The ischuria of paradox. Paradoxical ischuria: what is it, diagnosis and treatment

Acute urinary retention – sudden absence of urination with a full bladder and painful urge.

Etiology. Prostate adenoma, prostate cancer, sclerosis of the bladder neck, foreign body, stone, urethral rupture, neoplasm of the lower urinary tract; less often – diseases and damage to the central nervous system (tumor, injury). ARI of a reflex nature develops after operations, in elderly men after injection of atropine.

Pathogenesis. When the bladder is full, when the patient cannot spontaneously empty the bladder due to an obstruction in the neck of the bladder or urethra and failure of the main muscle - the detrusor. A new portion of urine coming from the kidneys increases intravesical pressure and urine spontaneously begins to flow out, overcoming the obstacle. In this case, the bladder does not empty completely. This often happens with benign prostatic hyperplasia (abbreviated as BPH, or prostate adenoma) in the last stage.

Clinic. The patient experiences anxiety, severe pain in the suprapubic region, a painful urge to urinate, and a feeling of fullness in the lower abdomen. Examination of patients with asthenic physique allows us to determine the symptom of a ball in the suprapubic region. Percussion above the bladder - dull sound; palpation is painful due to a strong urge to urinate.

Diagnostics based on medical history and examination of the patient. During the examination, it is important to pay attention to how the patient urinated before AUR, what color the urine was, and whether he took any drugs that promote urinary retention.

Differential diagnosis. It is necessary to differentiate AUR from anuria, in which there is no pain: since the bladder is empty, there is no sharp pain in the suprapubic region. We should not forget about this type of urinary retention, such as paradoxical ischuria, in which the bladder is full, the patient cannot empty the bladder on his own, and urine is involuntarily released in drops. If the patient releases urine with a urethral catheter, the leakage of urine stops for a while.

Treatment. An emergency action is to urgently empty the bladder. At the prehospital stage, this can be done by catheterizing the bladder with an elastic catheter or suprapubic puncture. If AUR lasts more than two days, leaving the catheter in the urinary tract with the prescription of preventive antibiotic therapy is justified. Contraindications to bladder catheterization: acute urethritis and epididymitis, orchitis, acute prostatitis, urethral trauma. Difficulties in catheterization, signs of urethrorrhagia, acute inflammation of the urethra, scrotal organs, prostate gland, urethral trauma, and the inability to insert a catheter indicate the need for hospitalization in the urology department. The use of a metal catheter in the prehospital setting is not required. Capillary puncture of the bladder is performed only in a hospital.

TICKET 40

Lung abscess. Etiology, classification, clinical course, diagnosis, treatment.

Lung abscess - 1) purulent melting of the pulmonary parenchyma. 2) a severe suppurative process, occurring with severe intoxication, accompanied by necrosis and melting of the lung tissue with the formation of cavities.

Reason most often it is pneumonia caused by staphylococcus, Klebsialla, anaerobes, as well as contact infection with pleural empyema, subphrenic abscess; aspiration of foreign bodies, infected contents of the paranasal sinuses and tonsils. Indirect causes include septic emboli that enter hematogenously from foci of osteomyelitis, gonitis, prostatitis, less often the lymphogenous route is noted - drift with boils of the upper lip, phlegmon of the floor of the mouth. Multiple abscesses, often bilateral, occur as a result of septicopyemia. A lung abscess can be a complication of a pulmonary infarction, the breakdown of a cancerous tumor in the lung.

Risk factors: occupational hazards (hypothermia, dust), tobacco and alcohol abuse.

CLASSIFICATION

Destructive pneumonitis is divided according to clinical and morphological form and pathogenesis.

According to the clinical and morphological essence, they distinguish: purulent abscesses, gangrenous abscesses, lung gangrene.

It should be noted that in dynamics these processes can transform into one another.

According to pathogenesis, destructive pneumonitis is divided into four groups: bronchogenic (aspiration, post-pneumonic, obstructive); hematogenous; traumatic; others associated, for example, with the transfer of suppuration from neighboring organs and tissues.

