13.1. Introduction
Urinary retention has a very major impact on patients' quality of life. It is classified into three forms:
Acute retention: This is the abrupt (over a period of hours) development of the inability to pass urine, associated with increasing pain and the presence of a distended bladder, which can be palpated when the patient is examined. The pain can be excruciating and can be described as similar to that caused by passage of a kidney stone. The bladder may contain between 500ml and one litre when the patient is seen, and the rapid stretching of the bladder results in pain. Acute retention may be precipitated by some other event (such as excessive fluid intake or constipation) or it may be apparently spontaneous.
Chronic retention: This is the gradual (over months or years) development of the inability to empty the bladder completely, associated with the presence of a distended bladder, which can be palpated when the patient is examined. The insidious nature of onset of the condition means that the bladder stretches slowly enough for there to be no pain. The bladder will usually contain more than a litre when the patient is seen. There may be lower urinary tract symptoms, sometimes leakage at night, but there may be no symptoms at all. Sometimes the bladder is distended at high pressure, and this result in back-pressure on the kidneys, with kidney failure to a varying degree. Chronic retention is defined as a residual volume of greater than one litre or a palpable bladder.
Acute-on-chronic retention: This is the abrupt development of acute retention in a patient who previously had chronic retention, either knowingly or more often unknowingly.
13.2. Management of men in acute retention
13.2.1. What is the effectiveness of alpha blockers in treating men after acute urinary retention?
Acute urinary retention due to benign prostatic enlargement (BPE) may be associated with an increase in alpha-adrenergic activity. Inhibition of these receptors by alpha blockers may decrease bladder outlet resistance thereby facilitating normal micturition and increasing the chances of a successful trial without catheter (TWOC).
See Evidence Table 47, Appendix D, Forest Plots in to , Appendix E and Economic Evidence Table 53, Appendix D.
13.2.1.1. Clinical evidence
Table 13-165Alpha blocker vs. placebo – Clinical study characteristics
View in own window
| Outcome | Number of studies | Design | Limitations | Inconsistency | Indirectness | Imprecision |
|---|
| Able to void176,193,194,272 | 4 | RCT | No serious limitations | No serious inconsistency | No serious indirectness | Serious imprecision (b) |
| Re-catheterisation176,272 | 2 | RCT | Serious limitations (a) | No serious inconsistency | No serious indirectness | Serious imprecision (b) |
- a
One study 272 did not report method of randomisation or allocation concealment.
- b
Imprecision due to small sample size and confidence intervals cross MID (0.75 or 1.25).
Table 13-166Alpha blocker vs. placebo - Clinical summary of findings
View in own window
| Outcome | Alpha-blocker | Placebo | Relative risk | Absolute effect | Quality |
|---|
| Able to void | 211/402 (52.5%) | 106/282 (37.6%) | 1.30 [1.10, 1.55] | 113 more per 1000 [8 to 207 more] | Moderate |
| Re-catheterisation | 54/105 (51.4%) | 64/98 (65.3%) | 0.79 [0.63, 1.01] | 137 fewer per 1000 [42 fewer to 7 more] | Low |
13.2.1.2. Economic evidence
We found a cost-effectiveness analysis17 comparing alpha blockers to placebo and immediate prostatectomy in patients hospitalized for acute urinary retention. Patients in the alpha blockers group were treated with Alfuzosin 10mg once daily for 3 days during the initial hospitalisation followed by TWOC. After a successful TWOC this group was treated again with Alfuzosin for 6 months. We report here only the comparison between alpha blockers and placebo.
Please see Economic Evidence Table 53 in Appendix D for further details.
Table 13-167Alpha blocker vs. placebo - Economic study characteristics
View in own window
| Study | Limitations | Applicability | Other Comments |
|---|
| Annemans200517 | Minor limitations (a) | Partial applicability (b) | Based on the ALFAUR study195 |
- a
Not a full economic evaluation
- b
Short follow-up (6 months) after which treated patients are very likely to need surgery.
Table 13-168Alpha blocker vs. placebo - Economic summary of findings
View in own window
| Study | Incremental cost (£) per patient | Incremental effects | ICER | Uncertainty |
|---|
| Annemans200517 | 349 (a) | Not reported | Not applicable | (95% CI £64-£624) |
- a
Costs include hospitalisation, drugs, unsuccessful TWOC followed by prostatectomy and tests, over 6 months.
13.2.1.3. Evidence statement(s)
View in own window
| Clinical | In men with acute urinary retention, an alpha blocker is more effective than placebo in increasing their chance of voiding after catheter removal.
In men with acute urinary retention, there was no significant difference between alpha blockers and placebo in the number of men who required recatheterisation after catheter removal. |
| Economic | In men with acute urinary retention, alpha blockers are cost-saving over a 6-month period. This evidence has minor limitations bur partial applicability. |
13.2.2. Recommendations and link of evidence
See recommendations and link of evidence in section 13.4.
