What is the management approach for a patient presenting with urinary retention?

Management of Urinary Retention

Immediate bladder decompression via urethral catheterization should be performed for relief of acute urinary retention, followed by appropriate diagnostic evaluation and management based on the underlying etiology. 1

Initial Assessment and Management

• Confirm diagnosis and quantify residual volume through bladder scanning or straight catheterization 1
• Perform immediate bladder decompression with urethral catheterization using silver alloy-coated catheters to reduce urinary tract infection risk 1
• Remove indwelling catheters as soon as medically possible, ideally within 24-48 hours, to minimize infection risk 1

Diagnostic Evaluation Based on Suspected Etiology

• For suspected urethral stricture: Perform urethrocystoscopy or retrograde urethrogram (RUG) 1
• For suspected posterior urethral injury: Obtain both retrograde urethrography and voiding cystourethrogram (VCUG) 1
• For patients with neurological conditions: Consider urodynamic studies to assess detrusor function 1
• Evaluate for constipation as a potential cause, particularly in elderly patients 1, 2

Management Based on Specific Etiology

For BPH-Related Retention:

• Administer an alpha blocker (e.g., tamsulosin 0.4 mg once daily) prior to attempting catheter removal to improve chances of successful voiding trial 1, 3
• Tamsulosin should be administered approximately one-half hour following the same meal each day 3
• If no response after 2-4 weeks, the dose can be increased to 0.8 mg once daily 3
• Surgical intervention should be considered for patients with refractory retention who have failed at least one attempt at catheter removal 1, 4

For Constipation-Related Retention:

• Perform digital fragmentation and extraction of stool if impaction is present 2
• Use osmotic laxatives (polyethylene glycol, lactulose) or stimulant laxatives (bisacodyl, senna) 2
• For severe impaction, consider tap water enemas until clear (contraindicated in patients with neutropenia, thrombocytopenia, intestinal obstruction, or recent colorectal surgery) 2

For Neurogenic Bladder:

• Implement intermittent catheterization rather than indwelling catheters for initial management 1
• Consider suprapubic cystostomy prior to definitive treatment for patients dependent on indwelling urethral catheter 1

Surgical Management Options

• Transurethral resection of the prostate (TURP) remains the benchmark for surgical therapies for BPH-related retention 4
• For high-risk patients who cannot undergo other treatments, prostatic stents may be considered, though they are associated with significant complications including encrustation, infection, and chronic pain 1, 4
• The selection of energy source and instrumentation should be based upon the surgeon's experience, patient's individual prostatic anatomy, and medical comorbidities 4

Follow-Up and Monitoring

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

Special Considerations

• For elderly patients with constipation-related retention: Ensure access to toilets, provide dietetic support, optimize toileting, and use PEG (17 g/day) 2
• For opioid-induced constipation leading to retention: Prescribe concomitant laxatives with osmotic or stimulant laxatives generally preferred 2
• For patients with infected or obstructing urinary stones: Immediate decompression is warranted 1
• For post-stroke urinary retention: Remove Foley catheters within 24 hours after admission when possible 1

Common Pitfalls and Caveats

• Failure to recognize and treat underlying constipation can lead to recurrent urinary retention 2
• Delaying catheter removal increases risk of urinary tract infection 1
• Neglecting to start alpha blockers at the time of catheter insertion reduces the chance of successful voiding in men with BPH 5, 6
• Up to 10% of urinary retention episodes might be attributable to medication use, particularly drugs with anticholinergic activity, opioids, alpha-adrenoceptor agonists, and calcium channel antagonists 7