For Student

History
An 84-year-old retired professor was admitted to the coronary care unit of an acute care hospital
with tachycardia and congestive heart failure. He had a history of chronic constipation for which
he had taken various sennacontaining preparations for many years. His most recent bowel regimen
also included psyllium hydrophilic mucilloid (Metamucil) twice daily, docusate sodium (Colace)
300 mg daily, daily prune juice, and milk of magnesia 30 cc as needed. He had no known history
of urinary difficulties.
Physical findings included atrial fibrillation with a ventricular rate of 150, and bibasilar rales.
Treatment consisted of enalapril and furosemide, diltiazem for rate control, and morphine for
dyspnea. A low salt diet was ordered and Colace 100 mg daily was prescribed for constipation.
The patient was kept on bed rest.
On the second hospital day, the patient complained that he was “not being given enough laxatives,”
and his diet orders were modified to include 10 g of bran with his breakfast cereal, and two high-
fiber cookies (5 g of fiber each) for dessert at lunch and dinner. At this time, diphenhydramine
(Benadryl) was added for insomnia.
By the third hospital day, his cardiac status had improved but he began to complain of an inability
to void, whereupon it was noted that he had not passed urine for at least 8 hours, although he had
been eating and drinking normally. A Foley catheter was inserted and 550 cc of clear urine was
passed. The catheter remained in place while cardiac workup was completed over the next few
days.
On the fifth hospital day, the patient developed a temperature of 101 oF (oral) and urinalysis
revealed many bacteria and eight to ten white blood cells per high power field. Urine and blood
cultures were sent to the laboratory and ciprofloxacin was begun. The patient began to complain
that the catheter was “annoying” him and that it was “probably to blame for the infection in the
first place.” He demanded that it be removed. The catheter was removed but, when the patient was
unable to pass urine 8 hours later, it was reinserted.

Tasks:
1. What factors have contributed to this patient’s problem?
2. How should this problem be managed?
3. What factors contributed to the urinary tract infection?
4. What additional factors contributed to this patient’s dilemma?
 Student’s name
For examiner
History
An 84-year-old retired professor was admitted to the coronary care unit of an acute care hospital
with tachycardia and congestive heart failure. He had a history of chronic constipation for which
he had taken various sennacontaining preparations for many years. His most recent bowel regimen
also included psyllium hydrophilic mucilloid (Metamucil) twice daily, docusate sodium (Colace)
300 mg daily, daily prune juice, and milk of magnesia 30 cc as needed. He had no known history
of urinary difficulties.
Physical findings included atrial fibrillation with a ventricular rate of 150, and bibasilar rales.
Treatment consisted of enalapril and furosemide, diltiazem for rate control, and morphine for
dyspnea. A low salt diet was ordered and Colace 100 mg daily was prescribed for constipation.
The patient was kept on bed rest.
On the second hospital day, the patient complained that he was “not being given enough laxatives,”
and his diet orders were modified to include 10 g of bran with his breakfast cereal, and two high-
fiber cookies (5 g of fiber each) for dessert at lunch and dinner. At this time, diphenhydramine
(Benadryl) was added for insomnia.
By the third hospital day, his cardiac status had improved but he began to complain of an inability
to void, whereupon it was noted that he had not passed urine for at least 8 hours, although he had
been eating and drinking normally. A Foley catheter was inserted and 550 cc of clear urine was
passed. The catheter remained in place while cardiac workup was completed over the next few
days.
On the fifth hospital day, the patient developed a temperature of 101 oF (oral) and urinalysis
revealed many bacteria and eight to ten white blood cells per high power field. Urine and blood
cultures were sent to the laboratory and ciprofloxacin was begun. The patient began to complain
that the catheter was “annoying” him and that it was “probably to blame for the infection in the
first place.” He demanded that it be removed. The catheter was removed but, when the patient was
unable to pass urine 8 hours later, it was reinserted.