13.3. Management of men with chronic retention
Catheters may be used as a long term solution where persistent urinary retention is causing incontinence, infection or renal dysfunction and an operative solution is not feasible. Their use is associated with an increased risk of adverse events including recurrent urinary infections, trauma to the urethra, pain and stone formation. Intermittent catheterisation releases a patient from having a continuous indwelling catheter which in many patients is better tolerated with an improvement in QOL and reduced morbidity.
The evidence for this section is reviewed and presented in the relevant chapters on the type of treatment. Please see the following chapters:
13.4. Recommendations and link to evidence
View in own window
| Recommendation | Immediately catheterise men with acute retention. |
| Relative values of different outcomes | The GDG considered the alleviation of pain to be the primary outcome of interest. |
| Trade off between clinical benefits and harms | Immediate catheterisation is required to alleviate the acute retention and pain. The potential harm of inserting a catheter includes urinary tract infections, haematuria, trauma to the urethra, pain and stone formation. The benefit greatly outweighs the small risk of adverse events. |
| Economic considerations | Not addressed as no other strategy can be considered. |
| Quality of evidence | No evidence was found. |
| Other considerations | None. |
View in own window
| Recommendation | Offer an alpha blocker to men for managing acute urinary retention before removal of the catheter. |
| Relative values of different outcomes | The most important outcomes are to restore normal voiding and increase the chance of a successful trial without catheter without the need for re-catheterisation. |
| Trade off between clinical benefits and harms | The GDG considered that men's ability to void and not being re-catheterised outweighed potential adverse events of the treatment, which includes dizziness, somnolence, postural hypotension, syncope, rhinitis, asthenia (fatigue), headache, erectile dysfunction, abnormal ejaculation. |
| Economic considerations | Alpha blockers can be cost-saving compared to placebo. Although the GDG considers the economic evidence to have drawbacks due to its short follow-up, it is their opinion that alpha blockers could still be cost-effective. |
| Quality of evidence | All the studies were imprecise as they crossed the minimally important difference confidence intervals. The re-catheterisation outcome was low quality as there were also limitations in the study design of one of the two studies retrieved.
The economic evidence has minor limitations but partial applicability as the follow-up is very short. |
| Other considerations | There is no clear evidence for how long this treatment should continue before TWOC, but it seems likely that this should be at least two days treatment before TWOC. |
View in own window
| Recommendation | Consider offering self- or carer-administered intermittent urethral catheterisation before offering indwelling catheterisation for men with chronic urinary retention. |
| Relative values of different outcomes | Alleviation of retention and prevention of incontinence, infection or renal dysfunction from persistent retention is important. Recurrent urinary tract infections, haematuria, trauma to the urethra, pain and stone formation are important adverse events to be considered. |
| Trade off between clinical benefits and harms | The benefits of alleviating retention and preventing incontinence, urinary tract infections and renal dysfunction from persistent catheterisation outweigh the harms. Harms include incorrect use of catheter, and complications such as recurrent urinary tract infections, trauma to the urethra, accidental removal, recurrent blockage and stone formation. Patients may also be in pain or discomfort. |
| Economic considerations | It is unlikely that there is much cost difference between the alternative strategies. |
| Quality of evidence | No clinical or economic studies were found. These recommendations were based on the consensus opinion of the GDG. |
| Other considerations | The ability of patients to self-catheterise and availability of support from carers are important considerations. |
View in own window
| Recommendation | Consider offering intermittent or indwelling catheterisation before offering surgery in men with chronic urinary retention. |
| Relative values of different outcomes | Renal failure is most important outcome. Other important outcomes include failure to void, enuresis, urinary infections. |
| Trade off between clinical benefits and harms | Risk of renal dysfunction outweighs any disadvantages for catheterisation. |
| Economic considerations | The GDG considered that the cost of catheterisation is justified when the patient is judged to be at risk of renal dysfunction. |
| Quality of evidence | No clinical or economic studies were identified. |
| Other considerations | The principal problem is impaired bladder function to a variable degree. Any form of treatment needs to bear this in mind. The decision to catheterise for chronic retention is a value judgement, where the risks of catheterisation may outweigh the benefits in a fit patient planned for early prostate surgery. |
View in own window
| Recommendation | Consider offering intermittent self- or carer-administered catheterisation instead of surgery in men with chronic retention who you suspect have markedly impaired bladder function. |
| Relative values of different outcomes | Change in symptom scoring was the only outcome reported but QOL would be more helpful as IPSS score is not a useful measure in men self catheterising. In chronic retention patients there is often little in the way of LUTS and hence undue reliance on scoring of LUTS may be misleading. |
| Trade off between clinical benefits and harms | The GDG considered the avoidance of surgery and surgical morbidity versus the benefit of a definitive solution and the inconvenience and discomfort of self- catheterisation over a potentially long period. Ultimately this will depend on an assessment of whether the bladder has sufficient function to result in adequate bladder emptying after surgical intervention. Discussion between the patient and clinician should take account of mode of presentation -high (associated renal failure) or low pressure chronic retention and evidence from assessment of post void residuals/catheterisation volumes and urodynamic assessment with pressure flow studies. |
| Economic considerations | In men with poor bladder function TURP might fail to solve the problem, generating unnecessary costs. |
| Quality of evidence | There was only one small study found in patients with chronic retention; the level of uncertainty with the evidence is very high.
