What is the treatment for urinary retention?

Treatment of Urinary Retention

Immediate bladder decompression via urethral catheterization is the first-line treatment for acute urinary retention, followed by initiation of an alpha blocker (tamsulosin 0.4 mg or alfuzosin 10 mg once daily) at the time of catheter insertion, with catheter removal attempted after at least 3 days of alpha blocker therapy. 1, 2, 3

Initial Management Algorithm

Acute Urinary Retention

Immediate bladder decompression:

• Perform urethral catheterization for immediate relief 1, 2, 3
• If blood is present at the urethral meatus after pelvic trauma, perform retrograde urethrography BEFORE attempting catheterization to rule out urethral injury 1, 2
• If urethral catheterization fails or urethral injury is confirmed, place a suprapubic catheter 1
• Consider silver alloy-coated catheters to reduce urinary tract infection risk 1, 2

Pharmacologic therapy:

• Start a non-titratable alpha blocker (tamsulosin 0.4 mg or alfuzosin 10 mg once daily) at the time of catheter insertion 1, 3
• Alpha blockers significantly improve trial without catheter (TWOC) success rates: alfuzosin achieves 60% success versus 39% with placebo, and tamsulosin achieves 47% versus 29% with placebo 1, 2, 3
• Continue alpha blocker therapy for at least 3 days before attempting catheter removal 1, 3
• Avoid doxazosin or terazosin as first-line agents in acute retention, as these require titration and doxazosin has been associated with increased congestive heart failure in men with cardiac risk factors 1

Trial without catheter (TWOC):

• Keep the catheter in place for at least 3 days of alpha blocker therapy before attempting removal, as there is no evidence that catheterization longer than 72 hours improves outcomes, and prolonged catheterization increases infection risk 1
• 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) 1

Chronic Urinary Retention

Definition and assessment:

• The American Urological Association defines chronic urinary retention as postvoid residual (PVR) volume >300 mL measured on two separate occasions and persisting for at least six months 1
• Confirm urinary retention through bladder scanning or straight catheterization to quantify residual volume 1, 2, 3

Management approach:

• Intermittent catheterization is generally recommended for initial management rather than indwelling catheters 1, 2, 3
• Perform catheterization 4-6 times daily at regular intervals (approximately every 4-6 hours) to maintain bladder volumes below 400-500 mL and prevent bladder overdistension 1
• For chronic intermittent catheterization, hydrophilic or low-friction catheters show benefit in reducing complications 1
• Chronic indwelling urethral or suprapubic catheters should only be recommended when therapies are contraindicated, ineffective, or no longer desired by the patient, with suprapubic tubes preferred over urethral catheters due to reduced likelihood of urethral damage 1

Etiology-Specific Management

BPH-Related Retention

Medical management:

• For patients with underlying BPH or persistent lower urinary tract symptoms, consider indefinite alpha blocker therapy as these medications are appropriate long-term treatment options 1
• For patients with large prostates (>30cc), combination therapy with alpha blockers and 5-alpha reductase inhibitors (finasteride or dutasteride) may be more effective than monotherapy for preventing future episodes of retention 1, 2
• Finasteride reduces acute urinary retention risk by 57% and surgery risk by 55% 1, 4
• 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, 4

Surgical management:

• Surgery is recommended for patients with refractory retention who have failed at least one attempt at catheter removal 1, 2, 3
• Transurethral resection of the prostate (TURP) is the benchmark surgical treatment for BPH-related urinary retention 1, 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 1
• For patients who are not surgical candidates, treatment with intermittent catheterization, an indwelling catheter, or stent is recommended 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, 2

Urethral Stricture

Diagnostic approach:

• Perform urethrocystoscopy or retrograde urethrogram (RUG) to diagnose urethral stricture if suspected as the cause 1
• For suspected posterior urethral injury, obtain both retrograde urethrography and voiding cystourethrogram (VCUG) to delineate the stricture length and location 1

Management options:

• For urgent management of urethral stricture, options include urethral dilation, direct visual internal urethrotomy, or immediate suprapubic cystostomy 1, 2
• For short bulbar urethral strictures, options include dilation, direct visual internal urethrotomy, or urethroplasty 1
• Consider self-catheterization after direct visual internal urethrotomy to maintain temporary urethral patency in patients who are not candidates for urethroplasty 1
• Urethroplasty may be offered as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization 1
• For patients dependent on an indwelling urethral catheter or intermittent self-dilation, consider suprapubic cystostomy prior to definitive urethroplasty 1

