What are the treatment options for urinary retention?

Treatment of Urinary Retention

For acute urinary retention, immediate bladder decompression via urethral catheterization followed by oral alpha blocker therapy (tamsulosin 0.4 mg or alfuzosin 10 mg once daily) is the first-line treatment, with the alpha blocker started at the time of catheter insertion and continued for at least 3 days before attempting catheter removal. 1, 2

Immediate Management

• Perform immediate bladder decompression via urethral catheterization for relief of acute urinary retention 2
• If blood is present at the urethral meatus after pelvic trauma, perform retrograde urethrography before attempting catheterization to rule out urethral injury 2
• Consider silver alloy-coated urinary catheters to reduce urinary tract infection risk 2
• Avoid indwelling catheters when possible; intermittent catheterization is generally preferred for initial management 2

Pharmacologic Therapy for Acute Retention

Alpha blockers significantly improve trial without catheter (TWOC) success rates:

• Alfuzosin achieves 60% success versus 39% with placebo 1, 2, 3
• Tamsulosin achieves 47% success versus 29% with placebo 1, 2, 3
• The overall evidence shows alpha blockers increase TWOC success (RR 1.55,95% CI 1.36 to 1.76) 3

Specific prescribing recommendations:

• Prescribe a non-titratable alpha blocker (tamsulosin 0.4 mg or alfuzosin 10 mg once daily) prior to voiding trial 1, 2
• Administer alpha blocker therapy for at least 3 days before attempting catheter removal 1, 2
• Avoid doxazosin or terazosin as first-line agents in acute retention, as these require titration 2, 4

Important caveats for elderly patients:

• Exercise caution with alpha blockers in patients with orthostatic hypotension, cerebrovascular disease, or history of falls 2
• Tamsulosin may have a lower probability of orthostatic hypotension compared to other alpha blockers 2
• Overall adverse effect rates are low and comparable to placebo 3, 5

Trial Without Catheter (TWOC)

• 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) 2
• Counsel patients that they remain at increased risk for recurrent urinary retention even after successful catheter removal 1, 2
• Alpha blockers reduce the incidence of recurrent acute urinary retention (RR 0.69,95% CI 0.60 to 0.79) 3

Management Based on Etiology

BPH-Related Retention:

For patients who fail TWOC:

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

Long-term medical management:

• For patients with prostatic enlargement (prostate volume >30cc, PSA >1.5 ng/mL, or palpable enlargement on DRE), 5-alpha reductase inhibitors (finasteride or dutasteride) should be used for symptom improvement 1
• Combination therapy with alpha blockers and 5-alpha reductase inhibitors reduces the risk of progression by 67%, acute urinary retention by 79%, and need for surgery by 67% compared to placebo 1, 6
• Finasteride reduces acute urinary retention risk by 57% (2.8% vs 6.6% for placebo) and surgery risk by 55% (4.6% vs 10.1% for placebo) 6

Urethral Stricture:

• Perform urethrocystoscopy or retrograde urethrogram to diagnose urethral stricture if suspected 2
• Consider urethral dilation, direct visual internal urethrotomy, or urethroplasty depending on stricture characteristics 2
• For patients dependent on catheterization, consider suprapubic cystostomy prior to definitive urethroplasty 2

Neurogenic Bladder:

• Patients with chronic urinary retention from neurogenic bladder should manage their condition with clean, intermittent self-catheterization 7
• Urodynamic studies may be necessary to assess detrusor function 2

Constipation-Related:

• Evaluate for constipation as a potential cause, particularly in elderly patients 2
• Treat underlying constipation with osmotic laxatives (polyethylene glycol, lactulose) or stimulant laxatives (bisacodyl, senna) 2

Catheter Management

• Remove indwelling catheters as soon as medically possible, ideally within 24-48 hours, to minimize infection risk 2
• For post-stroke patients with urinary retention, remove Foley catheters within 24 hours after admission when possible 2
• Prolonged use of indwelling catheters increases the risk of urinary tract infections and should be avoided 2

Follow-Up and Monitoring

• 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 2
• Patients with large prostates (>30cc) may benefit from combination therapy to prevent future episodes of retention 2
• 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 2

Common Pitfalls to Avoid

• Do not delay surgical intervention in patients with refractory retention, as this can lead to bladder decompensation and chronic retention 2
• Avoid blind catheter passage prior to retrograde urethrogram in cases of suspected urethral injury 2
• Do not assume alpha blocker therapy alone will manage concomitant hypertension; hypertension may require separate management 2
• Prostatic stents should only be considered in high-risk patients who cannot undergo other treatments, as they are associated with significant complications including encrustation, infection, and chronic pain 2