After Aquablation with catheter removal on postoperative day 3, what is the appropriate management for a post‑void residual of 250 mL?

Management of Post-Void Residual of 250 mL After Aquablation

A PVR of 250 mL on postoperative day 3 after Aquablation warrants close observation with repeat PVR measurement within 24–48 hours, but does not automatically require immediate re-catheterization unless the patient develops acute urinary retention symptoms or the PVR persists or worsens. 1

Initial Assessment and Monitoring Strategy

• Measure the PVR again within 24–48 hours using a bladder scanner (the preferred non-invasive method) to determine whether this represents transient postoperative bladder dysfunction or persistent retention. 2, 3

• Assess for symptoms of acute retention: inability to void, severe suprapubic discomfort, bladder distention on exam, or complete urinary retention. 3

• Evaluate for contributing factors including medications (anticholinergics, opioids), mobility limitations, pain control adequacy, and signs of urinary tract infection. 2

Decision Algorithm Based on Clinical Presentation

If Patient is Asymptomatic with PVR 250 mL:

• Continue observation without immediate intervention. Recent evidence demonstrates that routine catheterization based solely on an arbitrary PVR threshold (even >200 mL) does not confer clinical benefit when patients remain asymptomatic. 4

• Implement a prompted voiding schedule with caregivers reminding the patient to attempt voiding every 2–4 hours during waking hours to prevent bladder overdistention. 2, 5

• Repeat PVR measurement in 24–48 hours. If the PVR is decreasing and remains <300 mL without symptoms, continue conservative management. 1

If Patient Has Voiding Symptoms or PVR >300 mL:

• Initiate clean intermittent catheterization (CIC) every 4–6 hours to prevent bladder volumes exceeding 500 mL, which can cause detrusor muscle damage. 2, 5

• The threshold for intervention should be based on symptoms plus elevated PVR, not PVR alone. A PVR >100 mL with bothersome voiding symptoms (hesitancy, weak stream, sensation of incomplete emptying) warrants catheterization. 1

• Avoid indwelling catheter placement unless the patient cannot perform or tolerate intermittent catheterization, as indwelling catheters significantly increase CAUTI risk. 2, 1

Intermittent Catheterization Protocol

• Perform CIC every 4–6 hours (typically 4–5 times daily) to maintain bladder volumes below 400–500 mL and stimulate normal physiological filling and emptying patterns. 2

• Continue CIC until the PVR falls below 100–150 mL consistently for 24–48 hours, at which point a trial without catheterization can be attempted. 2, 1

• After each catheterization, document the volume drained to track improvement and adjust the catheterization schedule accordingly. 2

Special Considerations for Aquablation

• Transient urinary retention is common after prostate procedures due to prostatic edema, urethral inflammation, and bladder neck irritation. 1

• Male sex and pre-existing prostatism are major risk factors for postoperative retention, making vigilance particularly important in this population. 1

• Most cases resolve within 1–2 weeks as postoperative edema subsides, so aggressive early intervention may not be necessary if the patient tolerates the retention well. 6

When to Escalate Care

• Re-insert an indwelling catheter if:

  • The patient develops acute symptomatic retention with inability to void
  • PVR exceeds 500 mL on repeat measurement
  • The patient cannot master intermittent self-catheterization and has no caregiver assistance
  • Bladder overdistention occurs despite attempted CIC 2, 1

• If an indwelling catheter is placed, remove it within 3–5 days and reattempt a voiding trial, as prolonged catheterization (>3 days) dramatically increases CAUTI risk. 2, 1, 5

• Consider urological consultation if retention persists beyond 2 weeks or if the PVR remains >200 mL despite conservative measures. 1

Common Pitfalls to Avoid

• Do not automatically re-catheterize based on a single PVR measurement of 250 mL in an asymptomatic patient, as this exposes the patient to unnecessary catheter-related complications without proven benefit. 4

• Do not use an indwelling catheter when intermittent catheterization is feasible, as CIC has lower infection rates (0.84 UTIs per patient-year) and better quality of life outcomes. 7

• Do not allow bladder volumes to exceed 500 mL, as overdistention can cause permanent detrusor dysfunction. 2, 5

• Do not continue catheterization "just in case" once the PVR normalizes, as each additional day of catheterization increases CAUTI risk exponentially. 1, 5