Separately, it is necessary to consider the classification of lung abscesses. They are divided into: acute; chronic (duration more than 2-3 months).

Most abscesses are primary, i.e. are formed during necrosis of lung tissue during damage to the lung parenchyma (usually pneumonia). If an abscess occurs as a result of a septic embolism or rupture of an extrapulmonary abscess into the lung (with empyema), then it is called secondary. In addition, it is customary to distinguish single and multiple, unilateral and bilateral lung abscesses. Depending on the location within the lobe or the entire lung, it is customary to divide peripheral (cortical, subcortical) and central (hilar abscesses). It should be noted that this division is not applicable to giant abscesses.

Clinic

Signs of purulent-resorptive fever, hectic temperature, shortness of breath, local pain when breathing, paroxysms of barking cough with an increase in the amount of sputum when changing body position. Physically: bronchial breathing, variable wheezing. Three-layer sputum is typical: yellowish mucus, a watery layer, and a thin layer at the bottom. In the blood - leukocytosis with a shift of the formula to the left, anemia, hypoalbuminemia and dysproteinemia. Spontaneous internal drainage of the abscess is possible as a result of its breakthrough into the bronchus adjacent to the cavity, a sign of which is the sudden release of a large amount of foul-smelling (mouthful) sputum. During an external examination, before the abscess ruptures, mild cyanosis of the face and limbs can be detected. With extensive damage and involvement of the pleura in the process, the lag of the affected half of the chest in the act of breathing is visually determined. The patient takes a forced position on the sore side. With a chronic abscess, the fingers take the shape of drumsticks, and signs of right ventricular failure form. Tachypnea and tachycardia are characteristic. The duration of the first period takes from 4 to 12 days. The transition to the second period - the beginning of emptying of the cavities of destruction - is accompanied in typical cases by an improvement in the patient's condition. Palpation makes it possible to detect pain in the intercostal spaces on the sore side, which indicates the involvement of the pleura and intercostal neurovascular bundle. With a subpleural location of the abscess, vocal tremors are increased. As a large abscess empties, it may become weakened. Percussion in the initial phase on the affected side the sound may be slightly shortened

A frequent complication is perforation into the free pleural cavity with the formation of pleural empyema.

Diagnostics

The final diagnosis is established using x-ray examination in frontal and lateral projections, as well as tomography. Computed X-ray tomography is more informative.
An important role is played by bronchoscopy with aspiration of pus to determine microflora and select antibiotics, and biopsy for differential diagnosis with a disintegrating tumor.

TREATMENT

Patients with lung abscess require intensive treatment in a hospital setting. Patients are provided with a diet with an energy value of up to 3000 kcal/day, a high protein content (110-120 g/day) and a moderate restriction of fats (80-90 g/day). Increase the amount of foods rich in vitamins A, C, group B (decoctions of wheat bran, rose hips, liver, yeast, fresh fruits and vegetables, juices), calcium salts, phosphorus, copper, zinc. Limit the consumption of table salt to 6-8 g/day, liquid.

Conservative therapy for lung abscess is based on the use of antibacterial agents until clinical and radiological recovery (often 6-8 weeks). The choice of drug is determined by the results of bacteriological examination of sputum, blood and determination of the sensitivity of microorganisms to antibiotics. Antibacterial drugs are administered intravenously, and if the condition improves, they are given orally. To date, high doses of IV penicillin are effective in 95% of cases. Apply benzathine benzylpenicillin 1-2 million units intravenously every 4 hours until the patient’s condition improves, then phenoxymethylpenicillin 500-750 mg 4 times a day for 3-4 weeks. Due to the increase in penicillin-resistant strains of pathogens, it is recommended to prescribe clindamycin 600 mg IV every 6-8 hours, then 300 mg orally every 6 hours for 4 weeks. Chloramphenicol, carbapenems, new macrolides (azithromycin and clarithromycin), β-lactam antibiotics with β-lactamase inhibitors, and respiratory fluoroquinolones (levofloxacin, moxifloxacin) are also effective for lung abscess.

