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Acute urinary retention

Acute urinary retention
Authors:
Glen W Barrisford, MD, MS, MPH, FACS
Graeme S Steele, MBBCh, FCS
Section Editors:
Michael P O'Leary, MD, MPH
Korilyn S Zachrison, MD, MSc
Deputy Editor:
Jane Givens, MD, MSCE
Literature review current through: Dec 2022. | This topic last updated: Sep 29, 2021.

INTRODUCTION — Acute urinary retention (AUR) is the inability to voluntarily pass urine. It is the most common urologic emergency [1]. In men, AUR is most often secondary to benign prostatic hyperplasia (BPH); AUR is rare in women [2,3].

This topic will review issues related to evaluation and management of AUR. The diagnosis and treatment of BPH and chronic urinary retention in women are discussed separately.

(See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia".)

(See "Medical treatment of benign prostatic hyperplasia".)

(See "Surgical treatment of benign prostatic hyperplasia (BPH)".)

(See "Chronic urinary retention in females".)

EPIDEMIOLOGY — Acute urinary retention (AUR) is common in men. The incidence increases with age, occurring most frequently in men over age 60 [2-5]. It is estimated that, over a five-year period, approximately 10 percent of men over the age of 70 and almost one-third of men in their 80s will develop AUR [2,3,6].

By contrast, AUR is rare in women [7]. It is estimated that there are three cases of AUR per 100,000 women per year [8]. The female to male incidence rate ratio is 1:13.

PATHOGENESIS AND ETIOLOGIES — A variety of pathophysiologic mechanisms may be responsible for the development of acute urinary retention (AUR). Several mechanisms may occur concurrently. The most common mechanisms are outflow obstruction, neurologic impairment, or an inefficient detrusor muscle [9,10]. Other causes include medications, infection, and trauma.

Outflow obstruction – Obstruction is the most common cause of AUR [11]. The flow of urine can be impeded by mechanical factors (physical narrowing of the urethral channel) and/or dynamic factors (increased muscle tone within and around the urethra) [9,12,13].

In males, the most common cause of obstruction is benign prostatic hyperplasia (BPH) [2-5,11]. Other causes of outflow obstruction in men include constipation, prostate or bladder cancer, urethral stricture, urolithiasis, phimosis, or paraphimosis [4,13]. (See "Lower urinary tract symptoms in males" and "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia" and "Strictures of the adult male urethra".)

In females, obstruction is generally secondary to anatomic distortion, including pelvic organ prolapse (eg, cystocele or rectocele), pelvic masses, or, less commonly, urethral diverticulum [7,14-23]. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Urinary symptoms' and "Urethral diverticulum in females".)

Neurologic impairment – AUR may develop secondary to the interruption of the sensory or motor nerve supply to the detrusor muscle [4]. Incomplete relaxation of the urinary sphincter mechanism (dyssynergia) can also result in elevations in both voiding pressures and post-void residual volumes.

AUR can occur with spinal cord injuries from trauma, infarct or demyelination, epidural abscess and epidural metastasis, Guillain-Barré syndrome, diabetic neuropathy, and stroke [13]. AUR is typically accompanied by back pain and/or other neurologic deficits. Patients with neurologic impairment may develop acute-on-chronic urinary retention. (See individual topic reviews on each disorder.)

Inefficient detrusor muscle – AUR may occur in patients with an inefficient detrusor muscle when a precipitating event results in an acute distended bladder (eg, with a fluid challenge, during general or epidural analgesia without an indwelling catheter) [9,13,24-26]. This most often occurs in patients with obstructive urinary symptoms at baseline.

Medications – Multiple medications (table 1) are implicated as a cause of urinary retention; most common among these are the anticholinergic and sympathomimetic drugs [27].

Medications lead to AUR through a variety of mechanisms. Patients taking opioids and anticholinergic medications are at higher risk for AUR due to decreased bladder sensation [1,28]. Anticholinergic medications also reduce detrusor contractility [28]. Nasal decongestants that contain sympathomimetic agents increase smooth muscle tone in the region of the bladder neck.