No economic studies were identified. |
| Other considerations | Patient preference, fitness for surgery and the likelihood of success following a surgical intervention vs. continued catheterisation are factors in helping men to decide on the relative benefits of each option. |
View in own window
| Recommendation | Provide active surveillance (post void residual volume measurement, upper tract imaging and serum creatinine testing) to men with non-bothersome LUTS secondary to chronic retention who have not had their bladder drained. |
| Relative values of different outcomes | Preservation of renal function and relief of symptoms are considered to be the most important outcomes. |
| Trade off between clinical benefits and harms | Ensuring there is no deterioration of renal function or any other complications as a consequence of non intervention is worth the effort of recalling patients for monitoring. |
| Economic considerations | Follow-up is associated with costs but these could be offset by the timely identification of complications. |
| Quality of evidence | No clinical studies were identified. These recommendations were based on the consensus opinion of the GDG.
No economic studies were identified. |
| Other considerations | Regular follow up with serum creatinine and renal ultrasound should be provided. |
13.5. Supporting recommendations
View in own window
| Recommendation | Carry out a serum creatinine test and imaging of the upper urinary tract in men with chronic urinary retention (residual volume greater than 1 litre or presence of a palpable/percussable bladder). |
| Trade off between clinical benefits and harms | This is to differentiate between high pressure chronic retention with impaired renal function and low pressure retention with normal renal function. In the presence of abnormal renal function and renal dilatation, patients require early catheterisation and often hospital admission to monitor renal function until it stabilises. The benefits of preventing further deterioration of renal function outweigh any risks of catheterisation. |
| Economic considerations | There are costs associated with additional specialised tests. However, misdiagnosis of underlying conditions is associated with costs and health detriment that are likely to outweigh the costs of these tests. |
| Other considerations | None. |
View in own window
| Recommendation | Consider offering surgery on the bladder outlet without prior catheterisation to men who have chronic urinary retention and other bothersome LUTS but no impairment of renal function or upper renal tract abnormality. |
| Trade off between clinical benefits and harms | Quality of life of the patient is the most important outcome. Trauma to the urethra, discomfort, urinary infection, haematuria are also important outcomes. The benefits of catheterisation need to be considered against the complications of inserting a catheter. Quality of life of patients may be better without catheterisation. Duration between presentation and surgical intervention may influence the decision whether to catheterise or not. |
| Economic considerations | In this group of men the benefits of catheterisation are unlikely to outweigh the complications and costs. |
| Other considerations | TURP may be safer (less blood loss) and more effective for patients who have previously not been catheterised. |
View in own window
| Recommendation | Catheterise men who have impaired renal function or hydronephrosis secondary to chronic urinary retention. |
| Trade off between clinical benefits and harms | Improved renal function outweighs all other considerations such as complication from catheters. |
| Economic considerations | In this group of men the benefits of catheterisation outweigh its risks and costs. |
| Other considerations | Post obstructive diuresis needs to be carefully monitored and may be an indication for hospital admission. |
View in own window
| Recommendation | Continue or start long-term catheterisation in men with chronic retention for whom surgery is unsuitable. |
| Trade off between clinical benefits and harms | The benefits of catheterisation to reduce the risk of potential renal dysfunction and symptoms outweigh the complications of catheterisation. |
| Economic considerations | In this group of men the benefits of catheterisation outweigh its risks and costs. |
| Other considerations | The type of catheterisation is important in determining quality of life (intermittent or indwelling urethral or suprapubic).
Reassess for potential surgical intervention in the future. |
13.6. Summary of recommendations
Immediately catheterise men with acute retention.
Offer an alpha blocker to men for managing acute urinary retention before removal of the catheter.
Consider offering self- or carer-administered intermittent urethral catheterisation before offering indwelling catheterisation for men with chronic urinary retention.
Carry out a serum creatinine test and imaging of upper urinary tract in men with chronic urinary retention (residual volume greater than 1 litre or presence of a palpable/percussable bladder).
Catheterise men who have impaired renal function or hydronephrosis secondary to chronic urinary retention.
Consider offering intermittent or indwelling catheterisation before offering surgery in men with chronic urinary retention.
Consider offering surgery on the bladder outlet without prior catheterisation to men who have chronic urinary retention and other bothersome LUTS but no impairment of renal function or upper renal tract abnormality.
Consider offering intermittent self- or carer-administered catheterisation instead of surgery in men with chronic retention who you suspect have markedly impaired bladder function.
Continue or start long-term catheterisation in men with chronic retention for whom surgery is unsuitable.
Provide active surveillance (post void residual volume measurement, upper tract imaging and serum creatinine testing) to men with non-bothersome LUTS secondary to chronic retention who have not had their bladder drained.