The empirical choice of antibiotic for lung abscess is based on knowledge of the most common pathogens (anaerobes Bacteroides, Peptostreptococcus etc., often in combination with enterobacteria or Staphylococcus aureus).

The drugs of choice are: amoxicillin + clavulanic acid, ampicillin + sulbactam, ticarcillin + clavulanic acid, cefoperazone + sulbactam.

Alternative drugs include lincosamides in combination with aminoglycosides or cephalosporins of III-IV generations, fluoroquinolones in combination with metronidazole and monotherapy with carbapenems.

With microbiological identification of the pathogen, correction of etiotropic therapy is necessary in accordance with the identified pathogen and its sensitivity

Treatment is carried out in a hospital. Postural drainage, bronchoscopic sanitation, antibiotic therapy taking into account a weekly repeat antibiogram. Surgical treatment is indicated only if there is no effect from conservative treatment.
The prognosis is favorable: in most cases, obliteration of the abscess cavity and recovery are noted. X-ray monitoring is required 3 and 6 months after recovery.

Paradoxical ischuria is a condition in which the bladder cannot empty completely. As a result, a large amount of urine accumulates in it, which is why periodic involuntary leakage is observed. When the urinary tract is full, the patient experiences discomfort and severe pain in the lower abdomen.

Men are more likely to experience this pathology. It is diagnosed less frequently in women.

What causes the emergence of ishuria?

Paradoxical ischuria is a common symptom of urological diseases, that is, it is not considered a separate disease. According to statistics, 85% of all cases of urinary retention affect men over 55 years of age, which is caused by inflammation of the prostate.

Among other reasons leading to the pathological condition:

• Mechanical obstruction of the urethra. It may contain stones, tumors, and blood clots. Also, mechanical obstruction can be caused by edema - for example, with prostate adenoma, the surrounding structures, including the urethra, swell.
• The patient remains in a state of severe stress for a long time. Nervous experiences can provoke inhibition of reflexes responsible for full urination. The reason is more typical for individuals who have been diagnosed with mental disorders.
• Dysfunctional disorders. This refers to nerve conduction disorders in neurological diagnoses, dystrophy of the muscular layer of the bladder and other conditions in which normal contraction of the organ becomes impossible.

Some medications can cause problems. Thus, a number of sleeping pills and narcotic drugs cause urinary retention and have a depressing effect on bladder contractility.

Types of disease

Paradoxical ischuria is classified into types based on the following criteria:

• Retained ability to urinate.
• Duration of delay.

If the patient, by strongly straining the muscles, can empty the bladder even a little, they speak of incomplete retention. If it is possible to remove stagnant urine exclusively with the help of a catheter, a diagnosis of complete paradoxical ischuria is made.

As for the duration of urinary retention, there are two forms:

1. Spicy. Develops like an attack. Severe pain appears in the pubic bone area, the urge to urinate becomes pronounced. Visually, the doctor sees a protrusion in the lower abdomen.
2. Chronic. The patient's condition worsens gradually. For several weeks/months he complains of a feeling of incomplete emptying, and then there comes a point when he cannot empty his bladder on his own.

Symptoms

In the acute form, the patient experiences an irresistible urge to go to the toilet. However, urine does not come out even when he tenses his abs hard. Cutting pains appear in the lower abdomen. As biological fluid accumulates above the pubis, a characteristic protrusion in the form of a roller appears. At the same time, the patient may complain of insomnia, increased fatigue, loss of appetite and constipation.

With chronic paradoxical ischuria, the symptoms are not so bright. A person feels that his urinary tract is not completely emptied. He goes to the toilet frequently, but the amount of urine he produces gradually decreases, even if he drinks a lot of fluids. During urination, the patient strains greatly. The stream of urine is constantly interrupted. To feel relief, the patient can spend 5-10 minutes in the toilet.

