What are the treatment options for urinary retention after prostatectomy (prostate removal)?

Urinary Retention After Prostate Removal

For acute urinary retention after prostatectomy, initiate alpha-blocker therapy (tamsulosin or alfuzosin) 2-3 days before attempting catheter removal, and if the patient fails a trial without catheter despite medical therapy, proceed to surgery (TURP or other definitive surgical intervention) as the treatment of choice. 1

Immediate Management of Acute Retention

Initial Catheterization and Medical Therapy

• Place a Foley catheter immediately for bladder decompression 1, 2
• Start an alpha-blocker (preferably tamsulosin 0.4 mg or alfuzosin) prior to attempting catheter removal 1, 3
• Tamsulosin should be administered for at least 3 days before and 4 days after catheter removal to significantly reduce retention risk (reduces acute retention from 10% to 2.6%) 3
• Alpha-blockers are contraindicated in patients with prior history of alpha-blocker side effects, orthostatic hypotension, or cerebrovascular disease 1

Trial Without Catheter (TWOC)

• A voiding trial is more likely successful if retention was precipitated by temporary factors such as anesthesia or sympathomimetic medications 1
• Alpha-blocker therapy improves TWOC success rates (55% with alfuzosin vs 29% with placebo) 4
• Monitor post-void residual (PVR) volume after successful TWOC, as elevated PVR predicts recurrent retention and need for early surgical intervention 4

Definitive Management for Refractory Retention

Surgical Intervention

• Surgery is the treatment of choice for patients with refractory retention who have failed at least one attempt at catheter removal 1
• TURP remains the gold standard surgical approach for chronic retention 2
• Minimally invasive treatments (TUMT) have insufficient outcomes data from well-controlled trials and are not currently recommended 1

Non-Surgical Candidates

• For patients who are not surgical candidates due to medical comorbidities, offer: 1
  • Intermittent catheterization (preferred)
  • Indwelling catheter
  • Urethral stent

Important Clinical Considerations

Risk Factors to Assess

• Advanced age, larger prostate size, and shorter membranous urethral length increase retention risk 1
• Operative time, intravenous fluid administration, and anesthesia type contribute to postoperative retention 2
• Prior TURP or radiation therapy significantly increases retention risk 1

Complications Requiring Urgent Surgery

Surgery is mandatory for patients with: 1

• Renal insufficiency clearly due to BPH/retention
• Recurrent urinary tract infections secondary to retention
• Recurrent gross hematuria
• Bladder stones
• Large bladder diverticula with recurrent UTI or progressive bladder dysfunction

Common Pitfalls to Avoid

• Do not attempt early catheter removal (before postoperative day 7-8) without alpha-blocker coverage, as this significantly increases retention risk 3
• Avoid prolonged catheterization when possible, as bacterial colonization occurs at 4% per day 4
• Do not confuse urinary retention with post-prostatectomy incontinence—these require completely different management approaches 1
• Patients with elevated PVR after successful TWOC require close follow-up, as they are at high risk for recurrent retention (mean 4.1 months) 4

Distinguishing Retention from Incontinence

• Urinary retention presents with inability to void despite bladder fullness 2
• Post-prostatectomy incontinence (stress urinary incontinence) is expected short-term and generally improves by 12 months 1
• If diagnostic uncertainty exists between retention and incontinence, perform urodynamic testing to differentiate sphincteric dysfunction from bladder dysfunction 1