What is the management plan for urinary retention?

Management of Urinary Retention

The initial management for urinary retention should include immediate bladder decompression via urethral catheterization using a silver alloy-coated catheter to reduce infection risk, followed by treatment of the underlying cause. 1, 2

Initial Assessment and Management

• Confirm diagnosis of urinary retention through bladder scanning or straight catheterization to quantify residual volume 1
• Perform immediate bladder decompression via urethral catheterization for relief of acute urinary retention 1, 2
• Use silver alloy-coated urinary catheters to reduce urinary tract infection risk 3, 1
• Remove the catheter as soon as possible, ideally within 48 hours to minimize urinary tract infection risk 3

Specific Management Based on Etiology

For BPH-Related Retention:

• Administer an alpha blocker (e.g., tamsulosin or alfuzosin) prior to attempting catheter removal to improve chances of successful voiding trial (success rates of 60% vs 39% for placebo with alfuzosin, and 47% vs 29% for placebo with tamsulosin) 1, 2
• Consider 5-alpha reductase inhibitors (finasteride) for patients with prostate volume >30cc to reduce risk of acute urinary retention (57% reduction compared to placebo) 4
• For patients who fail trial without catheter (TWOC), surgical intervention may be necessary 2

For Urethral Stricture:

• Utilize urethral endoscopic management (e.g., urethral dilation or direct visual internal urethrotomy) or immediate suprapubic cystostomy for urgent management 3
• For short (<2 cm) bulbar urethral strictures, options include dilation, direct visual internal urethrotomy (DVIU), or urethroplasty 3
• Consider self-catheterization after DVIU to maintain temporary urethral patency in patients who are not candidates for urethroplasty 3

For Constipation-Related Retention:

• Treat underlying constipation with osmotic laxatives (polyethylene glycol, lactulose) or stimulant laxatives (bisacodyl, senna) 5
• Consider digital fragmentation and extraction of stool if impaction is present 5
• Increase fluid intake, dietary fiber, and physical activity to prevent recurrence 5

For Neurogenic Bladder:

• Implement intermittent catheterization rather than indwelling catheters for initial management 1, 2
• Consider urodynamic studies to assess detrusor function 1

Follow-Up and Monitoring

• Implement an individualized bladder-training program for patients with persistent urinary incontinence 3
• Use prompted voiding techniques for patients with urinary incontinence 3
• Inform patients who successfully void after catheter removal that they remain at increased risk for recurrent urinary retention 2
• For patients requiring long-term catheterization, schedule regular follow-up to assess for complications such as UTI, bladder stones, and renal function deterioration 1

Special Considerations

• In patients with stroke, remove indwelling catheters as soon as the patient is medically and neurologically stable 2
• For patients dependent on an indwelling urethral catheter or intermittent self-dilation, consider suprapubic cystostomy prior to definitive urethroplasty 3
• For medication-induced retention, discontinue or reduce the dose of the causative medication (common culprits include anticholinergics, opioids, alpha-adrenoceptor agonists, and benzodiazepines) 6
• Elderly patients are at higher risk for drug-induced urinary retention due to existing co-morbidities and polypharmacy 6

Pitfalls to Avoid

• Prolonged use of indwelling catheters increases the risk of urinary tract infections 2
• Not informing patients about the risk of recurrent retention after successful trial without catheter 2
• Failure to recognize and treat underlying constipation as a potential cause of urinary retention, particularly in elderly patients 5