Diagnosis of the disease

When palpating/examining the patient's abdomen, the doctor feels/sees a protrusion. To alleviate the patient's condition, he is given an antispasmodic and urine is removed using a catheter. Afterwards, studies are carried out aimed at establishing the cause of ischuria:

• General blood and urine tests.
• Cystoscopy.
• Ultrasound of the abdominal cavity.
• Endoscopy and X-ray with contrast.

To assess the size of the prostate gland, a man may be asked to undergo TRUS. If there is a suspicion that paradoxical ischuria is provoked by nervous experiences, the patient is referred for consultation to a neurologist or psychiatrist.

Treatment methods

Treatment for the described condition can be divided into:

• Emergency- designed to alleviate the patient's condition.
• Complex- ensures elimination of the causes that provoked the symptom, relieves inflammation.

In the first case, they carry out bladder catheterization. If it turns out that it is impossible to install a catheter (for example, with a tumor, stricture, phimosis), an epicystostomy is performed: with the help of surgery, access to the bladder is gained and a tube is inserted into it, draining biological fluid towards the anterior surface of the abdomen.

As for complex treatment, it depends on the cause that caused urinary retention. If a stone or tumor is to blame, surgery is performed. For dysfunctional lesions, urologists work together with neurologists and surgeons. They prescribe medications taking into account the patient’s age, the presence of chronic ailments, the severity of ischuria and some other factors. In each case, drug treatment is selected individually.

When urinary retention occurs as a result of stress, sedative pills and herbs help well.

Prevention of ischuria consists of timely detection and quality treatment of diseases of the genitourinary system, as well as pathologies that lead to damage to the prostate (in men).

Possible consequences and complications

The prognosis is favorable. The main thing is to quickly establish the cause of paradoxical ischuria and carry out its proper treatment. In advanced cases, the disease can lead to acute renal failure and bilateral hydronephrosis.

Chronic ischuria paradox is fraught with inflammation and infection of the urinary tract.

Ischuria (urinary retention) is a pathological process associated with impaired urination. It is often accompanied by, leads to the development of, and contributes to the occurrence of arterial hypertension. In most cases, acute urinary retention requires urgent surgery. But before you begin to treat ischuria, it is necessary to identify which diseases it is a symptom of. Without eliminating the cause that led to the disruption of urine outflow, the pathology cannot be cured.

How does ischuria manifest itself?

With ischuria, the bladder becomes full, but for some reason cannot empty itself normally.

Normally, urination is painless. After this process, there is virtually no urine left in the bladder. With ischuria, the bladder becomes full but cannot empty itself. Urinary retention occurs:

1. Full. Manifests itself in acute and chronic ischuria. There is an urge to urinate, but no urine is released. All the fluid accumulates in the bladder.
2. Partial. Such ischuria is characteristic of chronic pathology. After urination, some urine remains in the bladder. This is how chronic incomplete urinary retention develops.
3. Paradoxical ischuria (is a special form of chronic urinary retention). When the bladder is full, urine is released in drops. In this form, ischuria is accompanied by urinary incontinence.

Acute urinary retention occurs suddenly. When a large amount of urine accumulates in the bladder, patients with acute ischuria complain:

• for severe pain in the lower abdomen, perineum, rectum;
• painful, intense urge to urinate;
• inability to urinate.

With ischuria, the unbearable painful urge to urinate may decrease and then resume.

During an attack, patients are concerned not only with intense pain. The greatest discomfort is caused by a painful urge to urinate without emptying the bladder. And then the patients try to alleviate their condition by pressing on the bladder area and squatting.

Ischuria is detected not only by patient complaints. To establish a diagnosis, the following is carried out:

• examination (detect a round formation above the pubis);
• palpation (a full bladder can be felt, it is painful);
• (to detect prostate diseases);
• vaginal examination (to exclude urethra).

Sometimes long-term acute ischuria becomes chronic.

