gradually increasing difficulty urinating, urine output in a thin, sluggish stream	On rectal digital examination, the prostate gland is not enlarged; when passing the catheter, an obstacle in the neck of the bladder is overcome; Cystoscopy reveals pallor and rigidity of the posterior semicircle of the bladder neck	Catheterization of the urethra, transurethral resection or plastic surgery of the bladder neck
Bladder injury (transport or as a result of a fall from a height, a blow to the suprapubic area, pelvic bone fractures	Lack of urination due to leakage of urine from the damaged bladder into the abdominal cavity or peri-vesical tissue	When you have the urge to urinate, a few drops of bloody urine are released. During catheterization, the catheter passes freely into the bladder, the urine is bloody; with cystography - leakage of radiopaque substance into the free abdominal cavity or into the peri-vesical space	In case of bladder injuries with peritoneal rupture - urgent laparotomy and suturing of the bladder wall with a double-row cat-gut suture; for bladder injuries without peritoneal rupture - epicystostomy, suturing of the bladder wall; mandatory drainage of the bladder and peri-vesical tissue
Stones, foreign bodies of the bladder	Acute (often with sudden interruption of the urine stream during urination)	Urinary retention is usually preceded by a period of dysuria, hematuria when walking and physical activity, pyuria. Cystoscopy or cystography reveals stones and foreign bodies	For bladder stones - catheterization. Subsequently, cystolithotripsy may be performed; if cystoscopy is impossible or stone crushing fails, cystolithotomy is performed; small soft foreign bodies are removed using an operating cystoscope or cystolith-triptor
Bladder tumors	Acute (urinary retention may occur during profuse hematuria due to bladder tamponade with blood clots)	Recurrent hematuria. With rectal and bimanual palpation, a tumor can be felt; with cysto- and pericystography - filling defect and infiltration of the bladder wall; Cystoscopy reveals a tumor	Depending on the extent of the process - bladder catheterization, cystostomy, pyelonephrostomy or ureterocotaneostomy
Compression of the urethra and bladder neck by a tumor or inflammatory infiltrate emanating from adjacent organs and tissues	Chronic, sometimes acute	The presence of a tumor of the cervix, rectum. With paraproctitis - high temperature, pain in the perineum and rectum, with rectal digital examination - dense painful infiltrate in the pelvis	Catheterization of the bladder or (depending on the extent of the tumor process) epicystostomy, ureterocutaneostomy, nephrostomy
Neurogenic urinary retention
Lesions of the brain and spinal cord of various origins	Acute; for slowly developing lesions (tabes dorsalis, spinal cord tumor, syringomyelia, etc.) - chronic; paradoxical ischuria or a reflex (uncontrollable) act of urination may develop	Signs of disturbance of the motor and sensory innervation of the lower half of the body (decrease in all types of sensitivity, bedsores, changes in gait, deformation of the legs and feet, defecation disorders) and other symptoms of c. n. With.	Periodic catheterization of the bladder with an elastic catheter, electrical stimulation of the bladder (transrectal, radiofrequency), blockade of the pudendal nerves, transurethral electroresection of the bladder neck, reinnervation
Disturbances of the peripheral innervation of the bladder (primary atony or atony and areflexia that occurred after extended operations on the pelvic organs - extended hysterectomy, rectal extirpation)	In case of primary atony of the bladder - chronic, after extended operations on the pelvic organs - acute or chronic	Sometimes there is a violation of the sensitivity of the skin of the perineum and around the anus - in the innervation zones Siii-Siv (there are no symptoms of damage to the central nervous system); Cystoscopy and cystography reveal trabecularity of the bladder; residual urine is detected in the bladder	Periodic catheterization of the bladder (even in the presence of independent urination, it is necessary to release residual urine if its amount exceeds 50-100 ml), with frequent exacerbations of pyelonephritis and large amounts of residual urine - Monroe tidal system, electrical stimulation, transurethral resection of the bladder neck
Reflex urinary retention (postoperative, postpartum, with a forced long-term horizontal position, with trauma, hysteria)	Acute (should be differentiated from anuria, edges can occur in these conditions)	The bladder is full, the urge to urinate (in hysteria, this may be absent or mild)	Subcutaneous administration of proserine (1 ml of 0.05% solution) or strychnine nitrate (1 ml of 0.1% solution), irrigation of the genitals with warm water, a warm heating pad on the pubic area; if the above measures are unsuccessful - periodic catheterization of the bladder with an elastic catheter, presacral or pudendal novocaine blockades
Intoxication caused by alcohol, tranquilizers, drugs or other medicines, as well as severely leaking infectious diseases		Signs of intoxication (severe general condition of the patient, mental disorders, etc.). A full bladder is determined by palpation above the pubis	Periodic catheterization of the bladder with an elastic catheter, subcutaneous administration of strychnine, electrical stimulation until the patient’s general condition improves, accompanied by the restoration of independent urination
R. S. Simovsky-Veitkov; A. V. Livshits (neur.)

