What are the treatment options for urinary retention (inability to empty the bladder)?

From the Guidelines

Urinary retention treatment should prioritize catheterization to relieve immediate discomfort, followed by targeted treatment based on the underlying cause, with alpha blockers like tamsulosin or alfuzosin being a recommended option for patients with benign prostatic hyperplasia (BPH) prior to a voiding trial, as supported by the most recent guideline from 2021 1.

Causes and Treatment Options

The treatment of urinary retention depends on the underlying cause, which can range from obstruction due to an enlarged prostate (BPH) to non-obstructive causes such as neurogenic bladder or medication side effects. For acute retention, catheterization is the initial step to relieve discomfort.

• For BPH-related retention, medications such as tamsulosin (Flomax) 0.4mg daily or alfuzosin (Uroxatral) 10mg daily can relax the prostate and bladder neck muscles, improving urine flow.
• Surgical options like transurethral resection of the prostate (TURP) or other minimally invasive procedures may be considered for severe cases.
• Women may experience retention due to pelvic organ prolapse or medication side effects, requiring different treatment approaches.

Lifestyle Modifications and Precautions

Patients should:

• Avoid medications that worsen retention, such as antihistamines, decongestants, and anticholinergics.
• Increase fluid intake to 1.5-2 liters daily, unless contraindicated.
• Practice double voiding (urinating, waiting a few minutes, then trying again).
• Seek immediate medical attention if unable to urinate for more than 8 hours or experiencing severe pain.

Diagnosis and Further Evaluation

Proper diagnosis is essential, and further evaluation may include uroflowmetry, ultrasound post-void residual (PVR) assessment, and urethro-cystoscopy to confirm the diagnosis and assess the severity of the condition, as recommended by guidelines for urethral stricture diagnosis 1 and BPH management 1.

From the FDA Drug Label

In A Long-Term Efficacy and Safety Study, efficacy was also assessed by evaluating treatment failures Treatment failure was prospectively defined as BPH-related urological events or clinical deterioration, lack of improvement and/or the need for alternative therapy. BPH-related urological events were defined as urological surgical intervention and acute urinary retention requiring catheterization.

Compared with placebo, finasteride tablets was associated with a significantly lower risk for acute urinary retention or the need for BPH-related surgery [13.2% for placebo vs 6. 6% for finasteride tablets; 51% reduction in risk, 95% CI: (34 to 63%)].

The primary efficacy assessments included: 1) total American Urological Association (AUA) Symptom Score questionnaire, which evaluated irritative (frequency, urgency, and nocturia), and obstructive (hesitancy, incomplete emptying, intermittency, and weak stream) symptoms, where a decrease in score is consistent with improvement in symptoms; and 2) peak urine flow rate, where an increased peak urine flow rate value over baseline is consistent with decreased urinary obstruction.

The treatment options for urinary retention (inability to empty the bladder) include:

• Finasteride: may reduce the risk of acute urinary retention or the need for BPH-related surgery 2
• Tamsulosin: may improve symptoms of BPH, including obstructive symptoms such as incomplete emptying, and increase peak urine flow rate 3 Key points:
• Finasteride and Tamsulosin are two medications that may be used to treat urinary retention associated with BPH.
• Finasteride has been shown to reduce the risk of acute urinary retention or the need for BPH-related surgery.
• Tamsulosin has been shown to improve symptoms of BPH and increase peak urine flow rate.

From the Research

Treatment Options for Urinary Retention

The treatment options for urinary retention can be categorized into several approaches, including:

• Initial management: assessment of urethral patency with prompt and complete bladder decompression by catheterization 4, 5
• Use of alpha blockers: to increase the likelihood of a successful trial without catheter (TWOC) following acute urinary retention (AUR) 6, 7
• Suprapubic catheterization: may be superior to urethral catheterization for short-term management 5
• Clean, intermittent self-catheterization: for patients with chronic urinary retention from neurogenic bladder 5
• Surgical treatment: may be necessary in some cases, such as when a trial without catheter fails 7
• Medical treatments: including the use of 5 alpha-reductase inhibitors, alpha blockers, and anticholinergics 7

Specific Treatment Approaches

Some specific treatment approaches include:

• Use of tamsulosin and slow-release alfuzosin: to reduce the time for attempting catheter removal 6
• Use of prophylactic 5 alpha-reductase inhibitors: to prevent AUR in men with BPH having moderate to severe lower urinary tract symptoms and large prostate size 7
• Transurethral resection of the prostate (TURP): remains the "gold standard" if a trial without catheter fails 7
• Alternative minimally invasive procedures: can be considered in poor-risk patients, but its value is yet to be established 7

Considerations for Management

The management of urinary retention should take into account the underlying cause and chronicity of the condition, as well as the patient's overall health and medical history 4, 5, 8. A thorough history, physical examination, and selected diagnostic testing should be used to determine the cause of urinary retention in most cases 5.