TABLE 913 Etiology of Outlet Obstruction

Most patients with bladder outlet obstruction are in distress, and passage of a urethral catheter alleviates both their pain and their urinary retention. Copious intraurethral lubrication must be used, and if attempts at passage of a straight 16F Foley catheter fail, a 16F Coudé catheter should be passed. Be certain to pass either catheter to its fullest extent, obtaining a free flow of urine, and only then inflate the catheter balloon. This will prevent balloon inflation in the prostatic urethra. If the catheter drainage holes become obstructed with lubricating jelly, gentle irrigation with sterile saline or water will quickly establish urinary drainage. Spontaneous, complete drainage of a distended bladder can be accomplished rapidly without the need for repeated clamping of the catheter. Occasionally, when a bladder has been chronically distended, bladder mucosal edema develops. Rapid decompression following catheter placement may result in transient gross hematuria. The transient hematuria is usually self-limited, of little consequence, and responds to orally induced diuresis. Postmicturitional or bladder decompression syncope is rare and should be treated symptomatically.

The catheter should be left indwelling and connected to a portable leg drainage bag. The patient or his family must be instructed in the care and drainage of this simple device. The initiation of antibiotic therapy depends on the presence or absence of infected urine and on the length of time catheter will be left indwelling. The patient or a family member should be instructed on Foley balloon deflation, should it become necessary to remove the catheter because of bladder spasms that are not responsive to oral anticholinergic medication.

If urinary retention has been chronic or insidious, postobstructive diuresis may occur secondary to osmotic diuresis or interstitial tubular dysfunction. Postobstructive diuresis may occur in the presence of normal BUN and creatinine levels and may become an emergency if the patient suddenly becomes hypovolemic or hypotensive without warning. Thus, close monitoring of urine output is essential, with appropriate fluid replacement. For these reasons, all patients with chronic or insidious obstructive voiding symptoms and urinary retention should either be observed for 4 to 6 h or be admitted, with particular attention paid to hourly intake, urinary output, vital signs, and urine and serum electrolytes. Osmotic diuresis will dissipate or the dysfunctional tubules will recover within 24 to 48 h. In all cases of urinary retention, consultation and follow-up with a urologist for a complete genitourinary evaluation are necessary.

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