Infection – Infections may lead to AUR in the setting of inflammation that causes obstruction. For example, an acutely inflamed prostate gland from acute prostatitis can cause AUR, particularly in men who already have BPH [11,29]. Similarly, a urinary tract infection can cause urethritis and urethral edema resulting in AUR [1,29]. (See "Acute bacterial prostatitis", section on 'Clinical manifestations'.)

Genital herpes may cause AUR both from local inflammation as well as sacral nerve involvement. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Primary'.)

Other infections that have been associated with AUR include varicella zoster and vulvovaginitis [1,11,29].

Trauma – Patients with trauma to the pelvis, urethra, or penis may develop AUR from mechanical disruption [11]. (See "Blunt genitourinary trauma: Initial evaluation and management".)

Other – AUR may also occur postoperatively or in the postpartum period. (See "Overview of post-anesthetic care for adult patients", section on 'Inability to void'.)

CLINICAL PRESENTATION — Acute urinary retention (AUR) generally presents as an inability to pass urine, usually associated with lower abdominal and/or suprapubic discomfort [13]. Affected patients are often restless and may appear in considerable distress. In older adult patients, particularly those with dementia or other forms of cognitive impairment, AUR may present as an acute change of mental status [30].

These manifestations may be less pronounced when AUR is superimposed upon chronic urinary retention. Chronic urinary retention is often painless [31]. Acute-on-chronic urinary retention may present with overflow incontinence. The patients may complain of incontinence rather than the inability to pass urine.

Patients with AUR are likely to present initially to an emergency department or the office of a primary care clinician. Hospitalized patients may develop AUR, often related to medications or after surgical procedures. (See "Postoperative urinary retention in females" and "Overview of post-anesthetic care for adult patients", section on 'Inability to void'.)

EVALUATION OF SYMPTOMS — The initial evaluation of patients with symptoms suggestive of acute urinary retention (AUR) should begin with a history and physical examination to determine the likelihood of the disorder.

History – The patient history should focus on previous history of retention or lower urinary tract symptoms (table 2), prostate disease (hyperplasia or cancer), pelvic or prostate surgery, radiation, or pelvic trauma. The patient should also be asked about the presence of hematuria, dysuria, fever, low back pain, neurologic symptoms, or rash. Finally, a complete list of medications (including over-the-counter medications (table 1)) should be obtained.

Younger patient age, a history of cancer or intravenous drug abuse, and the presence of back pain or neurologic symptoms suggest the possibility of spinal cord injury or compression. However, patients with spinal pathology generally do not present primarily with AUR. These patients will most often have other signs and symptoms of spinal cord pathology, with AUR being one part of the clinical picture. (See "Clinical features and diagnosis of neoplastic epidural spinal cord compression", section on 'Clinical features' and "Spinal epidural abscess", section on 'Clinical manifestations'.)

Physical examination – The initial physical examination should include lower abdominal palpation. The urinary bladder may be palpable, either on abdominal or rectal examination. Deep suprapubic palpation will provoke discomfort.

DIAGNOSIS — The diagnosis of acute urinary retention (AUR) is made by demonstrating retained urine by either bladder ultrasound or catheterization, in the appropriate clinical setting. If the procedure can be performed relatively quickly, a bladder ultrasound is a good first choice for patients who are not in extreme distress, because it is noninvasive, it is more comfortable for the patient, and bladder decompression can be avoided if results are normal.

In patients whose history and physical examination strongly suggest a diagnosis of AUR, or those in acute distress, it is reasonable to proceed directly to catheterization, which is both diagnostic and therapeutic, rather than waiting to obtain a bladder ultrasound. Alternatively, a bladder scanner can be used if immediately available. (See 'Options for bladder decompression' below.)

A bladder volume on ultrasound ≥300 cc suggests urinary retention warranting decompression. However, the bladder ultrasound may be inaccurate due to body habitus, tissue edema, or prior surgery and scarring. If the patient is in discomfort and unable to void, a urethral catheter should be placed regardless of the estimated volume on bladder ultrasound.

Upon placement of a urethral catheter, the initial amount of urine drained should be noted. Patients with volumes <200 cc likely do not have acute urinary retention. These patients should undergo further evaluation by a urologist in an outpatient setting.

The decision of whether to leave the catheter in is discussed below. (See 'Acute management' below.)

