What are the next steps for a patient failing a trial of void?

Management of Failed Trial of Void

For patients failing a trial of void (TWOC), the next steps should include catheter reinsertion, alpha blocker therapy for at least 3 days, and a repeat voiding trial, with consideration of intermittent catheterization if appropriate. 1

Assessment After Failed Trial of Void

When a patient fails a trial of void, immediate management includes:

1. Reinsertion of urinary catheter to relieve acute urinary retention
2. Post-void residual measurement to quantify the volume of retained urine 1
3. Assessment for underlying causes that may be contributing to retention:
   • Benign prostatic hyperplasia (BPH) in male patients
   • Recent surgery (particularly pelvic, gynecologic, or urologic procedures)
   • Medication effects (anticholinergics, opioids)
   • Neurological conditions affecting bladder function

Pharmacological Management

Alpha blockers are the cornerstone of medical management for patients who have failed a trial of void, particularly when related to BPH:

• Initiate alpha blocker therapy (alfuzosin, tamsulosin) for at least 3 days before attempting another trial of void 1
• Alpha blockers work by antagonizing alpha1-adrenoreceptors in the prostate and bladder neck, reducing smooth muscle tone and improving urinary flow
• These medications improve TWOC success rates from 29-39% (placebo) to 47-60% (with alpha blockers) 1

Timing of Repeat Trial of Void

The evidence suggests:

• Allow at least 3 days of alpha blocker therapy before attempting a repeat trial of void 1
• Interestingly, research shows that the timing of repeat in-office voiding trials in post-hysterectomy patients does not predict success - patients who presented at less than 3 days, exactly 3 days, or more than 3 days postoperatively had similar success rates 2

Bladder Training and Management Options

For patients who have failed an initial trial of void:

• Implement a bladder training program with scheduled voiding every 2 hours during the day and every 4 hours at night 1
• Consider intermittent catheterization if post-void residual volume is >100mL 1
• Options for management include:
  1. Intermittent catheterization (recommended every 4-6 hours to prevent bladder filling beyond 500mL)
  2. Indwelling catheter with planned repeat trial of void
  3. Continued pharmacological management with alpha blockers 1

Behavioral Techniques

Implement behavioral techniques to improve voiding success:

• Double voiding (attempt to void, wait a few minutes, then try again)
• Relaxation techniques to reduce anxiety and pelvic floor tension
• Warm sitz baths to relax pelvic musculature
• Prompted voiding for patients with cognitive impairment 3
• High fluid intake during day and decreased fluid intake in evening 1

Long-term Considerations

Patients who fail multiple trials of void may require:

1. Urological consultation for potential surgical intervention, particularly for BPH
2. Long-term follow-up as patients who initially pass a TWOC remain at increased risk for recurrent urinary retention 1
3. Surgical options for refractory cases - long-term data suggests that 80% of patients who initially voided successfully with alpha blockers eventually required surgical intervention such as transurethral resection of the prostate (TURP) 1

Infection Prevention

• Monitor for signs of urinary tract infection, as the incidence is significantly higher in patients who fail voiding trials (37.3% vs 7.3%) 2
• Early catheter removal when possible reduces the risk of catheter-associated UTIs 1

By following this structured approach to managing failed trials of void, clinicians can optimize patient outcomes while minimizing complications associated with prolonged catheterization.