Acute Urinary Retention

Acute urinary retention
21/09/2016, 6:46 PM
Official reprint from UpToDate

www.uptodate.com 2016 UpToDate

Authors
Glen W Barrisford, MD, MS
Graeme S Steele, MBBCh, FCS
Section Editors
Michael P O'Leary, MD, MPH
Robert S Hockberger, MD, FACEP
Deputy Editor
Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2016. | This topic last updated: Sep 21, 2015.
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 the epidemiology, pathogenesis and etiology, clinical presentation, evaluation, diagnosis, acute
management, and subsequent evaluation and management of AUR. The diagnosis and treatment of BPH are discussed
separately. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia" and "Medical
treatment of benign prostatic hyperplasia" and "Transurethral procedures for treating benign prostatic hyperplasia".)
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].
In 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). These mechanisms may overlap within any specific etiology.
Three factors predominate the pathophysiologic mechanisms of AUR: outflow obstruction, neurologic impairment, and
an inefficient detrusor muscle [9].
Outflow obstruction The flow of urine is impeded with outflow obstruction by mechanical and/or dynamic factors
[10]. Mechanical obstruction refers to a physical narrowing of the urethral channel [11]. Dynamic obstruction refers
to increased muscle tone within and around the urethra [9].
Neurologic impairment AUR may develop secondary to the interruption of the sensory or motor nerve supply to
the detrusor muscle [4]. AUR may be related to incomplete relaxation of the urinary sphincter mechanism
(dyssynergia), which can result in elevations in both voiding pressures and post-void residual volumes. In other
patients, inefficient bladder (detrusor) muscle contraction is the overriding factor leading to urinary retention.
Patients with neurologic impairment may develop acute-on-chronic urinary retention or urinary retention can
develop acutely with acute spinal injury (infarction, demyelination) along with other neurologic deficits. (See
"Chronic complications of spinal cord injury and disease", section on 'Urinary complications' and "Anatomy and
localization of spinal cord disorders" and "Disorders affecting the spinal cord".)
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) [9,11-14]. This most often occurs in patients with obstructive urinary symptoms at baseline.
AUR is most often secondary to mechanical outflow obstruction [15]. Other etiologies include medication,
neurologic disease, infection, and trauma.
Obstruction Obstruction is the most common cause of AUR [15].
In men, the most common cause of obstruction is benign prostatic hyperplasia (BPH) [2-5,15]. In men with BPH,
risk factors for developing AUR include advanced age, severity of lower urinary tract symptoms, increased prostate
volume, decreased urinary flow rate, and PSA >2.5 [3,16].
Other causes of outflow obstruction in men include constipation, cancer (prostate or bladder), urethral stricture,
urolithiasis, phimosis, or paraphimosis [4,11]. (See "Lower urinary tract symptoms in men" and "Clinical
manifestations and diagnostic evaluation of benign prostatic hyperplasia" and "Treatment of urethral stricture
disease in men".)
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In women, obstruction is generally secondary to anatomic distortion, including pelvic organ prolapse (eg, cystocele
or rectocele), pelvic masses (either benign or malignant tumors), or, less commonly, urethral diverticulum [7,17-26].
(See "Pelvic organ prolapse in women: An overview of the epidemiology, risk factors, clinical manifestations, and
management", section on 'Urinary symptoms' and "Urethral diverticulum in women".)
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.
Neurologic impairment AUR can occur with spinal cord injuries from trauma, infarct or demyelination, epidural
abscess and epidural metastasis, Guillain-Barr syndrome, diabetic neuropathy, and stroke [11]. AUR is typically
accompanied by back pain and/or other neurologic deficits. (See "Chronic complications of spinal cord injury and
disease", section on 'Bladder dysfunction' and "Diabetic autonomic neuropathy", section on 'Genitourinary
autonomic neuropathy' and "Medical complications of stroke", section on 'Urinary incontinence' and "Spinal
epidural abscess" and "Clinical features and diagnosis of neoplastic epidural spinal cord compression, including
cauda equina syndrome".)
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
[15,29]. 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 [1,15,29].
Trauma Patients with trauma to the pelvis, urethra, or penis may develop AUR from mechanical disruption [15].
(See "Blunt genitourinary trauma: Initial evaluation and management".)
Other AUR may also occur postoperatively or in the postpartum period. (See "Overview of complications in
adults admitted to the post-anesthesia care unit", section on 'Postoperative inability to void' and "Overview of
postpartum care", section on 'Voiding difficulty and urinary retention'.)
CLINICAL PRESENTATION Acute urinary retention (AUR) generally presents as an inability to pass urine. It is
typically associated with lower abdominal and/or suprapubic discomfort [11]. Affected patients are often restless and