POST-DIAGNOSTIC EVALUATION — In patients with acute urinary retention (AUR), the post-diagnostic evaluation focuses on determining an etiology.

Physical examination – In patients with AUR of unknown etiology, further physical examination should include the following:

Rectal examination – A rectal examination should be done in both all patients to evaluate for masses, fecal impaction, perineal sensation, and rectal sphincter tone. A normal prostate examination does not preclude benign prostatic hyperplasia (BPH) as a cause of obstruction.

Pelvic examination – Women with urinary retention should have a pelvic examination.

Neurologic evaluation – The neurologic examination should include assessment of strength, sensation, reflexes, and muscle tone.

Laboratory studies – A urine sample should be obtained and sent for urinalysis and urine culture.

The need for other laboratory testing should be determined based upon findings from the patient's history and physical examination. Most patients who present to the emergency department with concern for urinary retention have serum chemistries and creatinine checked. These should be checked in any patient whose history suggests acute-on-chronic urinary retention to evaluate for renal failure.

Other labs that may be helpful include a complete blood count (CBC) for suspected infection. We do not check a prostate-specific antigen (PSA) as it is expected to be elevated during an episode of AUR.

ACUTE MANAGEMENT — The initial management of acute urinary retention (AUR) is prompt bladder decompression by catheterization, with urinalysis and culture.

Options for bladder decompression — Bladder decompression can be accomplished with urethral or suprapubic catheterization. There are no uniform guidelines for bladder decompression. Most patients will have an initial attempt at urethral catheterization.

Urethral catheterization — An initial attempt at urethral catheterization is appropriate for most patients (see 'Contraindications to urethral catheterization' below), particularly in patients for whom AUR is expected to resolve (eg, patients with urinary tract infections or AUR secondary to medication effect). A 14 to 18 gauge French catheter should be inserted as first-line in most patients with AUR [11]. Indications for choosing a smaller or larger catheter are discussed below. (See 'Difficulties with urethral catheterization' below.)

For patients with an initial urine volume of less than 200 cc, immediate catheter removal and subsequent observation for recurrence is usually appropriate. These patients should be evaluated for other causes of abdominal and/or suprapubic discomfort. (See "Evaluation of the adult with abdominal pain" and "Evaluation of acute pelvic pain in nonpregnant adult women".)

For patients with greater than 200 cc of urine, the volume drained in the first 10 to 15 minutes should be noted and recorded as it is useful for subsequent management regarding duration of catheter use. If this volume exceeds 400 cc, the catheter is typically left in place. For volumes less than 400 cc, the decision to leave the catheter in place is guided by the clinical scenario.

For patients with greater than 200 cc and less than 400 cc, the decision on catheterization may take into account multiple factors. Patient comorbidities, mental status, ability to return to the hospital, and numerous other factors may influence this decision to leave an indwelling catheter.

In patients with back pain or neurologic symptoms, the presence of spinal cord compression should be considered. Younger age, history of malignancy, or intravenous drug abuse can be associated risk factors.

In patients with AUR, we generally leave the catheter in place for three to five days, after which the patient is given a voiding trial. Examples of earlier catheter removal include postoperative patients who are initially unable to void but recover this ability within a few hours.

Contraindications to urethral catheterization — Urethral catheterization is contraindicated in patients who have had recent urologic surgery (eg, radical prostatectomy or urethral reconstruction), and these patients should have suprapubic catheterization. (See 'Suprapubic catheter' below.)

Although there is a theoretical risk to placement of a urethral catheter in the setting of acute bacterial prostatitis, these patients may have an attempt at gentle urethral catheterization by an experienced clinician. (See "Acute bacterial prostatitis", section on 'Nonantimicrobial therapy'.)

Difficulties with urethral catheterization — Some patients may have an obstruction that does not readily allow passage of the catheter. A partially obstructing urethral or prostatic scar may be present if the patient has had a prior transurethral procedure (eg, transurethral resection of the prostate), or pelvic trauma or radiation [10]. In this case, the obstruction may be bypassed by downsizing the catheter to a 10 or 12 gauge French indwelling catheter. In the absence of prior instrumentation or injury, the more common cause of obstruction would be an enlarged prostate. In this case, a larger catheter (20 or 22 gauge) with a firm coude tip may be needed and may require urologic consultation. (See "Placement and management of urinary bladder catheters in adults", section on 'Transurethral catheter placement'.)

