Treatment Options for Urinary Retention
The initial management for urinary retention should include immediate bladder decompression via catheterization, with alpha blockers prescribed prior to attempting catheter removal to improve chances of successful voiding. 1, 2
Initial Assessment and Management
- Confirm urinary retention through bladder scanning or straight catheterization to quantify residual volume 1
- Perform immediate bladder decompression via urethral catheterization for relief of acute urinary retention 1
- Consider silver alloy-coated urinary catheters to reduce urinary tract infection risk 1
- If blood is present at the urethral meatus after pelvic trauma, perform retrograde urethrography before attempting catheterization to rule out urethral injury 1
Pharmacological Management
- Administer an alpha blocker (e.g., tamsulosin or alfuzosin) prior to attempting catheter removal to improve chances of successful voiding trial 1, 2
- Success rates of 60% versus 39% for placebo with alfuzosin, and 47% versus 29% for placebo with tamsulosin have been reported 2
- For BPH-related retention, consider combination therapy with alpha blockers and 5-alpha reductase inhibitors (like finasteride) for preventing future episodes of retention in men with large prostates (>30cc) 1
- Finasteride has been shown to reduce the risk of acute urinary retention by 57% compared to placebo (2.8% vs 6.6%) 3
Surgical Management Options
- Transurethral resection of the prostate (TURP) remains the benchmark surgical treatment for BPH-related urinary retention 1
- For urethral stricture causing retention, options include urethral dilation, direct visual internal urethrotomy, or urethroplasty 1
- Sphincterotomy may be offered to facilitate emptying in appropriately selected male patients with neurogenic lower urinary tract dysfunction (NLUTD), but patients must be counseled about the high risk of failure or potential need for additional treatment 4
Management Based on Specific Etiologies
For BPH-Related Retention:
- Initial management with alpha blockers followed by a voiding trial 1, 2
- If the voiding trial fails, surgical intervention is recommended 1
- Finasteride has been shown to significantly reduce the risk for surgery (10.1% for placebo vs 4.6% for finasteride) 3
For Neurogenic Bladder:
- Intermittent catheterization is generally recommended rather than indwelling catheters 1, 2
- OnabotulinumtoxinA may be offered to NLUTD patients refractory to oral medications to improve bladder storage parameters and decrease episodes of incontinence 4
- Patients must be counseled about the risk of urinary retention after botulinum toxin therapy (20.49% for onabotulinumtoxinA vs 3.67% for placebo) 4
For Stress Urinary Incontinence in NLUTD:
- Slings should be offered to select patients with acceptable bladder storage parameters 4
- Urethral bulking agents may be offered but patients must be counseled that efficacy is modest and cure is rare 4
Follow-Up and Monitoring
- Remove indwelling catheters as soon as medically possible, ideally within 24-48 hours, to minimize infection risk 1
- Patients who successfully void after catheter removal should be informed that they remain at increased risk for recurrent urinary retention 2
- For patients with chronic retention requiring long-term catheterization, regular follow-up to assess for complications such as UTI, bladder stones, and renal function deterioration is essential 1
Important Caveats
- Avoid delaying surgical intervention in patients with refractory retention, as this can lead to bladder decompensation and chronic retention 1
- Prolonged use of indwelling catheters increases the risk of urinary tract infections and should be avoided when possible 2
- 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