What is the recommended in‑and‑out protocol for managing acute urinary retention and safely removing a urinary catheter?

In-and-Out Catheterization Protocol for Acute Urinary Retention

For acute urinary retention, perform immediate bladder drainage via in-and-out (intermittent) catheterization, measure the residual volume, and initiate alpha-blocker therapy before attempting a trial without catheter (TWOC) after less than 3 days of catheterization. 1

Initial Assessment and Diagnosis

When a patient presents with suspected acute urinary retention, confirm the diagnosis through:

• Bladder scanning to measure post-void residual volume (preferred non-invasive method) 2
• In-and-out catheterization if bladder scanner unavailable, which simultaneously confirms diagnosis and provides therapeutic relief 2
• Urinary retention is confirmed when post-void residual exceeds 300 mL 3

Obtain a focused history to identify precipitating factors including recent medication changes (anticholinergics, sympathomimetics), infection, recent anesthesia, or genitourinary procedures. 4 Document any history of benign prostatic hyperplasia, prior retention episodes, or urological conditions. 5

Immediate Management: Bladder Drainage

Perform urethral catheterization immediately to relieve retention and prevent bladder overdistention (>500 mL can cause detrusor muscle damage). 6, 7

Catheterization Options:

• In-and-out (intermittent) catheterization is preferred when feasible, as it avoids indwelling catheter complications 2, 1
• Indwelling urethral catheter if patient cannot perform self-catheterization or has severe retention requiring continuous drainage 3
• Suprapubic catheter is an alternative when urethral catheterization fails or is contraindicated, though evidence comparing it to indwelling urethral catheters remains debatable 1, 3

Measure and document the volume drained—this helps predict TWOC success (volumes >1000 mL associated with lower success rates). 1

Medical Therapy Before Trial Without Catheter

Initiate alpha-1 adrenergic receptor blocker therapy immediately after catheterization and before attempting catheter removal. 1 Meta-analysis demonstrates clear superiority of alpha-blockers over placebo in achieving successful voiding post-AUR. 1

Consider 5-alpha-reductase inhibitors for patients with documented benign prostatic hyperplasia to reduce future AUR episodes, though these agents work more slowly than alpha-blockers. 4

Catheter Duration and Removal Protocol

Remove the catheter after less than 3 days to minimize catheter-associated urinary tract infection (CAUTI) risk while allowing adequate time for medical therapy to take effect. 1 The evidence shows duration <3 days is safe in avoiding catheterization-related complications. 1

Trial Without Catheter (TWOC) Protocol:

1. Ensure alpha-blocker therapy has been started (ideally 24-48 hours before TWOC) 1
2. Remove catheter in the morning to allow adequate time for voiding assessment 8
3. Monitor first void: document time to void, volume voided, and patient comfort 8
4. Measure post-void residual via bladder scan or repeat in-and-out catheterization 2
5. TWOC is successful if:
   • Patient voids spontaneously with adequate volume
   • Post-void residual <300 mL 3
   • No significant discomfort or straining 5

Management of Failed TWOC

If the patient cannot void or has post-void residual >300 mL:

• Reinsert catheter (consider suprapubic if multiple urethral attempts) 1, 3
• Continue alpha-blocker therapy and consider adding 5-alpha-reductase inhibitor 1, 4
• Arrange urology referral for definitive management, as surgery becomes the endpoint after unsuccessful TWOC 1, 3

Clean Intermittent Self-Catheterization (CISC)

CISC is a safe and useful option for patients with chronic retention or recurrent AUR until definitive management. 1, 3 This approach:

• Avoids indwelling catheter complications 3
• Provides long-term promising outcomes in selected patients 1
• Requires patient ability and willingness to perform technique 3

Indications for CISC include acute or chronic urinary retention (post-void residual >300 mL) without bladder outlet obstruction. 3

Critical Pitfalls to Avoid

• Do not perform emergency surgery for uncomplicated AUR—medical management with alpha-blockers and TWOC should be attempted first 1
• Do not leave indwelling catheters >3 days without specific indication, as CAUTI risk increases significantly with duration 6, 1
• Do not attempt TWOC without initiating alpha-blocker therapy, as this significantly reduces success rates 1
• Do not use catheters solely for staff convenience or initial incontinence management 3

Special Populations Requiring Extended Catheterization

Consider catheterization beyond 3 days for:

• Pelvic surgery patients with significant intraoperative bladder edema or bladder neck involvement 6, 7
• Patients with ongoing sepsis or acute physiological derangement requiring strict fluid monitoring 6
• Patients remaining sedated or immobile 6
• Complicated bladder injuries or concurrent rectal/vaginal lacerations 6

When to Refer to Urology

Urgent urology referral is indicated for: 3

• Recurrent urinary tract infections despite appropriate management
• Acute infectious urinary retention (retention with concurrent UTI/sepsis)
• Suspected urethral injury or substantial urethral discomfort
• Failed TWOC requiring long-term catheterization consideration
• Significant lower urinary tract symptoms post-successful TWOC requiring surgical evaluation 1

Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment, though newer laser techniques are emerging. 1