Urinary retention (suspected)

Any person, 16 years and over, presenting with the inability to empty their bladder of urine partially or completely.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock Tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

Assessment	Intervention
ACVPU	If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
Nausea and/or vomiting	If present, see nausea and/or vomiting section
Genitourinary	Inspect indwelling urinary devices, if in situ Assess for blockages, kinks, blood or sedimentation Inspect catheter insertion point for signs of infection or obstruction

Glucose

Assessment	Intervention
BGL	Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol

Focused assessment

Complete an abdominal focused assessment.

Precautions and notes

• Retention with overflow can be associated with long-term or chronic urinary retention, where the bladder is unable to empty completely, though the patient still voids frequent small amounts.
• Medications with anticholinergic properties can contribute to urinary retention.
• Patient may become hypotensive post decompression of the bladder which should be transient and self-resolve.

Interventions and diagnostics

Specific treatment

Assess bladder with a bedside bladder scanner, if available, or by palpating.

If the patient has a painful, percussible or palpable bladder or if the detected volume is over 450 mL, and the patient cannot void:

• insert or change indwelling catheter (IDC) – if patient has had recent urologic, gynaecologic or spinal surgery within the past 6 weeks, or urinary diversion surgery, do not attempt catheterisation
• document residual urine volume
• measure the volume of urine hourly, via collection bag.

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Analgesia

Select pain score:

• 1–3 (mild)
• 4–6 (moderate)
• 7–10 (severe)

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

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Pathology

• FBC, UEC
• Urinalysis: mid-stream (preferred), clean catch or catheter urine. If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed
• Warfarinised: INR
• If bleeding suspected: group and hold
• Temp less than 35°C or 38.5°C and over: take two sets of blood cultures from two separate sites

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au