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Anuria

Anuria is defined as urine output of less than 100 ml in a 24-hour period. Causes include urinary tract obstruction and acute renal failure due to various mechanisms. (See Major causes of acute renal failure, page 24.) Anuria is rare; even with renal failure, the kidneys usually produce at least 75 ml of urine daily.

Because urine output is easily measured when the patient is in a controlled setting, anuria rarely goes undetected. However, without immediate treatment, it can rapidly cause uremia and other complications of urine retention.

Act Now: When anuria is detected, it’s essential to determine whether urine formation is present. An indwelling urinary catheter may be inserted to determine the presence of residual urine, mechanical obstruction, or cloudy, foul-smelling urine. Urine output greater than 75 ml/day may indicate a lower urinary tract obstruction. Urine output less than 75 ml/day may indicate renal dysfunction or an obstruction higher in the urinary tract.

Assessment

History

Obtain a complete history, including changes in voiding pattern or urine characteristics. Ask the patient how much fluid he normally ingests each day, how much he ingested in the past 24 to 48 hours, and the time and amount of his last urination. Note a history of kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about abdominal, renal, or urinary tract surgery and about drug use.

Physical examination

Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.

Pediatric pointers

In neonates, anuria is defined as the absence of urine output for 24 hours. It can be classified as primary or secondary. Primary anuria results from bilateral renal agenesis, aplasia, or multicystic dysplasia. Secondary anuria, associated with edema or dehydration, results from renal ischemia, renal vein thrombosis, or congenital anomalies of the genitourinary tract. Anuria in children commonly results from loss of renal function.

Geriatric pointers

In elderly patients, anuria is a gradually occurring sign of underlying pathology. Hospitalized or bedridden elderly patients may be unable to generate the necessary pressure to void if they remain in a supine position. Elderly patients with disease processes; such as Alzheimer’s disease or dementia; may be difficult or impossible to evaluate due to urinary incontinence or an inability to record their own urinary output.

Medical causes

Acute tubular necrosis (ATN)

Oliguria (occasionally anuria) is a common initial finding with ATN. Associated symptoms may reflect the underlying cause, such as hyperkalemia (muscle weakness, cardiac arrhythmias), uremia (anorexia, nausea, vomiting, confusion, lethargy, twitching, convulsions, pruritus, uremic frost, and Kussmaul’s respirations), and heart failure (edema, jugular vein distention, crackles, and dyspnea).

Cortical necrosis (bilateral)

Bilateral cortical necrosis is characterized by a sudden change from oliguria to anuria, along with gross hematuria, flank pain, and fever.

Glomerulonephritis (acute)

Acute glomerulonephritis produces anuria or oliguria. Related effects include mild fever, malaise, flank pain, gross hematuria, facial and generalized edema, elevated blood pressure, headache, nausea, vomiting, abdominal pain, and signs and symptoms of pulmonary congestion (crackles, dyspnea).

Hemolytic-uremic syndrome

Anuria commonly occurs in the initial stages of hemolytic-uremic syndrome and may last from 1 to 10 days. The patient may experience vomiting, diarrhea, abdominal pain, hematemesis, melena, purpura, fever, elevated blood pressure, hepatomegaly, ecchymosis, edema, hematuria, and pallor. He may also show signs of an upper respiratory tract infection.

Papillary necrosis (acute)

Bilateral papillary necrosis produces anuria or oliguria. It also produces flank pain, costovertebral angle tenderness, renal colic, abdominal pain and rigidity, fever, vomiting, decreased bowel sounds, hematuria, and pyuria.

Renal artery occlusion (bilateral)

Bilateral renal artery occlusion produces anuria or severe oliguria, commonly accompanied by severe, continuous upper abdominal and flank pain; nausea and vomiting; decreased bowel sounds; fever up to 102° F (38.9° C); and diastolic hypertension.

Renal vein occlusion (bilateral)

Bilateral renal vein occlusion occasionally causes anuria; more typical signs and symptoms include acute low back pain, fever, flank tenderness, and hematuria. Development of pulmonary emboli — a common complication — produces sudden dyspnea, pleuritic pain, tachypnea, tachycardia, crackles, pleural friction rub, and possibly hemoptysis.

Urinary tract obstruction

Severe obstruction can produce acute, and sometimes, total anuria, alternating with or preceded by burning and pain on urination, overflow incontinence or dribbling, increased urinary frequency and nocturia, voiding of small amounts, or altered urine stream. Associated findings include bladder distention, pain and a sensation of fullness in the lower abdomen and groin, upper abdominal and flank pain, nausea and vomiting, and signs of secondary infection, such as fever, chills, malaise, and cloudy, foul-smelling urine.

Vasculitis

Vasculitis occasionally produces anuria. More typical findings include malaise, myalgia, polyarthralgia, fever, elevated blood pressure, hematuria, proteinuria, arrhythmias, pallor, and possibly skin lesions, urticaria, and purpura.

Other causes

Diagnostic tests

Contrast media used in radiographic studies can cause nephrotoxicity, producing oliguria and, rarely, anuria.

Drugs

Many classes of drugs can cause anuria or, more commonly, oliguria through their nephrotoxic effects. Antibiotics, especially aminoglycosides, are the most typically seen nephrotoxins. Anesthetics, heavy metals, ethyl alcohol, and organic solvents can also be nephrotoxic. Adrenergics and anticholinergics can cause anuria by affecting the nerves and muscles of micturition to produce urine retention.

Nursing considerations

If catheterization fails to initiate urine flow, prepare the patient for diagnostic studies — such as ultrasonography, cystoscopy, retrograde pyelography, and renal scan — to detect an obstruction higher in the urinary tract. If these tests fail to reveal an obstruction, prepare the patient for further kidney function studies. If these tests reveal an obstruction, immediate surgery may be indicated to remove the obstruction, and a nephrostomy or ureterostomy tube may be inserted to drain urine.

Carefully monitor the patient’s vital signs and intake and output, initially saving any urine for inspection. Restrict daily fluid allowance to 600 ml more than the previous day’s total urine output. Restrict foods and juices high in potassium and sodium, and make sure that the patient maintains a balanced diet with controlled protein levels. Provide low-sodium hard candy to help decrease thirst. Record fluid intake and output, and weigh the patient daily.

Patient teaching

Explain all tests and procedures to the patient. Depending on the cause of anuria, review the disorder’s early warning signs and symptoms. If the patient requires surgery, withhold food and fluids. Review medications that may worsen renal function.

Pictures

Book Source Details

• Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Inability to urinate

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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.

More About Causes of Inability to urinate

• Back to symptom: Inability to urinate: Introduction (review 25 causes)
• Next Book Extract About Inability to urinate: Anuria (Signs & Symptoms: A 2-in-1 Reference for Nurses)
• All Book Extracts: All Online Book Extracts for Inability to urinate

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More About This Book: Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-624-5

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