Management of Acute and

Chronic Retention in Men

• Urinary retention is the inability to empty the
bladder to completion
– acute
– chronic
– acute on chronic
• AUR is rare in younger men; men in their 70 s are at
five times more risk of AUR than men in their 40 s

• 10% of men in their 70 s have experienced acute

urinary retention (AUR) over a 5-yr period; the risk
increases to one in three over 10 yr

• 60-yr-old man would have a 23% probability of

experiencing AUR if he were to reach the age of 80

• Retention is >10 times more common in men than in

women
• The most common underlying causes in
women are
– infection or inflammation occurring postpartum
– secondary to herpes
– Bartholin’s abscess
– acute urethritis
– vulvovaginitis
 Aetiology
Acute retention
• AUR is usually characterised by the sudden,
painful inability to void
• painless AUR is rare and is often associated
with central nervous system pathology
• AUR
– Precipitated
– Spontaneous retention
• Precipitated AUR may be triggered by such
events as
– surgical procedures with general or locoregional
anaesthesia
– excessive fluid intake
– bladder overdistension
– urinary tract infections (UTIs)
– prostatic inflammation
– excessive alcohol intake
– use of drugs with sympathomimetic or anticholinergic
drugs
 Spontaneous AUR
• In most cases, no triggering event is identified
and AUR is called spontaneous.

• Spontaneous AUR is most commonly associated

with benign prostatic hyperplasia (BPH) and is
regarded as a sign of progression.

• The difference between precipitated and

spontaneous retention has clinical relevance
because BPH surgery is less common in cases of
precipitated AUR
 Chronic retention
• Aetiology of CUR is more complex and can be
divided into
– high-pressure chronic retention (HPCR)
– low-pressure chronic retention (LPCR
 High-pressure chronic retention (HPCR)

• Bladder outlet obstruction usually exists in

HPCR, and the voiding detrusor pressure is
high but is associated with poor urinary flow
rates.
• The constantly raised bladder pressure in
HPCR during both the storage and voiding
phases of micturition creates a backward
pressure on the upper-tract drainage and
results in bilateral hydronephrosis.
 Low-pressure chronic retention (LPCR)

• LPCR- large-volume retention in a very

compliant bladder with no hydronephrosis or
renal failure
• Urodynamic studies - low detrusor pressures,
low flow rates, and very large residual
volumes
• LUTS are usually mild in CUR

• Nocturnal enuresis - drop in urethral resistance

during sleep.

• In nocturnal enuresis, urethral resistance is

overcome by the maintained high bladder
pressure, which causes incontinence (sometimes
inappropriately called overflow incontinence).
 Pathology and pathogenesis
Five factors have been implicated in
pathogenesis:
• prostatic infarction
• Adrenergic activity
• decrease in the stromal–epithelial ratio
• neurotransmitter modulation
• Prostatic inflammation
• Prostatic infarction caused by infection,
instrumentation, and thrombosis is seen in
prostatectomy specimens after AUR

• lead to neurogenic disturbance, preventing

relaxation of the prostatic urethra, or to
swelling and a rise in urethral pressure
• Rise in the prostatic intraurethral pressure
through an increase in a-adrenergic
stimulation (eg, stress, cold weather,
sympathomimetic agents used in cold
remedies).
• Prostatic infarction or prostatitis may
contribute to this process.
• Bladder overdistension also leads to increased
adrenergic tone.
Presentation and initial assessment
Acute retention
• The most common presentation is lower
abdominal pain and swelling, an inability to
pass urine (or passing only small amounts of
urine), and a palpable mass that arises from
the pelvis and that is dull to percussion.
• Although it is stated that patients with AUR
usually do not have previous LUTS,
• it is more likely that many of these patients
did not complain of these symptoms before
– might not have recognised the significance of
their symptoms
– assumed the symptoms to be an inevitable
consequence of ageing
• The volume drained is usually <1 l;

