Does a 78-year-old man with acute urinary retention after a hip fracture need a Prostate-Specific Antigen (PSA) test or Digital Rectal Examination (DRE)?

Management of Acute Urinary Retention in an Elderly Man After Hip Fracture

A 78-year-old man with acute urinary retention following hip fracture does not routinely need a PSA test or DRE at this time, as the retention is likely related to the acute trauma and perioperative factors rather than underlying prostate pathology.

Etiology of Acute Urinary Retention After Hip Fracture

• Acute urinary retention is extremely common in hip fracture patients, with incidence rates as high as 82% before surgery and 56% after surgery 1
• The retention is typically related to trauma, pain, immobility, medications (especially opioids and anesthetics), and the stress response to injury rather than underlying prostate pathology 1, 2
• Fecal impaction is strongly associated with postoperative urinary retention after hip fracture surgery (OR 4.78,95% CI 2.44-9.71) and should be assessed 3

Initial Management Approach

• The priority should be bladder decompression to prevent complications, using either:

  • Intermittent catheterization (preferred) - associated with earlier return to normal voiding (mean 5.1 days vs 9.4 days with indwelling catheters) 4
  • Indwelling catheter - should be removed within 24-48 hours after surgery to reduce risk of urinary tract infection and prolonged retention 2, 5

• Urinalysis should be performed to screen for hematuria and urinary tract infection 6

When PSA Testing and DRE Are Indicated

• PSA testing and DRE are not routinely indicated in the acute management of urinary retention after hip fracture 6

• PSA testing should only be considered in the following circumstances:

  • Patients with at least a 10-year life expectancy for whom knowledge of prostate cancer would change management 6
  • Patients for whom PSA measurement may change the management of their voiding symptoms 6
  • After resolution of the acute episode and any urinary tract infection (as infection can falsely elevate PSA) 7

• DRE should be considered only if:

  • There is suspicion of locally advanced prostate cancer causing obstruction 6, 8
  • As part of the evaluation of persistent lower urinary tract symptoms after recovery from hip fracture 6

Follow-up Recommendations

• Monitor for resolution of urinary retention with trial of voiding after catheter removal 4
• If retention persists beyond the expected recovery period (typically 5-10 days post-surgery), further urological evaluation may be warranted 1, 4
• For patients with persistent lower urinary tract symptoms after recovery, a complete urological evaluation including DRE and consideration of PSA testing would be appropriate 6

Important Considerations

• Urinary retention after hip fracture is primarily a consequence of the trauma and perioperative factors rather than an indication of underlying prostate disease 1, 2
• Focusing on early mobilization, adequate pain control, and prevention of constipation can help reduce the duration of urinary retention 5, 3
• Prolonged catheterization increases the risk of urinary tract infections and should be avoided 2, 4