If attempts to pass a catheter are not successful, urgent urology consultation may be an option for bedside flexible cystoscopy with either dilatation of a stricture or passage of a wire over which a urinary catheter may be placed [10].

Complications of urethral catheters are discussed separately. (See "Complications of urinary bladder catheters and preventive strategies", section on 'Urethral catheters'.)

Suprapubic catheter — Placement of a suprapubic (SP) catheter is sometimes necessary in patients who have contraindications to or fail urethral catheterization (eg, those with recent urologic surgery, acute prostatitis, urethral stricture disease, severe benign prostatic hyperplasia [BPH], or other anatomic abnormalities).

SP catheters are usually placed by a urologist. Suprapubic tubes can be placed in either the operating room, the emergency department, or occasionally an outpatient clinic. However, patient factors (age, health, medications, body mass index, prior surgical history, etc) may preclude placement outside of the operating room.

In cases when no urologist or appropriately trained clinician is available and the patient is in distress, bladder distention can be temporarily relieved with suprapubic aspiration via a needle. However, this treatment can make subsequent SP placement more difficult or even dangerous due to bladder decompression. If an appropriately trained medical professional will be available in the near future, needle decompression should be deferred. (See "Placement and management of urinary bladder catheters in adults", section on 'Suprapubic catheter placement'.)

SP catheters have some benefits over indwelling urethral catheters. We prefer SP catheters in patients who are expected to require long-term bladder drainage. SP catheters prevent bladder neck and urethral dilatation and therefore prevent urinary incontinence due to sphincter dysfunction. They also have the advantage of allowing assessment of the patient's ability to void before removing the catheter, they may be associated with fewer infections than an indwelling urethral catheter [32], and are less uncomfortable than urethral catheters. Lastly, SP catheters in men avoid the risk of subsequent urethral stricture, a common complication in men requiring long-term urethral catheterization [33].

However, SP catheters carry an increased risk for complications associated with placement, including bowel perforation and wound infection. (See "Complications of urinary bladder catheters and preventive strategies", section on 'Suprapubic catheters'.)

Rate of decompression — We recommend complete drainage of the bladder in patients with AUR. At one time, rapid complete bladder decompression was thought to increase the rate of potential complications (transient hematuria, hypotension, and postobstructive diuresis). However, partial drainage and clamping does not reduce these complications and may increase risk for urinary tract infection [31,34-36].

Complications of decompression — Complications associated with bladder decompression include [1]:

Hematuria – Hematuria occurs in 2 to 16 percent of patients but is rarely clinically significant [31]. For example, one trial found that hematuria occurred in approximately 11 percent of patients with AUR; hematuria resolved with irrigation for almost all patients [37].

Transient hypotension – After initial bladder decompression, patients may experience a transient hypotension [31]. However, blood pressure usually normalizes without intervention and does not progress to clinically significant hypotension.

Postobstructive diuresis – Relief of urinary tract obstruction can lead to a postobstructive diuresis, which is defined as a diuresis that persists after decompression of the bladder. A postobstructive diuresis is primarily a problem with chronic, not acute, urinary retention and usually represents an appropriate attempt to excrete excess fluid retained during the period of obstruction [38].

Any patient with urinary retention can develop postobstructive diuresis. Many patients can manage the increase in urine output by increasing oral fluid intake. In patients who are unable to do so or have severe postobstructive diuresis, we measure the urine output and replace one-half the urine volume with one-half isotonic saline. However, the rate of replacement and choice of replacement fluid may differ based on initial volume status and whether or not hypo- or hypernatremia is also present. (See "Maintenance and replacement fluid therapy in adults", section on 'Replacement fluid therapy'.)

Other treatments — When possible, medications that may be contributing to AUR (table 1) should be stopped. Patients with infectious etiologies should be treated appropriately.

Indications for hospitalization — The majority of patients can be safely managed as an outpatient once the bladder is decompressed [39]. Hospitalization is indicated for patients who have urosepsis, have obstruction related to malignancy, or acute myelopathy [11]. Patients with associated acute renal failure also require hospitalization [1].