• if the volume drained is 1 l, this can be used as

a distinction between acute and acute-on-
chronic retention, particularly if associated
with less pain (a finding that is more typical of
CUR).
 Chronic retention

• CUR occurs when a patient retains a

substantial amount of urine in the bladder
after each void
• finding of persistent residual volumes of >300
ml (some authors suggest >500 ml) after
voiding is often used as evidence of CUR
 Chronic retention
• Patients may be asymptomatic
• low volume micturition, increased frequency,
or difficulty initiating and maintaining
micturition.
• nocturnal incontinence
• palpable but painless bladder
• signs of chronic renal failure
• LUTS are uncommon
 Differential diagnosis
• diverticulitis or a diverticular abscess,
perforated or ischaemic bowel, or abdominal
aortic aneurysm can be referred as acute
retention
 Management
• Treatment of acute retention requires urgent
catheterisation
• The urine volume drained in the first 10–15
min following catheterisation must be
accurately recorded in the patient’s notes to
enable a distinction between acute and acute-
on-chronic retention. This has important
clinical implications
• Alfuzosin in Acute Urinary Retention (ALFAUR) study
show a significantly increased risk of failure for trial
without catheterisation (TWOC) in the
– elderly (65 yr)
– drained volume 1 L

• Patients with initially successful TWOC were more

likely to have recurrent AUR if their post-TWOC
volume was high.
– these patients should be offered elective TURP at an
earlier stage.
 Chronic retention
• The management of CUR is more complex
• Catheterisation is less urgent because the
condition is generally less painful or painless.
• Early catheterisation is indicated if renal
dysfunction or upper tract dilatation is
present.
• Patients must be monitored for
postobstructive diuresis
• The diuresis can result from
– offloading of retained salt and water (retained in
the weeks prior to the episode of retention)
– loss of the corticomedullary concentration
gradient, caused by reduced urinary flow through
the chronically obstructed kidney
– high urea level that results in osmotic diuresis
• In about 10% of cases, diuresis is excessive
and requires careful fluid replacement.
• Daily weighing is an accurate way of
monitoring fluid output.
• After the first 24 h, fluid replacement should
not strictly follow output
• Catheterisation is often followed by
haematuria; this is caused by renal tract
decompression and not usually by the
catheter itself.
• The practice of slow decompression is
unnecessary, and haematuria usually settles
after 48–72 h.
• If there is evidence of renal failure, which
settles with catheterisation, the patient
should not undergo a TWOC before a
definitive procedure has been considered
• If presenting electively through out-patients, the
indications for catheterisation before TURP in
cases of CUR are
– renal impairment
– water and salt retention

• otherwise, it is best to avoid catheterisation so as

to avoid infection and bladder shrinkage before
TURP, but the patients should be listed for early
surgery
• Patients with LPCR do poorly after TURP,
frequently failing to void completely after
surgery, even after prolonged periods of
catheterisation; this is probably due to
detrusor changes over time.

• Intermittent self catheterisation (ISC) should

be considered in this group
Urethral versus suprapubic catheterisation

The principal advantages of suprapubic

catheterisation are
• fewer UTIs
• less stricture formation
• TWOC without catheter removal
• the ability to maintain active sexual function
• Most urologists performed urethral
catheterisation (>80%) with suprapubic
catheters (SPCs) inserted for urethral catheter
failures
• Additionally, the survey also reported similar
complication rates for both types of catheter.
• Some disadvantages are associated with SPC insertion.
• It is a more complex procedure that not all health
professionals are adequately skilled to perform
• Serious complications, such as bowel perforation and
peritonitis