Neurogenic Lower Urinary Tract Dysfunction (NLUTD)

Medical management:

• For NLUTD patients with spinal cord injury and multiple sclerosis who are refractory to oral medications, onabotulinumtoxinA may be offered to improve bladder storage parameters, decrease episodes of incontinence, and improve quality of life measures 5, 2
• In NLUTD patients, other than those with spinal cord injury and multiple sclerosis, who are refractory to oral medications, clinicians may offer onabotulinumtoxinA to improve bladder storage parameters, decrease episodes of incontinence, and improve quality of life measures 5
• Critical caveat: In NLUTD patients who spontaneously void, clinicians must discuss the specific risks of urinary retention and the potential need for intermittent catheterization prior to selecting botulinum toxin therapy, as urinary retention rates are 20.49% for onabotulinumtoxinA versus 3.67% for placebo 5, 2

Catheterization management:

• For patients with neurogenic bladder, clean intermittent self-catheterization is the preferred long-term management strategy 1, 2

Surgical options:

• Sphincterotomy may be offered to facilitate emptying in appropriately selected male patients with NLUTD but must counsel them of the high-risk of failure or potential need for additional treatment or surgery 5, 2
• External urethral sphincterotomy may be performed in patients who are unwilling or unable to perform clean intermittent catheterization (CIC), particularly those with reflex voiding who can maintain urinary drainage and containment with a condom catheter, and have poor hand function or an unwillingness to perform CIC 5

Alternative treatments:

• Urethral bulking agents may be offered to NLUTD patients with stress urinary incontinence but must counsel them that efficacy is modest and cure is rare 5

Other Etiologies

Constipation-related retention:

• Evaluate for constipation as a potential cause of urinary retention, particularly in elderly patients 1
• Treat underlying constipation with osmotic laxatives (polyethylene glycol, lactulose) or stimulant laxatives (bisacodyl, senna) 1

Post-stroke retention:

• In patients with stroke who have urinary retention, remove indwelling catheters within 24 hours after admission when possible 1, 3
• Intermittent catheterization is generally recommended for initial management rather than indwelling catheters 1, 3

Infected or obstructing urinary stones:

• For patients with infected or obstructing urinary stones, immediate decompression is warranted 1

Antibiotic Considerations

When to use antibiotics:

• Urinary retention alone does not warrant antibiotics without confirmed infection 1
• Antibiotics should only be prescribed if systemic signs of infection are present or after culture confirms infection 1
• Culture results guide antibiotic decisions only if infection is confirmed, and treatment with appropriate antibiotics is recommended if culture shows significant bacteriuria with systemic symptoms 1
• For catheter-associated UTIs, fosfomycin, nitrofurantoin, fluoroquinolones, or cotrimoxazole are appropriate choices 1

Follow-Up and Monitoring

Short-term follow-up:

• Patients who successfully void after catheter removal should be informed that they remain at increased risk for recurrent urinary retention 1, 2, 3
• Indwelling catheters should be removed as soon as medically possible, ideally within 24-48 hours, to minimize infection risk 1, 2, 3
• Patients with persistently elevated post-void residual (PVR) volumes (>150 mL) may require continued alpha blocker therapy 1

Long-term follow-up:

• 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, 2
• In patients with neurological conditions, urodynamic studies may be necessary to assess detrusor function 1

Critical Pitfalls to Avoid

Catheterization errors:

• Avoid blind catheter passage prior to retrograde urethrogram in cases of suspected urethral injury, as it may exacerbate the injury 1
• Repeated intermittent catheterization for pelvic fracture urethral injury should be avoided, as this increases patient morbidity and delays definitive reconstruction 1

Timing errors:

• Avoid delaying surgical intervention in patients with refractory retention, as this can lead to bladder decompensation and chronic retention 1, 2
• Do not keep catheters in place longer than 72 hours before attempting TWOC, as prolonged catheterization increases infection risk without improving outcomes 1

Medication errors:

• Exercise caution with alpha blockers in elderly 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 doxazosin or terazosin, making it preferable in high-risk patients 1
• Do not assume alpha blocker therapy alone will manage concomitant hypertension in elderly patients; hypertension may require separate management 1

Patient counseling gaps:

• Not informing patients about the risk of recurrent retention after successful TWOC 3
• Failing to discuss the specific risks of urinary retention and the potential need for intermittent catheterization prior to selecting botulinum toxin therapy in NLUTD patients who spontaneously void 5, 2