Prior to discharge, patients should be instructed in managing the catheter, emptying their catheter bag, and monitoring their urine output. Prophylactic antibiotics are not indicated for patients with an indwelling urinary catheter. (See "Placement and management of urinary bladder catheters in adults", section on 'Catheter care' and "Placement and management of urinary bladder catheters in adults", section on 'Prophylactic antibiotics'.)

Duration of catheterization — The duration of catheterization depends on the underlying etiology for AUR. Patients with an underlying etiology that is being treated and expected to resolve (eg, urinary tract infection) should attempt a voiding trial as soon as possible that condition has been treated to avoid catheter complications. (See "Complications of urinary bladder catheters and preventive strategies", section on 'General complications' and "Complications of urinary bladder catheters and preventive strategies", section on 'Prevention of complications' and "Placement and management of urinary bladder catheters in adults", section on 'Catheter removal' and "Postoperative urinary retention in females", section on 'Spontaneous voiding trial'.)

In other patients who have underlying etiologies not likely to resolve (eg, spinal cord injury) and/or who have acute-on-chronic urinary retention, catheterization may become chronic. Those patients may benefit from either long-term clean intermittent catheterization (CIC) or SP placement. (See "Placement and management of urinary bladder catheters in adults", section on 'Clean intermittent catheterization' and 'Suprapubic catheter' above.)

The duration of catheterization in men with benign prostatic hyperplasia is discussed below. (See 'Trial without a catheter' below.)

Clean intermittent catheterization — CIC has fewer complications compared with indwelling urethral and SP catheterization. In patients with AUR, compared with indwelling catheters, CIC is associated with an increased rate of spontaneous voiding and reduction in urinary tract infections [40].

CIC may be a reasonable option in hospitalized patients where nursing care is available and AUR is expected to resolve in a short period of time. CIC is also a reasonable option for outpatients who are comfortable with managing the catheter and patients with acute-on-chronic urinary retention who are expected to require long-term catheterization (eg, prior spinal cord injury). (See "Placement and management of urinary bladder catheters in adults", section on 'Intermittent' and "Placement and management of urinary bladder catheters in adults", section on 'Clean intermittent catheterization' and "Chronic complications of spinal cord injury and disease", section on 'Bladder dysfunction'.)

SUBSEQUENT MANAGEMENT — For patients who have a known reversible etiology (eg, urinary tract infection or medication), no further evaluation is needed unless the acute urinary retention (AUR) does not resolve with treatment.

The appropriate subsequent evaluation of patients without benign prostatic hyperplasia (BPH) depends on history and physical exam findings. For example, women with posterior vaginal defects (eg, rectocele) leading to incontinence should be evaluated by a gynecologist. (See "Posterior vaginal defects (eg, rectocele): Clinical manifestations, diagnosis, and nonsurgical management".)

If the etiology for AUR is not found on initial evaluation, patients should be referred to a urologist to evaluate for less common anatomic etiologies (eg, urethral stricture or urethral diverticulum) and/or for possible bladder function testing. Urodynamic studies should be performed by a urologist with experience in functional bladder disorders. (See "Strictures of the adult male urethra" and "Urethral diverticulum in females".)

Benign prostatic hyperplasia — BPH is the most common cause of AUR [2-5,11]. Men who have not been diagnosed with BPH but who do not have another etiology for AUR and have a history suggesting BPH should be managed similarly to men with a known history of BPH. However, these men will need further evaluation to confirm the diagnosis of BPH. Men with BPH (or presumed BPH) with AUR should be evaluated by a urologist once they have had acute management with bladder decompression. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia".)

Men who have BPH and AUR are at risk for recurrent AUR. Studies performed before effective medical management was available found that one-half of men experienced a recurrence of AUR within one week, and two-thirds experienced a recurrence within one year [25,41].

Medical management — In men with BPH or presumed BPH, we recommend initiating an alpha-1-adrenergic antagonist (eg, alfuzosin 10 mg) at the time of initial catheterization. We also suggest ongoing treatment with an alpha-1-adrenergic blocker and a 5-alpha reductase inhibitor to delay the recurrence of AUR.