• Concerns regarding SPC safety may disappear in the

future with the introduction of the potentially safer
Seldinger SPC catheters.
• This is a new type of SPC insertion kit that replaces the
traditional blind insertion of the trocar with SPC
insertion over a guidewire
 Trial without catheter
• TWOC is now considered for most patients.
• It involves catheter removal after 1–3 d, allowing the
patient to successfully void in 23–40% of cases
,which enables patients to return home without the
potential morbidities associated with an in situ
catheter
• TWOC also allows surgery to be delayed to an
elective setting or may prevent the need for surgery .
 Factors leading to a high probability of successful
TWOC include
• lower age (<65 yr)
• UTI with no previous obstructive symptoms
• identified precipitating cause (eg, gross
constipation, recently started anticholinergic or
sympathomimetic drugs)
• PVR <1000 ml
• Prolonged catheterisation.
 Factors leading to a high probability of
unsuccessful TWOC
• patient age >75 yr
• drained volume >1 l
• previous LUTS
• voiding detrusor contraction (on urodynamics)
of <35 cmH2O
• In one study, a successful TWOC was achieved in
– 44% of patients after 1 d of catheterisation
– 51% of patients after 2 d
– 62% of patients after 7 d
• Patients most likely to benefit from prolonged
catheterisation were those with PVR >1300 ml
• Catheterisation >3 d, however, significantly
increased the risk of comorbidities and prolonged
hospitalisation
• Half of those for whom initial TWOC is successful will
experience recurrent AUR over the next year and
35% will require surgery within the following 6mo
• Patients with PVR >500 ml, no precipitating factor for
AUR, and maximum flow rate <5 ml/s were at
increased risk of further retention

• In the ALFAUR study, most of the patients who

required surgery after a successful TWOC needed
it for recurrent AUR
• This emphasises the importance of follow-up for
patients with risk factors for recurrent AUR, despite
initial successful TWOC
 Alpha-blockers and trial without
catheter
• AUR due to BPH may be associated with an
increase in a-adrenergic activity

• Inhibition of these receptors by a-blockers

may decrease bladder outlet resistance,
thereby facilitating normal micturition
• Alfuzosin 10mg daily for 2–3 d after
catheterisation almost doubles the likelihood
of a successful TWOC, even in patients who
are elderly (65 yr) with PVR > 1000 ml
• continued use of alfuzosin significantly
reduced the risk of BPH surgery in the first 3
mo; this effect was not significant after 6mo

• Patients at risk of recurrent AUR after

successful TWOC had a high PSA and PVR
 The role of clean intermittent self-
catheterisation
• Clean intermittent self-catheterisation (CISC)
is an alternative to an indwelling catheter.
• It is a safe, simple, and well-accepted
technique that results in fewer UTIs than
indwelling catheterisation .
• There are no external devices, and
maintenance of sexual activity is possible.
• It may also increase the rate of successful
spontaneous voiding.
• CISC can be used instead of an indwelling catheter after
an episode of AUR or CUR or it can be used in patients
who fail to void following a prostatectomy (who go into
retention secondary to detrusor failure following
TURP).

• This is important for patients with neurological bladder

dysfunction.

• A period of CISC prior to TURPmay be useful in patients

with LPCR, as it may allow recovery of bladder
contractility
 Prostatectomy after retention
• Prostatectomy after AUR is associated with an
increased morbidity due to
– infection
– perioperative bleeding
– increased transfusion rates
– 3-fold increase in mortality
• Higher percentage of men fail to void after
TURP compared with men undergoing surgery
for symptoms alone
 Prevention and risk factors
Risk factors include
• men >70 yr of age with LUTS
• IPSS >7 (ie, moderate or severe LUTS)
• flow rate of <12 ml/s
• prostate volume of >40 cm2
• PSA >1.4 ng/ml
• Hesitancy

• treatment with 5a-reductase inhibitors for periods of

>6mo reduces the risk of AUR by >50%.
 Conclusions
• The management of this condition must begin
with modifying risk factors for developing AUR
with 5a-reductase inhibitors
• follow-up, and early surgical intervention for
those who may benefit.
 Conclusions
• Once retention occurs, delay of surgery when
possible must be the aim to reduce the risk of
perioperative morbidity and mortality as well as
to allow the bladder to recover its contractility.

• This is the situation in which the use of a1-

blockers and TWOC are most useful.
• Finally, it is time to use SPC for retention patients
as a first-line approach, as many studies have
long suggested
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