Bibliography: Balueva L.F. Urological complications of radical operations for rectal cancer, Urol, and nephrol., No. 4, p. 51, 1976; To water E.I. New way treatment of postoperative and postpartum ischuria, Klin, med., vol. 5, No. 2, p. 117, 1927; Persianinov L. S. Operative gynecology, p. 552, M., 1976; Pytel A. Ya, and P o-gorelko I. P. Fundamentals of practical urology, p. 484, Tashkent, 1969; Epstein I. M. and Glazer Yu. Ya. Determination of residual urine radioisotope method, Urol, and nephrol., No. 6, p. 19, 1965; G i b e r t J. et Perrin J. Urologie chirurgicale, P., 1958; Klinische Urologie, hrsg. v. G. E. Aiken u. W. Staehler, S. 281, Stuttgart, 1973; M i ch o n P. Les retentions d’urine, in the book: Traite path. Med., publ. sous la dir de E. Sergent e. a., t. 13, p. 433, P., 1923.

Y. V. Gudinsky.

Ishuria - pathological condition associated with the inability to independently empty the bladder of urine when it is full. The condition is painful for a person and may be accompanied by severe pain. Urinary retention occurs more often in males, less often in women and children.

The disease develops when the bladder becomes full of urine, but for various reasons its outflow becomes difficult. The combination of the urge to urinate and the inability to do so puts a person in a state of anxiety. The pathology should be differentiated from anuria - with anuria, urine stops being produced by the kidneys; with ischuria, urine simply does not leave the bladder.

Classification of ischuria according to the nature of the urinary disorder:

acute complete - develops unexpectedly, urine output stops abruptly, but the urge persists, the condition is accompanied by severe pain in the lower abdomen;
acute incomplete - urine is released from an overfilled bladder, but with great effort and meager portions;
chronic complete - the ability to independently empty urine is impossible, it is removed by drainage and catheterization;
chronic incomplete - a person can urinate on his own, but the urine is not released in full, the residual amount of urine can reach up to a liter;
Paradoxical ischuria is a special form in which a person cannot perform a full act of urination, the urinary tract is greatly distended by accumulated urine, and its release occurs spontaneously drop by drop.

The disease in its acute form is difficult to bear physically and emotionally - it is possible to develop psychological problems and fear of emptying the bladder. The chronic course is practically invisible to humans, and is often diagnosed in advanced stages.

Causes and symptoms of pathology

Ischuria occurs against the background of various diseases urinary system, injuries, stressful conditions. The main reasons leading to urinary retention:

formation of obstacles in urinary tract due to infectious, non-infectious, oncological diseases - adenoma, prostatitis in the acute stage, urolithiasis disease, phimosis, prostate and urethral cancer;
the presence of blood clots in the urinary canal;
injuries of the genitourinary organs;
decreased contractile functions of the bladder against the background of dystrophic degeneration of its muscle tissue;
surgical interventions, including the postpartum period in women;
reflexive inhibition of the urge to empty the bladder against the background of severe stress;
uncontrolled, long-term use of narcotic and sedative medications;
taking large doses of alcoholic drinks.