Task 1 (3.0). The patient’s constipation, imposition of bed rest, medications, and, as an elderly
male, his likelihood of underlying benign prostatic hyperplasia (BPH; see Figure 14) have all
contributed to acute urinary retention. Rectal examination revealed a hard mass that had resulted
in fecal impaction and accumulation of abundant feces in the rectum, compressing the bladder and
resulting in urinary retention. Stool impaction is implicated as a cause of urinary retention in up to
10% of older hospitalized patients. Morphine, diltiazem, and diphenhydramine are likely to have
contributed to this patient’s fecal impaction by slowing bowel transit time. The anticholinergic
activity of morphine and diphenhydramine also contributed to urinary retention directly, by
inhibiting the detrusor muscle of the bladder, which contracts in response to cholinergic
stimulation. Common offenders include tricyclic antidepressants, first-generation antihistamines,
opioids, and gastrointestinal antispasmodics. Antispasmodics such as oxybutinin (Ditropan) and
tamsulosin (Detrol), which are used to treat detrusor instability (see Case 33), may result in
unwanted urinary retention. The probability that this patient had some degree of BPH increased
the likelihood that he would develop acute urinary retention. The prevalence of BPH increases
with age and, by age 80, approximately 80% of men have pathologic evidence of BPH. According
to a large prospective study, men aged 70–79 years have a one in ten chance of developing acute
urinary retention in the next 5 years, and the risk for men in their eighties is almost one in three
Task 2 (3.0). Fecal impaction can be treated with enemas, but, when a hard mass is felt on digital
rectal examination, manual disimpaction should be initiated first. This patient was treated with
manual disimpaction, after which he expelled soft feces spontaneously. Appropriate treatment
would also include discontinuation, when possible, of medications that interfere with bladder and
bowel function – in this case, morphine and diphenhydramine. Diltiazem, which is very
constipating, should be replaced if possible with a beta-blocker. Enemas can be given if necessary,
and follow up should include bathroom or commode privileges, physical activity as soon as
possible, and removal of the catheter. Antibiotics are not always necessary in catheter-induced
urinary tract infections, once the catheter has been removed, as most catheter-induced infections
are asymptomatic and bacteriuria may resolve on its own. Acute urinary retention is extremely
common in older men when they are hospitalized. Bowel function needs to be monitored on a daily
basis in patients at risk, and constipation treated right away in order to prevent fecal impaction.
Early mobilization, avoidance of dehydration, avoidance of constipating medications, and
avoidance of anticholinergic medications are other maneuvers that need to be employed. Male
patients should be assisted to get out of bed and stand to urinate if possible, or, if they are unable
to use a urinal or urinate effectively with one, a bedside commode may help. Likewise, bowel
movements are easier if the patient can be seated on the toilet, in the privacy of the bathroom.
Bladder catheters should be discontinued as soon as minute-to-minute measurement of urinary
output is no longer necessary, in order to avoid infection. Patients who have no history of
symptomatic urinary retention prior to hospitalization generally are again able to urinate if
precipitating factors are rectified. However, it is not unusual for an elderly man to be unaware of
a high urine residual volume, and urinary retention sometimes stubbornly persists. In these cases,
tamsulosin (Flomax) should be considered. This alpha-blocking agent selectively inhibits alpha-
1a adrenergic receptors, reducing smooth muscle contractions, reducing intraurethral pressure, and
increasing urine flow. Because tamsulosin has a greater specificity for the receptors in the bladder
and prostate, it does not lower systemic blood pressure and is an appropriate first-line treatment
for obstructive symptoms in BPH. Alternatively, a nonselective alpha-blocker such as terazosin
(Hytrin) can be given in patients requiring treatment for hypertension.
Task 3 (2.0). The indwelling catheter, acute urinary retention, and likelihood that the patient had
underlying BPH probably all contributed to the urinary tract infection. The incidence of catheter-
related urinary tract infections increases rapidly with the duration of catheterization at a rate of
about 10% per day. In addition, this patient had developed urinary retention prior to catheterization
and was already predisposed to infection. With BPH, this patient probably would have had an
elevated postvoid residual urine (see Case 33), increasing his risk of stasis and bacteriuria. Loss of
barrier defenses is an additional risk factor for urinary tract infections and bacterial colonization
in elderly patients. The uroepithelium appears to be less effective in providing a barrier to
infection. Changes in surface glycosaminoglycans and fibronectins contribute to adherence of
bacteria. In elderly women, predisposing factors include increased adherence of vaginal
uropathogens to uroepithelial cells, cystocele, which can increase postvoid residual volume, and
estrogen deficiency, which promotes colonization of the vagina with urinary pathogens.
Task 4 (2.0). The patient was known to suffer from chronic constipation. Intestinal transit time is
prolonged with age, but constipation is not a universal complaint. Chronic use of such laxatives
may permanently damage the electrical system of the colon. Irritant laxatives such as senna, and
possibly others, may directly affect the myenteric plexus. The result is “cathartic bowel,” an
overdistended colon with loss of haustrations and poor motility. Other irritant laxatives that may
cause cathartic bowel include 229 Urinary retention castor oil, cascara, aloe, bisacodyl, and
phenolphthalein. Prunes and prune juice contain a phenolphthalein derivative but have not been
reported to cause cathartic bowel. This patient’s bowel movements occurred to his satisfaction
only with a strict bowel regimen. This regimen was not given to him in the hospital, possibly
because it was viewed by the staff as an eccentric and excessive use of laxatives. Also, medications
are not always part of the hospital formulary and alternatives are not always sought for what might
be perceived as a “nonessential” medication. The sudden imposition of bed rest probably reduced
his bowel motility further. The diuretic and salt restriction, combined with age-related decline in
renal concentrating ability, is likely to have caused a relative dehydration and reduced water
content of feces. Although bran has been shown to reduce intestinal transit time in elderly
hospitalized patients, bran supplementation can sometimes form a bulky mass and cause fecal
impaction, especially when the water content of the diet is not concurrently increased, or if the
patient is bedridden. The difficulty of supine defecation and the lack of privacy are also likely to
be contributors to this patient’s dilemma, but these modifiable risk factors are often overlooked in
the hospital setting.