Factors affecting trial without catheter for first spontaneous acute urinary retention

Immediate or delayed trial without catheter in acute urinary retention in males: A systematic review

Objective

To compare the success of establishing spontaneous micturition following immediate trial without catheter (TWOC) to delayed TWOC in males catheterized for acute urinary retention.

Materials and methods

In this systematic review, we included studies reporting success rates of immediate TWOC or delayed TWOC (≤30 days) among males ≥18 years of age catheterized for acute urinary retention. We excluded studies on suprapubic catheterization, postoperative/perioperative catheterization and urinary retention related to trauma. We searched the following databases: MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Open Grey and Clinicaltrials.gov. The search was concluded on 30 November 2022. There were no restrictions on language or publication date. Risk of bias was assessed using the ROB 2.0 and ROBINS-I tools. We did random-effects restricted maximum likelihood model meta-analyses. Certainty of evidence was assessed using GRADE.

Results

We included 61 studies. In two randomized controlled trials (RCTs), both with some concerns for risk of bias, including in total 174 participants, the relative success rate was 1.22 (95% CI 0.84-1.76) favouring delayed TWOC. In two comparative cohort studies, both with serious risk of bias, including 642 participants, the relative success rate was 1.18 (0.94-1.47) favouring delayed TWOC. One study was excluded from this meta-analysis because of critically low quality. Four studies reporting success rates for cohorts with immediate TWOC, all with serious risk of bias, including 409 participants, had an overall success rate of 47% (29-66). Fifty-two studies reporting success rates for cohorts with delayed TWOC, all with serious risk of bias, including 12 489 participants, had an overall success rate of 53% (49-56). The certainty of the evidence was considered low for the RCTs and very low for the rest.

Conclusion

There was a limited number of appropriately designed studies addressing the research question directly. The evidence favours neither approach.

Elements for Trial Without Catheter (TWOC) Success in Benign Prostatic Hyperplasia Patients: Lessons We Have Learned

BACKGROUND

Benign prostatic hyperplasia (BPH) is a progressive disease that causes low urinary tract symptoms (LUTS). As prostatic volume grows, the prostatic urethra may become completely obstructed, resulting in full urine retention and acute hypogastric pain. Our research aimed to identify the optimal trial without catheter (TWOC) therapeutic approach and identify those factors that are associated with the recurrence of complete urinary retention (CUR).

METHODOLOGY

The study enrolled with complete urinary retention and BPH were included in the study, after the insertion of a Foley catheter. The patients received tamsulosin 0.4 mg/day as an alpha-blocker treatment. In our investigation, patients who encountered complete urinary retention were randomly categorized into four groups based on the duration of urinary catheterization as determined by the attending urologist.

RESULTS

Maintaining the urethrovesical catheter for three to seven days was related to the highest success of spontaneous urination, which was statistically significant compared to other study groups. (p=0.0007). Age over 70 years, no alpha-blocker before the urinary retention episode, and prostatic volume exceeding 50 ml were all associated with decreased TWOC efficacy. We found the highest rates of spontaneous urination were after three to seven days of urinary catheterization.

CONCLUSION

BPH and complete urine retention can be managed by TWOC in many cases. Several factors affect the test's efficacy. Prolonged urinary catheter maintenance over seven days, prostatic volume over 50 ml, and age over 70 years are poor prognostic indicators.

Predictive factors for the success of trial without catheter for men with urinary retention

OBJECTIVE

To investigate the trial of spontaneous urination without catheter (TWOC) outcomes for men with acute urinary retention, determine successful TWOC predictors, and evaluate the impact of add-on medication therapy on TWOC.

METHODS

This retrospective study included men with acute urinary retention and post-void residual (PVR) >250 mL who underwent TWOC between July 2009 and July 2019. Patients were divided into a medicated group who received alpha1 blocker on urinary retention diagnosis and a naïve group who did not. The trial was defined as unsuccessful if the PVR was >150 mL or if the patient experienced difficulty emptying their bladder with abdominal discomfort or pain, and a transurethral catheter was reinserted.

RESULTS

Among 576 men with urinary retention, 269 (46.7%) constituted the medicated group and 307 (53.3%) the naïve. The naïve group comprised more elderly patients (P = 0.010) with higher Eastern Cooperative Oncology Group performance status (PS) (P = 0.001) and smaller prostate volume (P = 0.028) than the other. In the medicated group, 153 men received additional oral medication before TWOC to increase the success rate. There were significant age differences (P = 0.041) in the medicated group and significant median PS differences (P = 0.010) in the naïve group between the successful and unsuccessful outcomes of TWOC. The multivariate logistic regression model demonstrated that age <80 years in medicated patients (P = 0.042, odds ratio [OR] 1.701) and PS <2 in naïve patients (P = 0.001, OR 2.710) were significant independent predictors of successful TWOC outcomes.

CONCLUSIONS

This is the first study classifying patients with urinary retention according to medication status. Both medicated and naïve groups had different patient backgrounds and TWOC outcome predictors, suggesting a discrepant etiology behind urinary retention. Hence, acute urinary retention management in men should vary based on medication status for male lower urinary tract symptoms when urinary retention is diagnosed.

