What is the best course of action for an elderly male patient with a history of Benign Prostatic Hyperplasia (BPH) presenting with impaired renal function, abdominal pain, back pain, and dysuria after a 5-day illness?

Immediate Urological Referral and Bladder Decompression Required

This elderly male with BPH presenting with severe acute kidney injury (GFR 13) and obstructive symptoms requires emergent urological consultation for bladder decompression via catheterization and definitive surgical management, as renal insufficiency clearly due to BPH is an absolute indication for surgery. 1, 2

Immediate Management Algorithm

Step 1: Emergency Bladder Decompression

• Place a urethral catheter immediately to relieve the likely obstructive uropathy causing acute-on-chronic kidney injury 1
• If urethral catheterization fails due to prostatic obstruction, proceed to suprapubic catheterization 1
• Measure post-void residual volume (though likely in retention given the clinical picture) 2, 3
• Monitor for post-obstructive diuresis after catheter placement, which can be massive and require careful fluid management 4

Step 2: Confirm Obstructive Etiology

• Obtain renal ultrasonography urgently to assess for hydronephrosis, which would confirm postrenal acute kidney injury from BPH-related obstruction 4
• The combination of dysuria, back pain (suggesting possible pyelonephritis or hydronephrosis), abdominal pain, and severe renal dysfunction in a BPH patient strongly suggests obstructive uropathy 1, 4
• Measure serum and urine electrolytes to assess for metabolic derangements from acute kidney injury 4

Step 3: Rule Out Concurrent Infection

• Obtain urinalysis and urine culture immediately, as the dysuria and 5-day illness may indicate concurrent urinary tract infection or pyelonephritis complicating the obstruction 1, 5
• If infection is present, initiate appropriate antibiotic therapy while awaiting culture results 1

Definitive Treatment Plan

Surgical Intervention (Primary Recommendation)

Surgery is the recommended treatment for patients with renal insufficiency clearly due to BPH 1, 2. The guideline evidence is unequivocal on this point:

• Transurethral Resection of the Prostate (TURP) is the gold standard for BPH patients with renal insufficiency 2, 6
• Open prostatectomy should be considered if the prostate is very large 2
• Transurethral Holmium Laser Resection/Enucleation may be beneficial given potentially fewer bleeding complications in a patient with renal impairment 2

Medical Bridge Therapy (Optional Pre-Surgical)

• Consider starting a non-titratable alpha-blocker (tamsulosin or alfuzosin) prior to attempting catheter removal for a voiding trial 1
• This is only appropriate if the patient does not have orthostatic hypotension or cerebrovascular disease that would increase risks 1
• However, given the severity of renal dysfunction (GFR 13), medical therapy alone is not an acceptable long-term strategy 1, 2

If Patient is Not a Surgical Candidate

• For patients whose overall health makes them unacceptable surgical risks, treatment with intermittent catheterization, indwelling catheter, or prostatic stent is recommended 1, 2
• This represents palliation rather than definitive treatment 1

Critical Pitfalls to Avoid

Do Not Delay Catheterization

• With GFR 13, every hour of continued obstruction risks irreversible renal damage 4
• Acute kidney injury is associated with increased mortality, cardiovascular events, and progression to chronic kidney disease 4

Do Not Attempt Medical Management Alone

• Balloon dilation is explicitly not recommended regardless of clinical scenario 1, 2
• Minimally invasive procedures (TUMT, etc.) have insufficient outcomes data in patients with urinary retention and renal insufficiency 1
• Medical therapy with alpha-blockers or 5-alpha reductase inhibitors is contraindicated as primary treatment when renal insufficiency is present 1

Do Not Miss Concurrent Complications

• Assess for other absolute surgical indications: recurrent UTIs, recurrent gross hematuria, bladder stones 1, 2
• The 5-day illness with dysuria raises concern for concurrent infection requiring immediate treatment 1, 5

Nephrology Consultation Indications

• Consult nephrology given stage 5 chronic kidney disease (GFR 13) for assessment of whether this represents acute-on-chronic kidney disease versus purely acute obstruction 4
• Nephrology should be involved for inadequate response to supportive treatment, stage 3 or higher acute kidney injury, and preexisting stage 4 or higher chronic kidney disease 4
• Renal replacement therapy may be necessary if kidney function does not improve after relief of obstruction 4

Post-Decompression Monitoring

• Reassess renal function 24-48 hours after catheter placement to determine degree of reversibility 4
• Adjust all medications according to renal function 4
• Discontinue any nephrotoxic medications 4
• Optimize volume status with isotonic crystalloid if prerenal component exists 4