Prostate hyperplasia is often the cause of chronic ischuria in men.

Clinical picture

Manifestations of ischuria are varied and depend on the form. The most pronounced symptoms are in acute forms: the patient’s condition sharply worsens, an irresistible desire to urinate arises, but urine does not come out even with straining. The situation is aggravated by cutting pain in the lower abdomen. A spherical protrusion forms above the pubis, especially noticeable in thin people and children. Associated symptoms often develop: problems with bowel movements (constipation), loss of appetite, insomnia.

Chronic forms are characterized by vague symptoms or absence clinical signs. The patient may be disturbed by the feeling of incomplete emptying of the bladder, a feeling of heaviness in the lower abdomen, and frequent urination when the daily volume of urine excreted decreases.

In the chronic course of paradoxical ischuria, not only the urinary process is disrupted, but also the procedure itself. The patient is able to urinate, but this requires straining the abdominal muscles and pressing on the bladder area. Urine is excreted in a thin, often interrupted stream. The process takes a long time; emptying can take up to 10–15 minutes.

Bladder bulging is clearly visible during visual examination

Complications

People often ignore problems associated with urination, which leads to aggravation of the situation. If ischuria is not treated, sooner or later complications will appear:

activation of pathogenic microflora in the urinary organs and the development of cystitis, purulent pyelonephritis;
the appearance of stones in the bladder;
the appearance of a diverticulum (protrusion) in the walls of the bladder;
development of hydronephrosis;
acute and chronic kidney failure;
urosepsis - bacterial infection of the blood against the background of inflammatory processes in the urinary system;
complete atrophy of the bladder.

First aid

If signs of ischuria appear, it is important to promptly seek medical help. If it is not possible to obtain it, you can alleviate the patient’s condition by providing first aid. All actions should be aimed at relieving spasm and relaxing the muscle layer of the bladder:

the patient is given no more than 200 ml of cool water to drink; mint and linden blossom tea will be helpful;
apply a warm compress or heating pad to the lower abdomen;
The spasm can be relieved by introducing a suppository with belladonna extract or paraverine into the rectum;
if suppositories do not work, a warm bath with the addition of chamomile infusion will help you relax.

Diagnostics

Carrying out complex diagnostics for ischuria is carried out by organizing laboratory and instrumental studies. At the initial visit, the doctor clarifies the complaints and conducts a visual examination with palpation. In acute cases, before the examination, the patient’s bladder is emptied with a catheter or drainage system. In chronic cases, the examination is aimed at identifying the underlying disease that provoked urinary retention.

Reliable diagnostic methods for ischuria:

radiography of the urinary organs;
Ultrasound of the bladder and prostate in men;
cytoscopy (examination of the bladder with an endoscope);
invasive urodynamic methods (cystometry, profilometry).

Blood tests (general and biochemistry) and urine tests are required. Their results will show whether an inflammatory process is present in the body and how pronounced it is. Data from a general urine analysis (content of leukocytes, protein, flat casts, bacteria) will indicate inflammation in the kidneys and ureters. Based on the results of blood biochemistry, one can judge the presence of abnormalities in the functioning of the kidneys and the whole organism.

Treatment tactics

Treatment of acute forms associated with retention of urine in large volumes begins with catheterization. If ischuria occurs after surgery or childbirth, they try to empty the bladder using alternative methods - irrigation of the external genitalia with warm water, injection of novocaine into the urethra, intravenous infusion of methenamine. If ineffective, a catheter is inserted.

Therapy for ischuria includes:

prescribing antimicrobial drugs (Furagin, Levomycetin) to destroy pathogenic flora and prevent infectious complications during catheter insertion;
washing the bladder cavity with antiseptic solutions with furatsilin and rivanol for disinfection;
puncture (puncture) of the bladder;
cytoscomy (insertion of a tube to drain urine through the abdominal wall);
epicystostomy (a method associated with the formation of a suprapubic fistula to remove urine over a long period).

