Rosen & Barkin's 5-Minute Emergency Medicine Consult (743 page)

• Significant postobstructive diuresis requiring IV fluids or pressors
  
• Sepsis
  
• Obstruction related to spinal cord compression
  
• Consider in patient with obstruction due to malignancy or mass
  
• Any process requiring acute urologic or surgical intervention
  

Most patients can be discharged

Most patients will need follow-up for ongoing evaluation and management of AUR as well as catheter management

• Carefully evaluate for evidence of a mass or malignancy as the cause of AUR.
  
• Carefully evaluate for evidence of spinal cord compression as the cause of AUR.
  
• Take a thorough drug history including over-the-counter medications, especially if no other clear reason for AUR.
  

• Barrisford GW, Steele GS. (2012, Apr 27) Acute Urinary Retention. Retrieved from
  www.uptodate.com
  .
  
• Rochelle JL, Shuch B, Belldegrun A. Urology. In: Brunicardi FC, Andersen DK, Billiar TL, et al.
  Schwartz's Principles of Surgery
  . New York, NY: McGraw Hill; 2009.
  
• Tintinalli JE, ed in chief.
  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide
  . 7th ed. McGraw-Hill Medical Publishers; 2011.
  

See Also (Topic, Algorithm, Electronic Media Element)

UTIs

CODES

• 598.9 Urethral stricture, unspecified
  
• 600.91 Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS)
  
• 788.20 Retention of urine, unspecified
  

BASICS

Urinary tract fistulas can form between any part of the urinary tract and structures in the thoracic cavity, the abdominal cavity, the pelvis, and the skin.

• Colovesical fistula:
  
  • Usually complication of primary GI disease such as diverticular disease (most common), Crohn's disease, or colon carcinoma
    
  • Iatrogenic (postsurgical or radiation treatment most common)
    
  • Urethral disruption from trauma
    
  • More common in males
    
• Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
  
  • Vesicovaginal fistula is the most common acquired fistula of the urinary tract
    
  • Etiology varies with geography (developed vs. developing countries):
    
    • In developed countries it is usually due to injury to the structures during surgery, pelvic pathology, radiation therapy, or injuries incurred in the healing process. Radiation-induced fistulas may not present for months to years after exposure.
      
    • In developing countries it is usually due to obstructed labor and obstetric trauma.
      

DIAGNOSIS

• Colovesical fistula:
  
  • Chronic or recurrent UTIs
    
  • Suprapubic pain
    
  • Abnormal urine: Pneumaturia, fecaluria, hematuria, malodorous urine, debris in the urine (food particles)
    
• Vesicovaginal fistula:
  
  • If after surgical procedure, may present on removal of urinary catheter or 1–3 wk post procedure
    
  • Usually painless
    
  • Constant urine leakage from the vagina (may be confused with urinary incontinence)
    
  • Perineal skin irritation due to urine leakage
    
• Urethrovaginal fistula:
  
  • Symptoms largely dependent on size and location of fistula
    
  • May be asymptomatic or with continuous vaginal urine drainage
    
• Ureterovaginal fistula:
  
  • Usually a history of recent surgery, particularly a complicated hysterectomy
    
  • Abdominal or flank pain, fever, and ileus. If these symptoms present, likely due to urinoma or renal obstruction
    
  • Intermittent urine leakage from vagina
    

• A thorough past medical, surgical, and obstetric history to determine risk factors
  
• Description and timing of presumed urinary discharge: Intermittent or positional usually due to ureterovesical fistula; continuous flow more likely to be from vesicovaginal fistula.
  
• Characteristics of presumed urinary discharge
  
• Associated symptoms
  

• Colovesical fistula:
  
  • There might be findings consistent with the primary GI disease; otherwise physical exam is frequently unremarkable
    
• Vesicovaginal, urethrovaginal, ureterovaginal fistulas:
  
  • Speculum exam may reveal a small reddened area of granulomatous tissue at site of the fistula opening. May also see pooling of the urine in the vaginal vault.
    

Must evaluate for associated urinary infection, renal obstruction, or acute emergencies related to primary disease processes (e.g., complications from a malignancy or Crohn's disease).

• Urinalysis:
  
  • Colovesical fistula:
    
    • WBCs, bacteria, and debris
      
  • Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
    
    • WBCs, bacteria
      
• BUN and creatinine:
  
  • If renal obstruction is present, might be abnormal.
    

• Usually not an emergent need to image and would discuss with specialist
  
• Colovesical fistula:
  
  • CT of the abdomen and pelvis with contrast
    
• Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
  
  • Cystoscopy with retrograde pyelography or IVP
    

• Usually an outpatient workup
  
• Colovesical fistula:
  
  • Oral administration of activated charcoal will result in black particles in urine, which can be diagnostic.
    
• Vesicovaginal, urethrovaginal, ureterovaginal fistulas:
  
  • Double-dye test: (1) Tampon is placed in vagina, (2) oral phenazopyridine is administered, (3) methylene blue or indigo carmine is instilled into the bladder, (4). if, after an hour, tampon is yellow-orange at the top, ureterovaginal fistula is suggested. Midportion blue discoloration suggests vesicovaginal fistula. Distal blue discoloration suggests urethrovaginal fistula.
    

• Colovesical fistula:
  
  • Recurrent UTI
    
  • Other causes of pneumaturia:
    
    • UTI with gas-forming organism such as clostridia
      
    • Fermentation of diabetic urine
      
    • Recent urinary tract instrumentation
      
• Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
  
  • Urinary incontinence
    
  • Normal vaginal discharge
    
  • Vaginitis
    

TREATMENT

Treat urosepsis (rare) with IV fluid bolus, pressors, and IV antibiotics as appropriate.

• Colovesical fistula:
  
  • Evaluate for complications from patient’s primary disease.
    
  • Obtain cultures if there are signs of UTI.
    
  • Initiate antibiotic if infection is found.
    
  • Urgent urologic referral for further management and possible surgical treatment.
    
• Vesicovaginal, urethrovaginal, and ureterovaginal fistulas:
  
  • Consider placing urinary catheter
    
  • Initiate antibiotics if a UTI is present.
    
  • Urgent referral to urologist and gynecologist for further care
    

FOLLOW-UP