Management of Elevated Post-Void Residual (PVR) Urine
The management of elevated post-void residual (PVR) urine should follow a stepwise approach based on PVR volume, with intermittent catheterization being the first-line intervention for patients with PVR volumes >100 mL. 1
PVR Volume Assessment and Clinical Significance
- PVR volumes between 200-300 mL may indicate significant bladder dysfunction and predict a less favorable response to treatment 1, 2
- PVR of 350 mL or greater strongly indicates bladder dysfunction and may herald disease progression, particularly in benign prostatic hyperplasia (BPH) 2
- No specific PVR "cut-point" has been established for clinical decision-making due to test-retest variability, but values above 180 mL have been associated with increased risk of bacteriuria in men 3
- For confirmation of abnormal findings, PVR measurement should be repeated due to marked intra-individual variability 1, 2
Management Algorithm Based on PVR Volume
For PVR <100 mL:
For PVR 100-200 mL:
- Initiate intermittent catheterization 1
- Monitor for urinary tract infections 1
- Evaluate for underlying causes including:
For PVR >200 mL:
- Implement intermittent catheterization every 4-6 hours 1
- Catheterization should be performed to prevent bladder filling beyond 500 mL 1
- Consider pharmacological therapy based on underlying cause:
Special Considerations for Specific Patient Populations
Neurological Conditions:
- Perform PVR assessment during initial urological evaluation of patients with relevant neurological conditions (e.g., spinal cord injury, myelomeningocele) 6
- Consider complex cystometrogram (CMG) during initial evaluation of patients with neurological conditions 6
- In patients with stroke or other neurological conditions, intermittent catheterization is preferred over indwelling catheters to reduce infection risk 1
Overactive Bladder (OAB):
- Caution should be used when performing botulinum toxin injection in patients with PVR >100-200 mL 1
- PVR should be measured prior to intradetrusor botulinum toxin therapy for OAB 1
- Patients at higher risk for elevated PVR with OAB include those >55 years, prior incontinence surgery, history of multiple sclerosis, and vaginal prolapse stage 2 or greater 8
Children with Dysfunctional Voiding:
- Treatment of constipation alone resulted in improvement of bladder emptying in 66% of children presenting with increased PVR 1
- Double voiding (several toilet visits in close succession) may be useful in children with increased PVR 6
- Regular monitoring with voiding charts, uroflowmetry, and PVR measurement is necessary 6
Common Pitfalls to Avoid
- Avoid using indwelling catheters when intermittent catheterization is feasible, as indwelling catheters increase UTI risk 1
- No level of residual urine, in and of itself, mandates invasive therapy for BPH 1, 2
- Don't rely solely on PVR without considering other clinical factors when making treatment decisions 2
- Remember that PVR volumes between 0-300 mL do not predict response to medical therapy for BPH 2
Surgical Considerations
- Consider surgical intervention for patients with persistent elevated PVR despite conservative management 9
- Transurethral resection of the prostate (TURP) can eliminate symptoms of BPH but is associated with relatively more complications than other available surgical and minimally invasive procedures 7
- In women with significant elevations in PVR following anti-incontinence procedures, bladder outlet obstruction (BOO) should be suspected 6