Alpha-1-adrenergic antagonists function to relieve the mechanical obstruction associated with BPH by relaxation of the smooth muscle at the bladder neck and the prostatic capsule [42]. A 2014 systematic review of nine randomized trials evaluating alpha-1-adrengeric antagonists prior to the removal of urethral catheters for AUR found moderate evidence that alpha-1-adrenergic antagonists increase success rates of trials without a catheter (relative risk [RR] 1.55, 95% CI 1.36-1.76) with low incidence of adverse effects [43].

Several different types of alpha-1-adrenergic antagonists are available with similar mechanisms and differing side effect profiles (table 3) [44]. Alfuzosin and tamsulosin have been evaluated in randomized, placebo-controlled trials in conjunction with a trial without a catheter (TWOC) [45-47]. The Alfuzosin in Acute Urinary Retention trial (ALFAUR) compared placebo with alfuzosin (10 mg once daily) in 360 men with AUR [47]. Alfuzosin increased the successful TWOC rate (62 versus 48 percent). Furthermore, in patients with a successful TWOC, treatment with alfuzosin delayed time to recurrence of AUR and need for surgical treatment [48]. Compared with placebo, the rate of surgery for recurrence of AUR in the first six months was lower in patients who received alfuzosin as maintenance therapy (17 versus 24 percent). Risk reduction for surgery with alfuzosin was 61, 52, and 29 percent at one, three, and six months, respectively.

5-alpha reductase inhibitors (eg, finasteride and dutasteride) decrease the incidence of AUR in men with BPH but do not reduce the early recurrence of AUR [49-51]. Patients need to be treated for more than one year to prevent AUR and reduce the need for surgery.

Trial without a catheter — Initial bladder decompression and initiation of medical therapy should be followed by a TWOC. We suggest that patients have two trials prior to considering surgical therapy. We generally have patients attempt a TWOC one to two weeks after the catheter is placed. While a second TWOC for patients who fail the initial trial has a lower rate of success than the initial TWOC, for patients who fail the initial TWOC, we suggest a second trial of TWOC after an additional two weeks with the catheter.

In our office, a voiding trial starts with catheter removal early in the morning, either at home or in the office. Patients are encouraged to hydrate aggressively and to return to the office in the early afternoon for a postvoid residual (PVR). A PVR over 400 cc is generally considered a failure, under 200 cc would be a success, and PVRs between 200 to 400 cc result in a risk benefit discussion of options. If the patient is unable to void or if they are voiding with high PVRs, they are offered instruction in clean intermittent catheterization. If they are unable or unwilling to do this, a catheter is placed.

Reported success rates for initial TWOC in men with prostate disease with AUR have ranged from 20 to 40 percent [45]. Factors that favor a successful TWOC include age less than 65 years, detrusor pressure greater than 35 cm H2O, a drained volume of less than one liter at catheterization, and the identification of a precipitating event [41,45].

The optimal duration of catheter management in men with BPH prior to a trial of voiding has been evaluated, with contradictory findings. Randomized trials found an increase in the likelihood of spontaneous voiding when catheters were removed at seven days rather than immediately or after two days [52,53]. However, an observational study in 2600 men with AUR found that men who were catheterized for three days or less had greater success with spontaneous voiding compared with men catheterized for more than three days [54]. Two limitations of this observational study include the potential for greater underlying comorbidity in the men who were catheterized longer; and that 80 percent were treated with an alpha-1-adrenergic antagonist.

Surgical therapy — Men who fail a second TWOC may require surgical therapy. Surgical therapy remains the definitive treatment of AUR. Among symptomatic patients with BPH, transurethral resection of the prostate (TURP) reduces the risk of developing AUR by 85 to 90 percent [55]. (See "Surgical treatment of benign prostatic hyperplasia (BPH)".)

We evaluate all patients being considered for surgical intervention following an episode of AUR with urodynamic studies, to determine whether retention is directly related to outlet obstruction, with concomitant elevation in bladder pressures, or to an inefficient bladder muscle. Patients with bladder impairment are unlikely to benefit from a surgical procedure aimed to reducing outlet resistance.