Chronic ischuria is characterized by aching pain and the presence of urination. It’s just that urine is released in a sluggish, weak stream, in small quantities. In this case, the walls of the bladder are stretched, the tone of the smooth muscles of the detrusor is disrupted. This leads to the fact that each time more urine remains in the bladder. As a result, vesicoureteral reflux develops and inflammatory kidney diseases occur.

To prevent ischuria from leading to dire consequences, it must be eliminated immediately. But the treatment depends on the underlying disease. After all, ischuria is a symptom of various pathologies.

What diseases is ischuria a symptom of?

Ischuria occurs due to a mechanical disturbance in the outflow of urine due to functional disorders of the smooth muscles of the bladder. Accordingly, urinary retention accompanies various pathologies:

• benign;
• spicy ;
• progressive cervical pregnancy;
• hematocolpometer;
• urethral leiomyoma;
• foreign bodies of the bladder, urethra;
• blood clot in the bladder;
• urethrocele;
• cancer (, urethra, prostate);
• germination of a malignant tumor into the neck of the bladder, urethra.

Ischuria may be a consequence of neurogenic bladder dysfunction:

• detrusor areflexia;
• spine surgery;
• meningomyelocele;
• psychogenic bladder dysfunction.

Sometimes ischuria is observed due to psychogenic bladder dysfunction. Often this disorder occurs in operated patients due to pain in the abdominal cavity. Ishuria in this case is due to:

• pain in the wound with tension in the muscles of the anterior abdominal wall;
• decreased detrusor tone (due to anesthesia).

Urinary retention may occur in bedridden patients. Due to the forced long horizontal position, the circulation of venous blood is disrupted. Congestion occurs in the organs and tissues of the pelvis, leading to detrusor hypotension, and in men prostate edema occurs. As a result, urinary retention develops.

Ishuria accompanies various neurogenic, urological, gynecological and oncological diseases. And sometimes urinary retention can occur due to taking medications. In women, overfilling and the inability to empty the bladder sometimes occurs during pregnancy, when the uterus compresses the neck of the bladder.

The connection between the nature of ischuria and its clinical manifestations and the underlying disease

The nature of urinary retention and the main clinical signs will help determine which disease symptom is ischuria:

Diagnosis	The nature of ishuria	Main clinical signs
Impaired patency of the vesicourethral segment		difficulty urinating; thin stream; presence of residual urine in the bladder
Atresia of the external urethral meatus	full	a newborn baby does not urinate for 1 day after birth
Narrowing of the external opening of the urethra	chronic, progressive	urination is difficult; urine stream is weak, thin
Phimosis	chronic, progressive	enlargement of the preputial sac; weak stream of urine
Injury to the penis by a foreign object	acute	visual inspection
Urethral rupture	acute	fresh injury (with and without a fracture of the pelvic bones); urethrorrhagia; subcutaneous hemorrhages; swelling of the urethra; Urethrogram shows urethral rupture
Urethral stricture	first partial chronic, then complete	a history of urethral trauma, gonorrhea; On the urethrogram, single or multiple narrowing of the urethra
Urethral stone	acute	history of renal colic; sudden interruption of the urine stream during urination; instrumental and x-ray studies
Foreign body of the urethra	acute	anamnesis data; palpation; instrumental and x-ray examinations
Urethral tumor	chronic, first partial, then complete	urethroscopy, urethrography - show the presence of a tumor
Compression, invasion of the urethra by a tumor, inflammatory infiltrate	chronic incomplete with possible attacks of acute	vaginal and rectal examination data
	acute, preceded by dysuria	data from digital rectal examination
Benign prostatic hyperplasia	chronic, gradually progressive, often manifests itself as paradoxical ischuria	prostate enlargement; rectal examination data
Prostate cancer		rectal examination data
Bladder neck sclerosis	gradually progressing, in the form of paradoxical ischuria	data from digital examination of the rectum, urethrocystoscopy, cystography
Brain damage (hemorrhage, thrombosis)	acute	neurological signs of brain damage
Spinal cord injury	acute, then becomes fully chronic	history of spinal injury; absence of organic disorders; paraplegia; violation of the act of defecation
Spinal cord lesion	chronic	signs of certain spinal cord damage
Primary atony of the bladder	progressive, chronic with attacks of acute ischuria	no organic obstruction to the outflow of urine from the bladder, no diseases of the central nervous system
Reflex urinary retention	acute	occurs after injury or after surgery

The list of pathologies that cause ischuria is long. To accurately determine the cause of acute and chronic urinary retention, you need to undergo an examination. The necessary clinical studies will be prescribed by your doctor. Further treatment will depend on the nature of ischuria and the cause of this unpleasant symptom.

