Urinary retention with no foley drainage(long)

[eegrnbsn]

I had a patient with a situation I nor any of the nurses or even our MD's have ever encountered before..wanted to get some feedback.

Pt. comes to ER with CC of unable to urinate x24hr. Bladder scan shows 400ML urine in bladder. Admitted to our floor. Noc RN attempts foley placement x3. Each time, foley is in urethra, but no urine drainage. RN is positive foley is in correct place..anatomy is by the book. Notifies MD, urologist consulted. Foley is not left in d/t cannot be "positive" it is in correctly? So pt. has no foley at this time.

Next day, pt. is voiding sm. amts. at a time (goldenrod-colored urine) 30-50ML at a time..doing so spontaneously. No c/o discomfort or bladder distention. This is a very small hospital and is a wkend and no urologist can come to the hosp until Monday...pt. refuses to get cath attempts again unless by urologist..keep this voiding pattern up all day shift and night shift. Voids 400 on days, 150 on nights, urine is progressively getting darker and more concentrated.

Next day, pt. has only voided 30 ML very dark amber urine spontaneously. MD notified poor urine output still. Still no foley. Bladder can shows scan shows 700ML urine in bladder. Convince pt. to allow RN to try foley insertion again. Foley goes right in..drains 25 ML amber urine total for 3 hrs.

Pt. ends up getting transferred to larger hosp with urological services.

We are all stumped. Issue is clearly not with cath placement..clearly in the bladder b/c it did drain the sm. amt. amber urine (just like she had been voiding). WHAT could be the cause of a pt. who cannot void but 30-50ML at a time, despite over 700ML in bladder, and foley still will not drain urine?

My thought (of course I am not a physician...) is that when we are bladder scanning this pt...we are not seeing urine. What if what we're seeing is a mass? What if this pt. has stopped producing urine (the reason for the urine becoming darker) so this is why it is not draining..and a mass is what we're seeing on the bladder scan? Can a bladder scan even show anything besides urine?(ie a mass/tumor?) I don't know. No one really acted on this, for ex. U/S her pelvis, etc...(this pt. does have a hx of uterine CA within the past yr. that she under went chemo and radiation for..)

And now I will never know the answer b/c as I said this pt. has been transferred to a larger hospital! Any thoughts?

[highlandlass1592, BSN, RN]

You may not see a mass or a tumor but it can read abdominal fluid, say ascites and show it in the bladder as being urine. I've had that happen with patients. I'd be curious what renal function is, BUN/Creat. And the point you make about previous CA hx is probably relevant too.

[elizabeth321]

Even though his bladder was full....he was only voiding overflow urine.....small amounts that were escaping....

catheter was not flowing either because it was plugged by blood clots or it was not in the bladder but slipped under the bladder neck

[horrorxgirl]

Sounds like there is probably mucous in the bladder that is clogging the catheter. Or like the above person mention, sometimes ascites can give a false read as a full bladder. I had a patient who didn't void all night before and a scan read well over 1000 mls of urine. I st cath and only got like 300. It was ascites.

[MntnGirl]

pt could have a fistula like situation where the foley is going that route instead of into the bladder. i agree with the posted reply above that the small void amounts may be the pt just topping off - bladder is full and the overfill is just kind of 'splashing off' creating this small void events.

[flyingchange]

One of my pts at clinical had generalized edema and wasn't voiding much even with a foley placed. He was in acute delirium and kept complaining of a need to urinate. Bladder scans showed him at >1000 mL from every angle. It was hard to tell about the foley placement due to his anatomy (very pronounced phimosis, and scrotal edema) but he was eventually draining an appropriate amount of clear yellow urine. Bladder scans continued to show >1000 mL. We decided it was most likely showing the fluid retention and not necessarily urine in the bladder. I'll never know the end to my story either as clinical placement finished soon after.

[mamamerlee, LPN]

The only time I saw something like this was in a case of a very elderly woman who was eventually dx'd with a large tumor. When I straight cath'ed her, I only got a very small amt. The doc thought I didn't know what I was doing, and ordered a foley. Poor lady was so upset. She could barely tolerate the balloon being expanded. She ended up in surgery a day or 2 later.

Doc never apologized. (Like I really thought he would....!)

[TigerGalLE, BSN, RN]

pt could have a fistula like situation where the foley is going that route instead of into the bladder. i agree with the posted reply above that the small void amounts may be the pt just topping off - bladder is full and the overfill is just kind of 'splashing off' creating this small void events.

I agree with this. People who have had radiation are more likely to develop fistulas.