Is there a link between urinary retention and TERA (treatment or intervention) in patients with a history of urological conditions, such as Benign Prostatic Hyperplasia (BPH)?

Link Between Urinary Retention and Treatment/Management in BPH

Yes, there is a well-established link between urinary retention and BPH, with acute urinary retention (AUR) representing one of the most significant complications of BPH and a major indication for surgical intervention. 1, 2

Epidemiology and Risk Factors

Acute urinary retention affects 0.4-25% of men with BPH seen in urological practice annually and is the presenting feature in 25-30% of patients undergoing transurethral resection of the prostate (TURP). 3 The condition predominantly affects men, with BPH accounting for 53% of all urinary retention cases. 4

Key risk factors for developing AUR in BPH patients include: 1, 3

• Higher serum PSA levels (predictor of future prostate growth and AUR risk) 1
• Severity of lower urinary tract symptoms (LUTS) 3
• Reduced peak urinary flow rate (Qmax <10 mL/sec) 3
• Larger prostate volume 3
• Elevated post-void residual (PVR) volume 3
• Advanced age 3

Immediate Management of AUR in BPH

Surgery is recommended for patients with refractory retention who have failed at least one attempt at catheter removal. 1 However, initial management should focus on bladder decompression and medical optimization:

Initial Bladder Decompression

• Perform immediate urethral catheterization for complete bladder decompression 1, 5, 4
• If urethral catheterization fails, place a suprapubic catheter 5
• Suprapubic catheters improve patient comfort and decrease bacteriuria compared to urethral catheters in short-term management 4, 6

Alpha-Blocker Therapy

Concomitant administration of a non-titratable alpha blocker (tamsulosin 0.4 mg or alfuzosin 10 mg once daily) is an option prior to attempted catheter removal. 1 This recommendation is based on evidence showing:

• Alfuzosin achieves 60% trial without catheter (TWOC) success versus 39% with placebo 5
• Tamsulosin achieves 47% TWOC success versus 29% with placebo 5
• Alpha blockers should be started at the time of catheter insertion and continued for at least 3 days before attempting catheter removal 5, 7

Important caveat: Alpha blockers would not be appropriate in patients with prior history of alpha-blocker side effects or unstable medical comorbidities (e.g., orthostatic hypotension or cerebrovascular disease). 1 A voiding trial is more likely successful if underlying retention was precipitated by temporary factors such as anesthesia or alpha-adrenergic sympathomimetic cold medications. 1

Medical Prevention of AUR in BPH

5-Alpha Reductase Inhibitors

Finasteride reduces the risk of acute urinary retention by 57% and the need for BPH-related surgery by 55% compared to placebo. 8 The FDA-approved indication for finasteride includes reducing the risk of acute urinary retention in men with symptomatic BPH and enlarged prostate. 8

In the pivotal 4-year A Long-Term Efficacy and Safety Study, finasteride demonstrated: 8

• 2.8% incidence of AUR versus 6.6% with placebo (57% risk reduction)
• 4.6% surgical intervention rate versus 10.1% with placebo (55% risk reduction)
• 17.9% reduction in prostate volume from baseline

Combination Therapy

Combination therapy with finasteride plus doxazosin reduces the risk of AUR by 79% and the need for surgery by 67% compared to placebo. 8 In the MTOPS trial, combination therapy showed: 8

• 0.5% incidence of AUR versus 2.4% with placebo
• 67% reduction in risk of overall disease progression
• Superior efficacy compared to either monotherapy alone

Surgical Management

Surgery is recommended as a guideline for patients with refractory retention who have failed at least one attempt at catheter removal. 1 TURP remains the benchmark surgical treatment for BPH-related urinary retention. 5, 7

Surgery is also recommended for patients with: 1

• Renal insufficiency clearly due to BPH
• Recurrent urinary tract infections due to BPH
• Recurrent gross hematuria due to BPH
• Bladder stones clearly due to BPH, all refractory to other therapies

Critical pitfall: Surgery conducted urgently after AUR is associated with higher morbidity and mortality compared to delayed prostatectomy. 2 Alpha blockers can help delay surgery and may avoid surgery altogether in a subgroup of patients. 2

Alternative Management for Non-Surgical Candidates

For patients who are not surgical candidates, treatment with intermittent catheterization, an indwelling catheter, or stent is recommended. 1 Chronic indwelling urethral or suprapubic catheters should only be used when therapies are contraindicated, ineffective, or no longer desired by the patient. 5

Monitoring and Follow-Up

Patients who successfully void after catheter removal remain at increased risk for recurrent urinary retention. 5 The American Urological Association defines chronic urinary retention as PVR volume greater than 300 mL measured on two separate occasions and persisting for at least six months. 4