How to manage urinary retention after ureteral stent placement?

Management of Urinary Retention After Ureteral Stent Placement

Immediate catheter drainage is the primary treatment for urinary retention following ureteral stent placement, with urgent evaluation to identify and address the underlying cause.

Immediate Management

• Place or maintain a urethral catheter to decompress the bladder and relieve retention 1, 2
• Measure post-void residual volume if the patient can void at all to quantify the degree of retention 2
• Assess for signs of infection (fever, leukocytosis, cloudy urine) as infected obstructed systems require urgent intervention 2, 3
• If sepsis or fever is present with retention, obtain urine cultures before and after decompression and initiate immediate antibiotics 2

Diagnostic Evaluation

Identify the specific cause of retention through targeted assessment:

• Evaluate stent position and patency using plain radiography (KUB) or ultrasound to rule out stent migration (occurs in ~5% of cases) or malposition 1, 3
• Assess for bladder outlet obstruction through physical examination looking for prostatic enlargement, urethral stricture, or blood clots 3
• Rule out stent-related complications including encrustation (more common with prolonged indwelling time >3 months), infection, or bladder spasm causing functional obstruction 4, 5, 6
• Consider CT imaging if there are signs of significant complications such as perinephric stranding, obstruction despite stent presence, or concern for ureteral injury 2, 3

Specific Management Based on Etiology

If Stent Migration or Malposition is Identified:

• Cystoscopic repositioning or replacement is required for confirmed stent migration 3
• This should be performed urgently if associated with obstruction or infection 3

If Bladder Spasm or Irritative Symptoms are Predominant:

• NSAIDs (diclofenac, ibuprofen) are first-line for stent-related pain and spasm, as they decrease ureteral smooth muscle tone 2, 7
• Use the lowest effective dose to minimize cardiovascular and gastrointestinal risks 7
• Alpha-blockers can be considered for patients with contraindications to NSAIDs or as adjunctive therapy 7
• Anticholinergics may help reduce bladder spasm if irritative symptoms are severe 7

If Stent Encrustation is Present:

• Multimodality endoscopic approach is required for severely encrusted stents, potentially including cystolitholapaxy, ureteroscopy, and lithotripsy 6
• Do not attempt forced removal of heavily encrusted stents as this can cause ureteral avulsion or retained fragments 4, 6
• Average of 2-3 procedures may be needed for complete removal of severely encrusted retained stents 6

If Infection is Present:

• Third-generation cephalosporin (ceftazidime) is superior to fluoroquinolones for infected obstructed systems 2
• Adjust antibiotics based on culture results 2
• Intensive care may be necessary in severe sepsis cases 2

When to Remove or Replace the Stent

• Early stent removal should be considered if severe, refractory symptoms persist despite medical therapy and the original indication for stenting has resolved 7, 3
• Persistent severe pain unresponsive to management after 48-72 hours warrants urologic consultation for potential stent removal 3
• Signs requiring immediate urologic intervention include anuria, severe flank pain, rising creatinine, or signs of obstruction despite stent presence 3

Critical Pitfalls to Avoid

• Do not delay urologic consultation if there are signs of stent migration, obstruction, or severe uncontrolled pain 3
• Do not ignore signs of infection (fever, leukocytosis) as progression to urosepsis can be rapid 3
• Do not attempt blind catheterization if urethral injury is suspected, as this can worsen the injury 3
• Do not force removal of encrusted stents, as this can cause ureteral avulsion or leave retained fragments 4, 6

Follow-up Considerations

• Catheter drainage for uncomplicated extraperitoneal bladder issues typically requires 2-3 weeks with follow-up imaging to confirm healing 1
• Regular assessment of symptom control and medication side effects is essential 7
• If retention persists beyond initial catheter drainage, cystoscopy may be needed to evaluate for anatomic obstruction or stent-related complications 3