What is the best course of treatment for a patient with Benign Prostatic Hyperplasia (BPH) presenting to the emergency department with urinary retention?

Management of Urinary Retention in BPH Patients

For a patient with BPH presenting to the emergency department with urinary retention, immediate bladder decompression via urethral catheterization should be performed, followed by administration of an alpha blocker (e.g., tamsulosin or alfuzosin) prior to attempting catheter removal to improve chances of successful voiding. 1, 2

Initial Management

• Confirm urinary retention through bladder scanning or straight catheterization to quantify residual volume 2
• Perform immediate bladder decompression via urethral catheterization for relief of acute urinary retention 2
• Consider using silver alloy-coated urinary catheters to reduce urinary tract infection risk 2
• Administer a non-titratable alpha blocker (tamsulosin or alfuzosin) prior to attempted catheter removal to improve chances of successful voiding trial 1, 2
• Alpha blockers would not be appropriate in patients with prior history of alpha-blocker side effects or unstable medical comorbidities (e.g., orthostatic hypotension, cerebral vascular disease) 1

Trial Without Catheter

• After 2-3 days of catheterization and alpha blocker therapy, attempt a voiding trial 1, 3
• A voiding trial is more likely to be successful if the underlying retention was precipitated by temporary factors (e.g., anesthesia or alpha-adrenergic sympathomimetic cold medications) 1
• If the voiding trial fails, surgical intervention is recommended 1

Surgical Management

• Surgery is recommended for patients with refractory retention who have failed at least one attempt at catheter removal 1
• Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment for BPH-related urinary retention 1, 2
• For patients who are not surgical candidates, treatment with intermittent catheterization, an indwelling catheter, or stent is recommended 1

Alternative Management Options

• 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, 2
• 5-alpha reductase inhibitors (finasteride, dutasteride) can be used for long-term management to reduce the risk of recurrent acute urinary retention in men with enlarged prostates 4, 5
• Combination therapy with alpha blockers and 5-alpha reductase inhibitors may be more effective than monotherapy for preventing future episodes of retention in men with large prostates (>30cc) 1, 4, 5

Follow-Up Considerations

• Patients who successfully void after catheter removal should be informed that they remain at increased risk for recurrent urinary retention 2, 3
• Regular follow-up is essential to assess for complications such as UTI, bladder stones, and renal function deterioration in patients requiring long-term catheterization 2
• Patients should be counseled that acute urinary retention and the potential need for surgery are significant concerns that can substantially impact quality of life 6

Important Caveats

• Avoid delaying surgical intervention in patients with refractory retention, as this can lead to bladder decompensation and chronic retention 1
• Alpha blockers mainly help to delay surgery and may avoid it altogether in only a subgroup of patients 3
• Urgent prostatic surgery after acute urinary retention is associated with greater morbidity and mortality than delayed prostatectomy, so stabilizing the patient with catheterization and medical therapy first is preferred 3
• Surgery is also recommended for patients who have renal insufficiency, recurrent UTIs, recurrent gross hematuria, or bladder stones due to BPH and refractory to other therapies 1