What is the initial management for urinary retention caused by prostate cancer?

Initial Management of Urinary Retention Caused by Prostate Cancer

For urinary retention caused by prostate cancer, the initial management should include immediate bladder catheterization followed by alpha blocker therapy (such as tamsulosin 0.4mg daily or alfuzosin 10mg daily) for at least three days before attempting a trial without catheter. 1

Initial Assessment and Intervention

• Immediate relief: Bladder catheterization is the first step to relieve acute urinary retention
• Medication initiation: Start alpha blocker therapy at the time of catheter insertion
  • Preferred options: Tamsulosin 0.4mg daily or Alfuzosin 10mg daily
  • These medications relax the smooth muscle at the bladder neck and prostate, improving voiding function

Trial Without Catheter (TWOC)

• Complete at least 3 days of alpha blocker therapy before attempting TWOC 2
• For the TWOC procedure:
  1. Fill the bladder with 300-400 mL of sterile fluid
  2. Remove the catheter
  3. Ask the patient to void
  4. Measure post-void residual (PVR)
  5. Success defined as PVR <100 mL 1

Follow-up Management

• Inform patients who pass a successful TWOC that they remain at increased risk for recurrent urinary retention 2
• Continue alpha blocker therapy for ongoing management
• Monitor PVR volumes regularly
• Assess symptom improvement using validated questionnaires (IPSS)

Additional Treatment Considerations

For Persistent Symptoms or Enlarged Prostate

• Consider adding 5-alpha reductase inhibitors (5-ARIs) such as finasteride or dutasteride for long-term management in men with enlarged prostates (>30cc)
• The combination of alpha blocker and 5-ARI reduces the risk of AUR by 68% and BPO-related surgery by 71% compared to alpha blocker monotherapy alone 1

For Mixed Obstructive and Storage Symptoms

• Consider adding mirabegron (a beta-3 agonist) to alpha blocker therapy
• This combination improves urinary frequency and urgency with low risk (1.7%) of worsening retention 1

Surgical Management

• If medical management fails, surgical intervention may be necessary
• Transurethral resection of the prostate (TURP) is an effective option to free patients from long-term catheterization
• Note that advanced age is associated with higher long-term failure rates requiring catheterization after TURP 3
• In a study of patients undergoing TURP for urinary retention, 87% were catheter-free at follow-up, with a mean quality of life score of 1.08 3

Cautions and Contraindications

• Anticholinergics/antimuscarinics are contraindicated in patients with PVR >150ml 1
• Non-selective alpha blockers have a higher risk of orthostatic hypotension
• Monitor for side effects of alpha blockers, particularly orthostatic hypotension with first doses
• Identify and discontinue or reduce medications that can exacerbate urinary retention (anticholinergics, alpha-adrenergic agonists, opioids, antipsychotics, and antidepressants) 1

Long-term Considerations

• Regular follow-up to evaluate treatment efficacy and adjust therapy as needed
• For patients with prostate cancer undergoing radiation therapy, prophylactic use of alpha blockers may help prevent acute urinary retention 4
• Clean intermittent self-catheterization is preferred over indwelling catheters for long-term management if necessary 1