With respect to the timing of surgery, the general recommendation is to wait 30 days or more following an episode of AUR [39]. Patients who undergo surgery immediately following an episode of AUR are at an increased risk of complications, including intraoperative bleeding and sepsis related to bacteriuria [39,56]. In one cohort study, 1242 men who underwent prostatectomy for AUR had an excess risk of death at 30 and 90 days after the procedure compared with men undergoing elective prostatectomy (RR 26.6 and 4.4, respectively) as well as an increased risk of perioperative complications [39]. Some, but not all of this excess risk could be explained by older age, larger prostate size, and higher comorbidity in the men with AUR.

Urethral stenting is no longer used as it provided only modest improvement in symptoms and was associated with a variety of complications including: stent migration, encrustation, infection, and calculus formation [57]. As a result, this is no longer used. Prostatic urethral lift (Urolift) has become an attractive, minimally invasive, low-risk surgical procedure associated with improvement in urinary symptoms and preservation of ejaculatory function [58,59].

Other conditions — The management of other conditions that are associated with AUR are discussed in the individual topics reviews. As examples:

Spinal cord injury (see "Chronic complications of spinal cord injury and disease", section on 'Urinary complications')

Urethral stricture (see "Strictures of the adult male urethra")

Urethral diverticulum (see "Urethral diverticulum in females")

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Benign prostatic hyperplasia".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Neurogenic bladder in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

Common causes – Acute urinary retention (AUR) is the most common urologic emergency and is seen more often in men than women. Benign prostate hyperplasia (BPH) is the most common underlying condition in men, but there are many possible etiologies. Medications are frequently implicated (table 1). (See 'Epidemiology' above and 'Pathogenesis and etiologies' above.)

Clinical presentation – Patients generally present with the abrupt inability to pass urine. It is typically associated with lower abdominal and/or suprapubic discomfort. Patients who have chronic urinary retention may not have abdominal pain but may complain of symptoms of overflow incontinence. Persons with dementia or other forms of cognitive impairment may present with an acute change in mental status. (See 'Clinical presentation' above.)

Diagnosis – The diagnosis is made by demonstrating retained urine by either bladder ultrasound or catheterization. If the procedure can be performed relatively quickly, a bladder ultrasound is a good first choice for patients who are not in extreme distress, because it is noninvasive, it is more comfortable for the patient, and bladder decompression can be avoided if results are normal. In patients whose history and physical examination strongly suggest a diagnosis of AUR, it is reasonable to proceed directly to catheterization, which is both diagnostic and therapeutic. (See 'Diagnosis' above.)

Acute bladder decompression – Initial management of AUR consists of prompt bladder decompression usually with an indwelling urethral catheter. Urethral catheterization is contraindicated in patients who have had recent urologic surgery (eg, radical prostatectomy or urethral reconstruction). A suprapubic catheter may be necessary when obstruction precludes a urethral catheter and is also preferred in patients who are expected to require longer-term catheterization. (See 'Acute management' above.)

Limited need for hospitalization – The majority of patients can be managed as outpatients once bladder decompression is accomplished. Hospitalization is indicated for patients with urosepsis, acute renal failure, or obstruction related to malignancy or spinal cord compression. (See 'Indications for hospitalization' above.)

Ongoing medical treatment – In men with BPH or presumed BPH, treatment also includes an alpha-1-adrenergic antagonist (eg, alfuzosin 10 mg daily) initiated at the time of initial catheterization. Ongoing combination treatment is generally necessary to prevent recurrence of AUR. (See 'Medical management' above and "Medical treatment of benign prostatic hyperplasia".)

Catheter removal – In men with BPH, removal of the catheter after a period of time after initiation of medical treatment ("trial without catheter" or TWOC) results in successful spontaneous micturition in up to 40 percent of patients, although recurrent AUR is common. We suggest a trial of catheter removal in one to two weeks. For patients who fail the initial TWOC, we advise a second trial of TWOC after an additional two weeks with the catheter. (See 'Trial without a catheter' above.)

Men with BPH who fail a second TWOC may need surgical therapy. A urodynamic evaluation is advised prior to prostate surgery for patients who have experienced AUR. (See 'Surgical therapy' above.)

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Topic 6883 Version 47.0

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