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Chapter 39. Genitourinary Emergencies

Joseph Heidenreich, MD

Oliguria or Anuria

General Considerations

It is helpful to categorize the mechanism as prerenal (eg, resulting from decreased or abnormal renal perfusion), renal (eg, resulting from intrinsic renal disease), or postrenal (eg, disease of the urinary collecting system distal to the renal parenchyma). Prerenal and postrenal causes are often suggested by the history and physical examination. Additionally, it is be helpful to determine the presence and extent of acute kidney injury (AKI) that frequently accompanies oliguria and anuria.

Prerenal Causes

Prerenal causes include hypovolemia, sepsis, and heart failure.

Renal Causes

Renal causes include tubular, glomerular, vascular, or interstitial disease.

Postrenal Causes

Supravesical Obstruction

Supravesical obstruction rarely causes oliguria or anuria, because bilateral disease is required to reduce decreased urine flow. There are two types of supravesical obstruction: (1) ureteral obstruction (usually tumor) and (2) ureteropelvic or ureterovesical obstruction.

Intravesical or Infravesical Obstruction

Intravesical or infravesical obstruction is more common than supravesical obstruction and may be from many causes (Table 39–1).

Table 39–1. Diagnostic Clues to the Cause of Bladder Outlet Obstruction.
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Table 39–1. Diagnostic Clues to the Cause of Bladder Outlet Obstruction.
CauseFrequency of OccurrenceResults of History and Physical ExaminationLaboratory Tests and Other Studies
Prostatic hypertrophyCommonGradually increasing difficulty in voiding, often with abrupt worsening. Enlarged prostate on rectal examination is commonUrethral catheterization may be difficult.
Urethral strictures or valvesUncommonOften previous attacks of urethritis or urethral trauma. Onset may be gradual or abruptUrethral catheterization often difficult. Urethrogram or urethroscopy is diagnostic
Bladder stones or tumorUncommonHematuria is common. Obstruction may be intermittentUrethral catheter is passed without difficulty. Cystogram or cystoscopy is diagnostic
Neuropathic bladderVery commonOnset may be gradual and painless or abrupt and painful. Look for associated neurologic abnormalities (sacral dermatomal hypesthesia, poor rectal sphincter tone, neuralgic pain)Urethral catheter passed without difficulty. Cystometrogram is diagnostic
Traumatic urethral injuryUncommonMale; history of trauma, prostatic dislocation, urethral bleedingDo not pass catheter. Retrograde urethrogram and percutaneous cystogram are diagnostic

Clinical Findings

History

Obstruction

Differentiate between reduced urine output (with normal or nearly normal voiding patterns) and oliguria associated with difficult in voiding, feeling of incomplete voiding, and diminished urinary stream. The latter findings suggest obstruction.

Associated Medical Conditions

Ask about coexisting cardiac, pulmonary, renal, or other underlying disease that might contribute to renal or prerenal oliguria.

Drugs

The patient's medications might cause problems with urination or be nephrotoxic. Anticholinergics ...

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