How to manage a 70-year-old male patient with a history of urinary retention, presenting with a 5-hour history of urinary retention and lower abdominal pain, who has a past medical history of diabetes and hypertension, and is currently on Telmisartan (telmisartan) 40mg, with an ultrasound showing a distended bladder?

Management of Acute Urinary Retention in a 70-Year-Old Male

Immediately catheterize the patient with a urethral catheter to decompress the bladder, start tamsulosin 0.4 mg or alfuzosin 10 mg once daily at the time of catheter insertion, and plan for a trial without catheter after 3 days of alpha blocker therapy. 1, 2

Immediate Management

Bladder Decompression

• Perform immediate urethral catheterization to relieve the acute retention and lower abdominal pain 1, 2
• If urethral catheterization fails, place a suprapubic catheter 1
• Consider silver alloy-coated catheters to reduce urinary tract infection risk 1, 2
• Document the volume drained (this helps predict success of future voiding trials) 3

Pharmacologic Therapy

• Start tamsulosin 0.4 mg once daily OR alfuzosin 10 mg once daily immediately at catheter insertion 1, 2
• Alpha blockers significantly improve trial without catheter success: alfuzosin achieves 60% success vs 39% placebo, tamsulosin achieves 47% vs 29% placebo 1
• Avoid doxazosin or terazosin as first-line agents - they require titration and doxazosin increases congestive heart failure risk in men with cardiac risk factors 1
• Tamsulosin may have lower orthostatic hypotension risk compared to other alpha blockers, making it preferable in this 70-year-old patient 1

Investigations to Order

Immediate Laboratory Tests

• Urinalysis with dipstick to check for hematuria, pyuria, proteinuria, or infection 2
• Serum creatinine and BUN to assess renal function, as urinary retention can cause post-renal acute kidney injury 4, 3
• Serum glucose to assess diabetic control 2
• Document the post-void residual volume from catheterization 2, 3

Additional Diagnostic Testing

• Digital rectal examination (DRE) to evaluate prostate size, consistency, and abnormalities - benign prostatic hyperplasia accounts for 53% of acute urinary retention cases in men 2, 3
• Renal ultrasound if creatinine is elevated to assess for hydronephrosis, as ultrasound has >90% sensitivity for detecting hydronephrosis 4
• Consider PSA testing after discussing risks/benefits, particularly since life expectancy considerations and whether prostate cancer diagnosis would change management 2
• International Prostate Symptom Score (IPSS) questionnaire to quantify baseline symptoms 2

Rule Out Other Causes

• Assess for constipation on abdominal examination - a common cause of urinary retention in elderly patients 1, 2
• Review medications for anticholinergics, sympathomimetics, or opioids that can precipitate retention 2, 3
• Perform focused neurologic examination of perineum and lower limbs to rule out neurogenic causes 2

Trial Without Catheter (TWOC)

Timing and Preparation

• Keep catheter in place for at least 3 days while on 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
• The voiding trial is more likely successful if retention was precipitated by temporary factors (anesthesia, cold medications with alpha-adrenergic sympathomimetics) 1

Post-TWOC Management

• If voiding trial succeeds: Continue alpha blocker indefinitely as these are appropriate long-term treatments for BPH 1
• Counsel that he remains at increased risk for recurrent retention even after successful catheter removal 1, 2
• Consider adding a 5-alpha reductase inhibitor (finasteride or dutasteride) if prostate is enlarged (>30cc), as combination therapy reduces acute retention risk by 79% and surgery risk by 67% 1

If TWOC Fails

• Surgery is recommended for patients with refractory retention who fail at least one catheter removal attempt 1, 2
• Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment 1
• For non-surgical candidates: intermittent catheterization, indwelling catheter, or prostatic stent (though stents have significant complications including encrustation, infection, and chronic pain) 1

Follow-Up Plan

Short-Term (4-12 weeks)

• Reevaluate with IPSS questionnaire 2
• Measure post-void residual volume - persistently elevated PVR >150 mL may require continued alpha blocker therapy 1
• Consider uroflowmetry if voiding symptoms persist 2

Long-Term Monitoring

• Monitor for recurrent retention episodes 1, 2
• Assess diabetic control and adjust medications as needed 2
• Continue hypertension management separately from alpha blocker therapy - do not assume alpha blocker alone will manage his hypertension 1

Critical Pitfalls to Avoid

• Do not delay catheterization - prolonged retention can lead to bladder decompensation and renal dysfunction 3, 5
• Do not prescribe antibiotics unless there are systemic signs of infection or positive urine culture - retention alone does not warrant antibiotics 1
• Do not remove catheter before 3 days of alpha blocker therapy, as this reduces TWOC success rates 1
• Do not use indwelling catheter long-term as first-line - remove within 24-48 hours if possible to minimize infection risk 1, 2
• Do not delay surgical referral if TWOC fails, as this can lead to chronic retention and bladder decompensation 1

Special Consideration for This Patient

Given his history of a similar episode 6 months ago, this represents recurrent acute urinary retention, which significantly increases the likelihood that he will require definitive surgical management rather than conservative therapy alone 1, 2