What is the treatment for acute urinary retention?

Acute Urinary Retention Treatment

Immediately decompress the bladder via urethral catheterization, start an oral alpha-blocker (tamsulosin 0.4 mg or alfuzosin 10 mg once daily) at the time of catheter insertion, continue for at least 3 days, then attempt catheter removal with a trial without catheter (TWOC). 1, 2

Initial Management Algorithm

Step 1: Immediate Bladder Decompression

• Perform urethral catheterization immediately to relieve acute retention and prevent bladder decompensation 1, 2, 3
• If urethral catheterization fails or blood is present at the urethral meatus after pelvic trauma, perform retrograde urethrography before attempting catheterization to rule out urethral injury 1
• Place a suprapubic catheter if urethral catheterization is unsuccessful or urethral injury is confirmed 1
• Measure and document the volume drained; volumes >1000 mL suggest chronic retention with acute decompensation 3

Step 2: Pharmacologic Therapy

• Start tamsulosin 0.4 mg once daily OR alfuzosin 10 mg once daily at the time of catheter insertion 1, 2
• Alpha-blockers significantly improve TWOC success rates: alfuzosin achieves 60% success versus 39% with placebo; tamsulosin achieves 47% versus 29% with placebo 1, 2
• Continue alpha-blocker therapy for at least 3 days before attempting catheter removal 1, 2
• Avoid doxazosin or terazosin as first-line agents because they require titration and doxazosin increases congestive heart failure risk in men with cardiac risk factors 1

Step 3: Trial Without Catheter (TWOC)

• Keep the catheter in place for at least 3 days of alpha-blocker therapy before attempting removal 1
• There is no evidence that catheterization longer than 72 hours improves outcomes, and prolonged catheterization increases infection risk 1
• TWOC is more likely to succeed if retention was precipitated by temporary factors such as anesthesia or alpha-adrenergic sympathomimetic cold medications 1, 4

Step 4: Post-TWOC Management

• If TWOC succeeds: Counsel the patient that he remains at increased risk for recurrent urinary retention even after successful catheter removal 1, 2
• If TWOC fails: Recommend surgical intervention for patients with refractory retention who have failed at least one attempt at catheter removal 1, 2

Etiology-Specific Considerations

BPH-Related Retention

• Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment for BPH-related urinary retention after failed TWOC 5, 1
• For patients with large prostates (>30cc), consider adding a 5-alpha reductase inhibitor (finasteride 5 mg daily or dutasteride) to alpha-blocker therapy 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 alone reduces acute urinary retention risk by 57% and surgery risk by 55% 6

Urethral Stricture

• Perform urethrocystoscopy or retrograde urethrogram if urethral stricture is suspected 1
• Urgent management options include urethral dilation, direct visual internal urethrotomy, or immediate suprapubic cystostomy 1

Pyonephrosis/Obstructive Pyelonephritis

• Urinary tract decompression is lifesaving in patients with pyonephrosis 5
• Percutaneous nephrostomy (PCN) or retrograde ureteral stenting with antibiotic therapy are first-line treatment options 5
• Preprocedural antibiotics are recommended when urosepsis is suspected or known 5
• Third-generation cephalosporin ceftazidime demonstrates superiority over fluoroquinolone ciprofloxacin in clinical and microbiological cure rates 5

Special Populations and Situations

Elderly Patients

• Exercise caution with alpha-blockers in patients with orthostatic hypotension, cerebrovascular disease, or history of falls, as these medications can cause dizziness and postural hypotension 1
• Tamsulosin may have a lower probability of orthostatic hypotension compared to other alpha-blockers 1
• Evaluate for constipation as a potential cause of urinary retention and treat with osmotic laxatives (polyethylene glycol, lactulose) or stimulant laxatives (bisacodyl, senna) 1

Post-Stroke Patients

• Remove indwelling catheters within 24 hours after admission when possible 1
• Intermittent catheterization is generally recommended for initial management rather than indwelling catheters 1, 2

Neurogenic Bladder

• Clean intermittent self-catheterization is the preferred long-term management strategy 1
• Perform catheterization 4-6 times daily at regular intervals (approximately every 4-6 hours) to maintain bladder volumes below 400-500 mL 1
• Urodynamic studies may be necessary to assess detrusor function 1

Catheter Selection and Management

Catheter Type

• Silver alloy-coated urinary catheters should be considered to reduce urinary tract infection risk 1
• For chronic intermittent catheterization, hydrophilic or low-friction catheters show benefit in reducing complications 1

Catheter Removal Timing

• Remove indwelling catheters as soon as medically possible, ideally within 24-48 hours, to minimize infection risk 1, 2
• Prolonged use of indwelling catheters increases the risk of urinary tract infections, which account for nearly 40% of all nosocomial infections 1

Long-Term Catheterization

• Chronic indwelling urethral or suprapubic catheters should only be used when therapies are contraindicated, ineffective, or no longer desired by the patient 1
• Suprapubic tubes are preferred over urethral catheters due to reduced likelihood of urethral damage 1

Antibiotic Use

• Urinary retention alone does not warrant antibiotics without confirmed infection 1
• Prescribe antibiotics only if systemic signs of infection are present or after culture confirms infection 1
• For catheter-associated UTIs, appropriate choices include fosfomycin, nitrofurantoin, fluoroquinolones, or cotrimoxazole 1

Critical Pitfalls to Avoid

• Never allow the bladder to fill beyond 500 mL to prevent detrusor muscle damage and prolonging retention 4
• Avoid blind catheter passage prior to retrograde urethrogram in cases of suspected urethral injury, as it may exacerbate the injury 1
• Do not assume alpha-blocker therapy alone will manage concomitant hypertension in elderly patients; hypertension may require separate management 1
• Avoid repeated intermittent catheterization for pelvic fracture urethral injury, as this increases patient morbidity and delays definitive reconstruction 1
• 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 1
• Do not delay surgical intervention in patients with refractory retention, as this can lead to bladder decompensation and chronic retention 1

Indications for Urgent Urological Consultation

• Signs of upper urinary tract involvement such as renal insufficiency or hydronephrosis 4
• Recurrent gross hematuria, bladder stones, or recurrent UTIs clearly due to obstruction 4
• Retention persisting despite intermittent catheterization and reversible causes have been addressed 4
• Renal insufficiency, recurrent UTIs, recurrent gross hematuria, or bladder stones due to BPH and refractory to other therapies 1