In some diseases, the treatment tactics for ischuria change:

for benign prostatic hyperplasia, first drug treatment, then empty the bladder from its contents with a catheter;
in the presence of prostate cancer, cytostomy is effective;
in patients with prostatitis in combination with ischuria, trocar cystostomy is used - puncture followed by installation of a permanent catheter;
therapy dosage form ischuria includes the complete abolition of medications with the prescription of safe analogues; catheterization in such a situation is carried out if necessary.

Preventive measures

Compliance with simple preventive measures will help avoid problems with urination.

Ischuria is a pathology characterized by a disorder of the normal process of emptying the bladder. This condition must be distinguished from one in which urine does not enter this organ at all.

A large number of predisposing factors can cause such a disorder, which is why it is customary to divide them into several large groups. In addition, urinary retention is affected by non-compliance with the recommendations of the attending physician regarding the use of medicines.

The correct diagnosis can be made on the basis of laboratory tests, but in addition, instrumental diagnostic measures and personal work of the clinician with the patient will be required.

Ishuria in women and men requires immediate medical care aimed at draining urine from the bladder. This is done using minimally invasive techniques or surgery.

As mentioned above, urinary retention can be caused by wide range predisposing factors that will differ not only in nature, but also depending on the patient’s gender. This is due to the fact that the urinary system in men and women is structured differently.

injury to the urethra, which implies a violation of the structural integrity of the urethra;
malignant or benign neoplasms of the urethra;
congenital or acquired anomalies in the development of the urinary canal - this should include the formation of the urethral valve, i.e. a small fold on the inner surface of the wall of this organ, as well as hypertrophy of the seminal tubercle - in this case, an increase in the size of the mound located in the posterior part of the urethra is observed;
tumors of various nature in the brain or spinal cord;
spinal cord injury;
pathologies that cause disruption of myelin secretion;
previous operations in the pelvic or peritoneal area;
severe emotional shock or fear;
drinking large quantities of alcoholic beverages, which leads to a state of severe alcoholic intoxication;
forced, i.e. prolonged immobilization due to a serious illness;
neurogenic bladder syndrome;
dystrophic degeneration of the muscular layer of this organ;
accumulation of a large number of blood clots in the bladder;
stones or sand or urethra.

Causes of urinary retention in men:

the formation of a benign tumor on the prostate gland, which is also called.
defeat .
the course of an acute inflammatory process in the prostate gland.
- this is a pathological condition in which a narrowing of the skin covering the head of the penis occurs, which prevents its exposure.

Female representatives are also characterized by the presence of specific predisposing factors. The causes of urinary retention in women are:

period of pregnancy;
complicated course of labor;
the formation of pathological tumors or;
partial or complete prolapse of the uterus from the vagina to the outside.

IN childhood This pathology is most often caused by:

entry of a foreign object into the lower tract of the urinary system.
fear to relieve minor need due to pronounced pain syndrome, which is often expressed with or.

In addition, this type of urination disorder can be caused by uncontrolled use of certain medications, namely:

narcotic medications;
psychoactive hypotonic drugs;
atropine-like substances;
sleeping pills.

Classification

Depending on the fullness of the bladder, urinary retention occurs:

complete – characterized by a sudden cessation of urine output when the bladder is full. Since self-emptying is impossible, a catheter is often used for this.
incomplete - the process of urine emission is carried out with pronounced difficulties. At the same time, the person feels pain and discomfort.

According to the nature of the course of ischuria, it happens:

acute - pathology develops over several hours from the moment of influence of one or another etiological factor. Patients feel a strong urge to urinate;
chronic - the patient can urinate on his own, but a large amount of urine remains in the bladder, which should not normally be the case. Urine volumes can vary from one hundred milliliters to several liters. In this case, patients do not feel strong urges.

A separate form is paradoxical ischuria - this is a condition characterized by the fact that the bladder is full, a person cannot relieve himself, but urine is spontaneously released in small drops.