Where and how to treat ischuria

For acute urinary retention, the primary goal of treatment is to empty the bladder. To do this, it is catheterized.

For effective treatment of urinary retention, it is necessary to cure the underlying pathology that caused ischuria. To stop the symptom, it is necessary to restore the flow of urine. And for this, various methods are used, depending on the nature of urinary retention.

Treatment of acute ischuria

During an acute attack of urinary retention, the patient is sent to the emergency surgical department, where the bladder is first emptied. To do this, it is catheterized. The procedure is contraindicated:

• at ;
• epididymo-orchitis;
• acute prostatitis;
• prostate abscess;
• urethral injury.

Sometimes, due to certain pathologies, it is not possible to install a catheter. Then the following methods are used to drain urine:

• capillary puncture of the bladder;
• open epicystostomy;
• trocar epicystostomy.

With the development of reflex ischuria, they resort to a conservative method of restoring urination:

1. If the patient's condition allows, he should be seated or put on his feet. Sometimes in this position, urination is restored.
2. To prevent ischuria, an α-blocker is prescribed 2-3 days before surgery.
3. Apply a warm heating pad to the bladder area. Proserin or pilocarpine is administered subcutaneously or intramuscularly.

If these methods do not work, bladder catheterization is performed.

If the cause of ischuria is a stone in the urethra, then treatment depends on the location of the stone:

1. Stone in the prostatic urethra. It is moved into the bladder using a metal bougie. Next, contact or extracorporeal lithotripsy is performed.
2. Stone in the urethra. Remove with special forceps. Contact laser, electrohydraulic, and pneumatic stone crushing is performed during optical urethroscopy.
3. Stone in the area of ​​the scaphoid fossa. Meatotomy is indicated.

To remove a stone, it is extremely rare to resort to urethrotomy. The indication for its use is the presence of urethral stricture. Next, urethroplasty is necessary.

Chronic ischuria

For chronic urinary retention, treatment depends on the severity of ischuria. If urinary dysfunction results in:

• to disruption of urodynamics;
• the presence of a large amount of residual urine in the bladder;
• chronic renal failure.

Then it is necessary to immediately drain the bladder using a cystostomy. And only when the signs of chronic renal failure are eliminated and bladder function is restored, the factors that caused ischuria are eliminated.

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 of the 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. It must be remembered that not everyone, even a healthy person, can 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 long-term sufferers of incomplete retention, weakened by chronic pyelonephritis and renal failure, need 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 with a 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.

Ischuria is acute urinary retention that occurs due to the inability to urinate independently. It is associated with a serious condition that requires immediate decisions from not only the doctor, but also the patient himself.

Medicine distinguishes three forms of the disorder:

• acute;
• chronic;
• paradoxical.

There may be different types of each type of ischuria:

1. Fully spicy. It occurs spontaneously and is characterized by acute abdominal pain, as well as frequent urination. There is no outflow of urine. In this case, urine continues to accumulate in the bladder.
2. Incomplete ischuria of the chronic type is a protracted course of the disease in which urine comes out, but not in the volume required to completely empty the bladder. Patients faced with this condition complain of heaviness in the bladder and severe pain.
3. Complete chronic ischuria is a condition in which bladder emptying can be accomplished with the help of a catheter. The duration of the disease can range from a month to several years.
4. Incomplete chronic ischuria is a disease in which the urine is emptied by approximately 20%, and the remainder of the urine is excreted through the use of a catheter.
5. Paradoxical ischuria. What it is? This is a condition associated with loss of elasticity of the sphincter, which is actively involved in the process of urination, due to overstretching of its walls. In this condition, urine comes out in a minimal volume, and quite often involuntarily.

