My 35 year old patient with chronic alcoholism blames benign prostatic hypertrophy for his difficulty voiding. Could his bladder dysfunction be related to his alcoholism?

Several case reports in the literature have stressed the association of bladder dysfunction (BD) with chronic alcohol abuse1,2.  Although some cases may be associated with concurrent thiamine deficiency (with its attendant neuropathy), other cases of BD do not appear to be. The mechanism of BD in this setting may be related to the toxic effect of alcohol on peripheral, autonomic and/or central nervous systems2,3.

Binge drinking may also be associated with urinary retention, with spontaneous atraumatic urinary bladder rupture having been reported on several occasions4. Lastly, alcohol withdrawal alone may precipitate urinary retention5.  

Unfortunately, many cases of abdominal pain due to urinary retention in the setting of alcohol abuse or withdrawal may be mistakenly attributed to ascites or other causes5.  High index of suspicion for BD is essential to minimize its complications.

In our patient, given the low prevalence of benign prostatic hypertrophy in men less than 40 years of age, urinary retention due to alcohol-related BD is more likely.

 

References

  1. Yuan R, Carcciolo VJ, Kulaga M. Chronic abdominal distension secondary to urinary retention in a patient with alcoholism. JAMA 2002;287;318-19.
  2. Sheremata WA, Sherwin I. Alcoholic myelopathy with spastic urinary bladder. Dis Nerv Syst 1972;33:136-139.
  3. Mellion M, Gilchrist JM, De La Monte S. Alcohol-related peripheral neuropathy: nutritional, toxic or both? Muscle Nerve 2011;43:309-16.
  4. Muneer M, Abdelrahman H, El-Menyar A, et al. Spontaneous atraumatic urinary bladder rupture secondary to alcohol intoxication: a case report and review of literature. Am J Case Rep 2015;16:778-81.
  5. Iga J-I, Taniguchi T, Ohmori T. Acute abdominal distension secondary to urinary retention in a patient after alcohol withdrawal. Alcohol Alcoholism 2005;40:86-87.
My 35 year old patient with chronic alcoholism blames benign prostatic hypertrophy for his difficulty voiding. Could his bladder dysfunction be related to his alcoholism?

Is intermittent urethral catheterization preferred over continuous indwelling catheters for short-term management of urinary retention in my hospitalized patient?

For continuous urethral catheterization (CUC), the estimated daily risk of acquisition of bacteriuria is 3% to 8%1-3.  For intermittent urethral catheterization (IUC), the incidence of bacteriuria is 1% to 3% per insertion4. The Infectious Diseases Society of America recommends that IUC should be considered as an alternative to short-term CUC to reduce catheter-associated bacteriuria or UTI based on “poor evidence”  (Category C) and, as relates to symptomatic UTIs, without properly designed randomized-controlled studies2.  

A Cochrane systematic review of CUC vs IUC in hospitalized patients failed to find any significant differences between the 2 interventions as relates to the rates of symptomatic UTI and asymptomatic bacteriuria in hospitalized patients requiring short-term catheterization5.   Of interest, nearly 3 times as many people developed acute urinary retention with IUC compared to CUC in this study (16% vs 45%, respectively, RR 0.45, 95% CI 0.22-0.91).  

In short, despite its theoretical advantage in reducing the risk of UTIs due to lack of a constant presence of a catheter, solid data to support preference of ICU over CUC in short-term management of urinary retention in hospitalized patients is still lacking.

References

  1. Lo, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:464-78.
  2. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625-663.
  3. Kunin CM, McCormack RC. Prevention of catheter-induced urinary-tract infections by sterile closed drainage. N Engl J Med 1966;274:1155-61.
  4. Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med 1999;159:800-808.
  5. Kidd EA, Stewart F, Kassis NC, et al. Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterization in hospitalized adults (review). Cochrane Database of Systematic Reviews 2015; Issue 12. Art No. :CD004203.

 

 

 

Is intermittent urethral catheterization preferred over continuous indwelling catheters for short-term management of urinary retention in my hospitalized patient?

What is an abnormal post-void residual (PVR) volume?

Although measurement of PVR is a common everyday occurrence in hospitalized patients, the threshold of what constitutes an abnormal value is often poorly defined and not standardized. However, most urologists consider volumes of 50 mL to 100 mL to constitute the lower threshold of abnormal PVR (1). Large PVRs are reportedly associated with urinary tract infections, especially in persons at risk (e.g. diabetes, spinal cord injury), while PVRs >300 ml may be associated with an increased risk of upper urinary tract dilatation and renal insufficiency. Chronic urinary retention is often defined as a PVR > 300 ml (2).

1. Kelly CE. Evaluation of voiding dysfunction and measurement of bladder volume. Rev Urol 2004;6 (suppl 1):S32-S37.

2. Kaplan SA, Wein AJ, Staskin DR, Roehrborn CG, Steers WD. Urinary retention and post-void residual urine in men: separating truth from tradition. J Urology 2008;180:47–54.

What is an abnormal post-void residual (PVR) volume?

How might constipation lead to urinary retention?

The association between constipation and urinary retention is well known (1,2). Several mechanisms may explain this relationship,  including sharing of the innervations of the internal anal and urinary sphincters  via S2-S4 nerve roots, and the presence of impacted stool in the rectum leading to invaginations in the posterior wall of the bladder and urethral obstruction (1,2).  Interestingly, in laboratory experiments involving rats, rectal distention with a balloon diminished bladder contractility (2).   So, along with many other factors, constipation should routinely be considered a potential cause of acute urinary retention.  

1. Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am Fam Physician 2008;77:643-650.

2. Ariza Traslavina, Del Ciampo LA, Ferraz IS. Acute urinary retention in a pre-school girl with constipation. Rev Paul Pediatr 2015;33:488-492.

How might constipation lead to urinary retention?

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?

The great majority of hospitalized patients with ASB do not need treatment with antibiotics. In fact, there are only a couple of conditions for which treatment of ASB is indicated:  pregnant women (due to risk of pyelonephritis and low-birth infants/pre-term delivery) and before  GU instrumentation, such as transurethral resection of the prostate or other GU procedures for which mucosal bleeding is anticipated (1).  So for the great majority of our hospitalized patients, including the elderly, diabetic women, institutionalized residents of long-term facilities, and spinal cord injury patients treatment of ASB is not indicated.  Even in the case of renal transplant patients, supportive evidence for the  use of prophylactic antibiotics in ASB is so far lacking (2).  It’s worth emphasizing that  pyuria accompanying ASB is not an indication for treatment.

1. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54

2. Coussement J, Abramowicz D. Should we treat asymptomatic bacteriuria after renal transplantation? Nephrol Dial Transplant 2013;0:1-3.

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?

Although historically sterile pyuria has been associated with genitourinary (GU) tuberculosis, there are many more common causes to consider in the hospitalized patient.  Recent antibiotic exposure (within past 2 weeks) in the setting of UTI is one of the most frequent causes.  Prostatitis is also an often overlooked cause.  About 15% of hospitalized patients with systemic infections outside of the GU tract (e.g. pneumonia) may also have sterile pyuria. Non-infectious causes include current or recent catheterization of bladder, urinary stones, stents, GU malignancy, papillary necrosis,  and analgesic nephropathy.  I would start out with a prostate exam.

Wise GJ, Schlegel PN. Sterile pyuria. N Engl J Med 372;11:1048-54.

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?