Symptoms

The presence, as well as the degree of intensity of symptom expression, will differ depending on the form in which the pathology occurs.

For example, for acute ischuria, in addition to the inability to empty the bladder independently, the following clinical manifestations are characteristic:

severe pain syndrome;
the appearance of a kind of swelling in the lower abdomen, in the area of projection of the overfilled bladder. In the medical field, such a sign is usually called a trabecular bladder;
anxiety and irritability associated with the inability to empty the bladder when it is full.

In the chronic course of such a disease, the symptoms will not be as pronounced as for the acute course. In some cases, there is a complete absence of any signs other than the main one.

Diagnostics

Despite the fact that establishing the correct diagnosis is based on laboratory tests, they are preceded by primary diagnostic measures and complemented by instrumental studies.

The first stage of diagnosis is aimed at ensuring that the urologist:

studied the medical history and collected the patient’s life history - this will help to establish which etiological factor was the source of ischuria;
performed a thorough physical examination aimed at palpating the lower anterior abdominal wall. This will make it possible to detect a full bladder and differentiate ischuria from anuria;
interviewed the patient in detail to find out the first time of onset of the main symptom and additional symptoms. This will allow you to accurately determine the course of paradoxical, chronic or acute ischuria.

TO laboratory research worth mentioning:

– will indicate the occurrence of a pathological process in the body, which could cause urinary retention.
blood biochemistry - for possible detection of renal dysfunction. This will be indicated by a large number of end products of the protein metabolism process.
– is carried out for incomplete ischuria and allows you to identify signs of the inflammatory process in the kidneys.

The following instrumental diagnostic measures will help confirm the diagnosis and the causes of the pathology:

– to assess the volume and nature of the contents in the bladder;
and MRI - to detect pathological neoplasms in the urethra or bladder.

Treatment

When the diagnosis of ischuria is confirmed, immediate medical care is necessary, aimed at emptying the bladder.

Such events include:

taking alpha-blockers or cholinomimetics.
temporary installation of a flexible urethral catheter.
if it is impossible to carry out the previous manipulation, they resort to installing a thick or thin catheter.
bladder puncture - resorted to if it is not possible to perform any of the above procedures. The puncture is made on the midline, which is located at a distance of two transverse fingers above the pubic area.
trocar puncture - performed under local anesthesia and consists of making a vertical incision through all layers of the abdominal cavity. Its width should not exceed one centimeter. If the procedure is carried out correctly, a stream of urine will appear.
epicystostomy, or drainage of urine through a tube in the abdomen.
– carried out in severe cases.

Further treatment of ischuria is aimed at eliminating the cause of the pathology:

for prostate adenoma, the use of cholinomimetics and adrenergic blockers is indicated, after which the patient undergoes catheterization or cystostomy. Next, an operation is performed to remove the tumor;
in case of prostate cancer, it is necessary to perform a trocar cystostomy, open surgery or chemotherapy;
for ureteral strictures, catheterization is used;
In case of injuries, immediate surgical intervention is indicated;
with – catheterization followed by colporrhaphy;
for stones or sand in the bladder, catheterization and stone removal are used.

In any case, therapy will be individual.

Possible complications

Late diagnosis and treatment of ischuria is fraught with the development of the following complications:

chronic renal failure;
the occurrence of an inflammatory process in the kidneys or bladder;
bladder diverticulum;

Prevention and prognosis

To avoid the occurrence of such a disease, you must:

completely stop drinking alcoholic beverages;
avoid injuries to the genitourinary system;
prevent hypothermia of the body;
take medications only after being prescribed by a clinician - it is very important to follow the daily dosage and duration of use;
engage in early diagnosis and timely treatment of diseases that can lead to ischuria;
before undergoing a planned surgical operation, it will be useful to learn how to urinate in a horizontal position, especially for men;
undergo a full examination at a medical facility several times a year.

Since the symptoms of ischuria cannot be ignored, this disease has a favorable prognosis. However, we should not forget about the possible development of complications from those pathologies that caused such a violation of the urination process.