What is the initial treatment for urinary retention due to Benign Prostatic Hyperplasia (BPH)?

Initial Treatment for Urinary Retention due to BPH

For patients with acute urinary retention due to BPH, the initial treatment is catheterization followed by administration of an alpha blocker prior to attempting catheter removal. 1

Management Algorithm for Acute Urinary Retention due to BPH

Initial Management

• Immediate bladder decompression via urethral catheterization 1
• Start an alpha blocker (preferably a non-titratable one like tamsulosin or alfuzosin) 1
• Continue alpha blocker therapy for at least 3 days before attempting a trial without catheter (TWOC) 1

Alpha Blocker Selection

• Tamsulosin (0.4mg daily) or alfuzosin are preferred due to:
  • No need for dose titration, reducing first-dose hypotensive effects 2
  • Less effect on blood pressure compared to other alpha blockers, making them safer for elderly patients 2
  • Once-daily dosing improving compliance 2

Trial Without Catheter (TWOC)

• After at least 3 days of alpha blocker therapy, attempt catheter removal 1
• Alpha blockers significantly improve TWOC success rates:
  • Alfuzosin: 60% success vs 39% with placebo 1, 3
  • Tamsulosin: 47% success vs 29% with placebo 1, 4

Follow-up After Successful TWOC

• Inform patients about increased risk of recurrent urinary retention even after successful TWOC 1
• Continue alpha blocker therapy to reduce risk of recurrent retention 1, 3

Special Considerations

For Patients with Failed TWOC

• If catheter removal fails after alpha blocker treatment, surgery is recommended 1
• For patients who are not surgical candidates, options include:
  • Intermittent catheterization 1
  • Indwelling catheter 1
  • Prostatic stent placement 1

For Patients with Large Prostates (>30cc)

• Consider adding a 5-alpha reductase inhibitor (5ARI) like finasteride to the alpha blocker 1, 5
• Finasteride reduces the risk of acute urinary retention by 57% compared to placebo (2.8% vs 6.6%) 5
• The combination can reduce the risk of BPH progression and need for surgery 5

Contraindications to Alpha Blockers

• Prior history of alpha blocker side effects 1
• Unstable medical comorbidities (e.g., orthostatic hypotension, cerebrovascular disease) 1
• For patients with hypertension, doxazosin has been associated with higher incidence of congestive heart failure than other antihypertensive agents 2

Pitfalls and Caveats

• TWOC is more likely to be successful if retention was precipitated by temporary factors (e.g., anesthesia, alpha-adrenergic sympathomimetic cold medications) 1
• Alpha blockers provide short-term improvement, but many patients may still require surgical intervention in the long term 3
• Balloon dilation is not recommended as a treatment option for BPH 1
• Despite initial success with alpha blockers, patients should be monitored for recurrent retention as the long-term efficacy in preventing further episodes is not well established 3