Ultrasound prostate parameters as predictors of successful trial without catheter after acute urinary retention in patients ongoing medical treatment for benign prostatic hyperplasia: a prospective multicenter study

BACKGROUND

Alpha-blockers (ABs) are considered the standard treatment after initial management of acute urinary retention (AUR). However, no data are available on the predictors of a successful trial without catheter (TWOC) in patients previously on treatment with ABs and 5alpha reductase inhibitors (5ARI). The aim of our study was to investigate prostate ultrasound parameters as predictors of TWOC outcome.

METHODS

A consecutive series of patients, on treatment with ABs alone or in combination with 5ARI, experiencing AUR were prospectively enrolled. Clinical data (i.e., age, body mass index (BMI) and IPSS), urinary ultrasound features including hydronephrosis, prostate volume-TRUS, bladder wall thickness (BWT), intravesical prostatic protrusion more than 10mm (IPP≥10) were related to TWOC outcome performed seven days after AUR. A binary logistic regression analysis was computed to detect predictors of successful TWOC.

RESULTS

Overall,143 patients with a median age of 72 years (IQR 64-77) were enrolled. Seventy-mine patients (54%) with smaller prostate volume (59 [IQR 52-74] vs. 99 [IQR 74-125] mL, P=0.008) and a thinner BWT (5[IQR 4.8-5.2] vs. 5.2 [4.7-5.5] mm P=0.001) recovered voiding at TWOC. IPP≥10 was less common in patients with successful TWOC 11 (14%) vs. 33 (52%), P=0.001. On multivariate analysis, IPP<10mm (OR 6.10 [95%CI 2.61-14.20], P=0.001), lower IPSS (OR 0.95 [95% CI 0.89-0.99], P=0.045), smaller TRUS (OR 0.96 [95% CI 0.95-0.97], P=0.001), thinner BWT OR 1.23 (95%CI 0.73-0,92) P=0.001were the independent predictors of voiding recovery.

CONCLUSIONS

Patients receiving medical treatment for BPH and experiencing AUR still present a 54% probability of a successful TWOC. Ultrasound may help to identify patients with successful TWOC.

Terazosin versus Alfuzosin in Treatment of Acute Urinary Retention in Patients with Benign Prostatic Hypertroph

Objective

To compare the efficacy and adverse reactions of terazosin and alfuzosin in treatment of acute urinary retention in patients with benign prostatic hypertrophy.

Design

Case control study.

Setting

Emergency department of a regional hospital in Hong Kong.

Methods

Our study included all adult male with age at least 18 years old presented with acute urinary retention, having residual urine volume greater than or equal to 300 ml after urinary catheterisation and with a presumed diagnosis of benign prostatic hypertrophy. Patients treated with terazosin from December 2013 to February 2014 were retrospectively included while patients treated with alfuzosin from April to September 2014 were prospectively included. We compared the two groups on: trial without catheter (TWOC) rate, potential adverse effects including drug-associated postural hypotension, haemodynamic changes and prolongation of corrected QT interval in electrocardiogram. Cost effectiveness analysis was performed.

Results

A total of 116 patients were included with 59 and 57 patients in the terazosin and alfuzosin group respectively. Logistic regression showed that residual urine volume (odds ratio [OR]=0.998, 95% confidence interval [CI]=0.996-0.999, p=0.008) and presence of precipitating factors (OR=2.264, 95% CI=1.045-5.793, p=0.045) were independent predictors of successful TWOC. There was no significant difference in the TWOC rate for patients treated with alfuzosin and terazosin. There was significantly more symptomatic postural hypotension in the terazosin group compared with the alfuzosin group. The number need to treat with alfuzosin for terazosin to avoid one adverse drug effect was 12.3 patients (95% CI=4.7-21.6) and 9.9 patients (95% CI=5.3-84.6) to reduce one postural hypotension and symptomatic postural hypotension respectively.

Conclusions

Alfuzosin is comparable to terazosin in TWOC rate. However, alfuzosin is associated with a lower rate of symptomatic postural hypotension and less haemodynamic impact than terazosin. (Hong Kong j.emerg.med. 2015;22:210-218)

Hydronephrosis Predicts Successful Catheter Removal after Painful Urinary Retention - Preliminary Results of a Prospective Single Center Study

INTRODUCTION

The study aims to identify candidates who can be managed conservatively after the first episode of spontaneous painful acute urinary retention (AUR).

METHODS

A total of 20 patients with primary spontaneous painful AUR were prospectively included in the study. Twenty-four hours after AUR, the catheter was removed. When residual urinary volume was <100 ml, patients were referred without catheter, when residual urinary volume was ≥100 ml, the catheter was replaced and removed again at day 4, 7 or 10 after AUR, respectively. Receiver operating characteristic curves, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to assess predictors for successful catheter removal.

RESULTS

Thirteen out of 20 (65%) patients had a successful catheter removal until day 10 after AUR. Among them 12 of 13 (93.2%) had a successful catheter removal until day 4 of AUR. Hydronephrosis urinary volume and Qmax at the time of AUR were significant numeric predictors for failure of successful catheter removal. In addition, we calculated a prediction model combing age + prostate volume + urinary volume + Qmax that highly predicts successful catheter removal (sensitivity 100%, specificity 69%, PPV 64%, NPV 100%).

CONCLUSION

We found for the first time a significant association between hydronephrosis and successful catheter removal. Successful catheter removal until day 4 after AUR can safely be managed without immediate transurethral resection of the prostate.