How is it developing? The cause may be a stone that prevents the passage of urine from the bladder, or the urinary ducts are compressed under the pressure of various factors. Urinary retention can occur for a number of reasons:

• mechanical damage. Injuries can lead to them:

1. Urethral injury.
2. Adenoma.
3. Prostatitis.
4. Formations in the prostate gland.
5. Prostate abscess.
6. Bladder stones.
7. Phimosis.

• diseases of the central nervous system (tumors of the brain or spinal cord, myelitis, severe injuries);
• reflex functional disorders. System functions may be disrupted due to the following conditions:

1. Operations (in the rectum, female genitals, perineum).
2. Childbirth.
3. Stress.
4. Alcohol intoxication.
5. Prolonged bed rest.

• intoxication with drugs (sleeping pills, narcotic drugs, analgesics).

First aid for symptoms of ischuria

In a case where a person is faced with a serious problem, and it is not possible to consult a doctor, first aid must be provided to the patient. It consists of relieving pain and restoring the ability to empty the bladder independently.

1. To begin with, you can give the patient a glass of cool water and insulate the lower abdomen with a heating pad.
2. A cleansing enema will also help.
3. A belladonna suppository can be inserted into the rectum.
4. If you don’t have candles on hand, a bath with chamomile infusion will help. You can drink mint, linden or chamomile tea.

Before starting treatment, it is necessary to carry out a number of diagnostic measures that will give a complete picture of the urinary system. Before this, the bladder is completely cleared of urine using a catheter. After which you need to take tests: blood and urine.

A test is also performed that measures the level of prostate-specific antigens.

If surgical intervention is chosen as a method of solving the problem, the following procedures must be performed before the operation:

• Ultrasound of the bladder and prostate;
• cytoscopy;
• X-ray examination;
• urodynamic test.

The main condition for recovery is to ensure adequate sleep, avoid alcohol and smoking.

The attending physician selects the optimal method of treatment based on the results of the examination and a preliminary interview with the patient.

The standard treatment regimen includes the following types of therapy:

• drug therapy;
• temporary installation of a catheter to remove urine from the bladder;
• epicystomy to remove urine for a long time;
• surgical intervention.

The selection of medications depends on the primary disease, which resulted in urine retention.

The following drugs are prescribed for the treatment of ischuria:

• Levomycetin;
• Prozerin;
• Furadonin;
• Furagin.

If the cause is central nervous system disease, the patient is prescribed sound effects and medications.

To treat the catheter, a solution of Rivanol or Furacilin is used. This will avoid bladder infection and prevent complications.

Traditional methods can significantly improve the patient's condition. Chewing juniper berries is considered the most effective.

Also in medicinal recipes the following can be used:

1. Infusion of birch buds and dill seeds.
2. Infusion of lily of the valley flowers.
3. Decoction of burnet rhizomes.
4. Infusion of cloudberry leaves.
5. Infusion of herbs: cinquefoil, rue, valerian and lemon balm.
6. Oat straw decoction.
7. Infusion of rowan berries.
8. Herbal mixture consisting of fennel, elderberry, combined with juniper fruits and parsley. A decoction is prepared from the mixture, which is taken several times a day.

More complex decoctions can also be prepared, for which 5-7 herbs are selected.

Possible complications

In the absence of timely diagnosis and appropriate treatment, various complications may arise. Urine retention itself is not the root cause, but acts as a complication of various diseases.

However, the leakage of urine itself can lead to other complications. Among them:

• renal failure;
• cystitis;
• acute and chronic pyelonephritis;
• stone formation;
• macrohematuria.

To prevent such developments, you need to seek help from the clinic as soon as possible. Adequate treatment and ensuring complete rest of the patient can improve the condition and prevent the development of the disease.