may appear in considerable distress.
These manifestations may be less pronounced when AUR is superimposed upon chronic urinary retention. Chronic
urinary retention is often painless [30]. 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 women" and "Overview of complications in adults admitted to the post-anesthesia care unit", section
on 'Postoperative inability to void'.)
EVALUATION The evaluation for acute urinary retention (AUR) should begin with a history and physical exam
focusing on factors that help identify an etiology. A urinalysis and culture should be sent on all patients; other labs and
studies depend on the patient's presentation.
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
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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, including cauda equina syndrome", section on 'Clinical features' and
"Spinal epidural abscess", section on 'Clinical manifestations'.)
Physical examination In patients with AUR of unknown etiology, the physical examination should include the
following:
Lower abdominal palpation The urinary bladder may be palpable, either on abdominal or rectal
examination. Deep suprapubic palpation will provoke discomfort.
Rectal examination A rectal examination should be done in both men and women, 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, although the
sample may only be available after catheter insertion.
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 room with concern for urinary retention have
serum chemistries and creatinine checked. These should be checked in any patient whose history suggests acuteon-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
PSA (prostate-specific antigen) as it is expected to be elevated during an episode of AUR.
DIAGNOSIS Most patients with suspected acute urinary retention (AUR) will have a bladder ultrasound that will
confirm the diagnosis. However, in patients whose history and physical examination strongly suggest a diagnosis of
AUR, it is reasonable to proceed with catheterization without a bladder ultrasound, which is both diagnostic and
therapeutic.
A bladder ultrasound that suggests a volume of 300 cc in a patient unable to void suggests urinary retention. 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. The volume of urine drained in the first 10 to 15 minutes should be noted and recorded. If this volume
exceeds 400 cc, the catheter is typically left in place. For volumes of 200 to 400 cc, the decision to leave the catheter in
place is guided by the clinical scenario; and for volumes less than 200 cc, immediate catheter removal and a voiding trial
is appropriate for most patients. Patients with volumes less than 200 cc likely do not have acute urinary retention and the
patient 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 women".)
ACUTE MANAGEMENT The initial management of acute urinary retention (AUR) is prompt bladder decompression
by catheterization.
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, particularly
in patients for whom AUR is expected to resolve (eg, patients with urinary tract infections or AUR secondary to
medication effect).
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. 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 'Suprapubic catheter' below and "Acute bacterial prostatitis",
section on 'Nonantimicrobial therapy'.)
Indwelling catheter A 14 to 18 gauge French catheter should be inserted as first-line therapy in most patients
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with AUR [15].

Some patients may have an obstruction that does not readily allow passage of the catheter. If the patient has had a prior
transurethral procedure (eg, transurethral resection of the prostate), a partially obstructing urethral or prostatic scar may
be present. 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, 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'.)
Complications of urethral catheters are discussed separately. (See "Complications of urinary bladder catheters and
preventive strategies", section on 'Urethral catheters'.)
Clean intermittent catheterization Clean intermittent catheterization (CIC) has fewer complications
compared with indwelling urethral and suprapubic 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 [31].
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 able 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'.)
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. 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, such bladder decompression can make subsequent SP placement more difficult. If an appropriately trained
medical professional is 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 suprapubic (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. SP catheters for men avoid the risk of subsequent
urethral stricture, a common complication in men requiring long-term urethral catheterization [32]. They also have the
advantage of allowing assessment of the patient's ability to void before removing the catheter.
SP catheters may also be associated with fewer infections than an indwelling urethral catheter. In a randomized trial of
60 patients with AUR comparing indwelling urethral with SP catheterization, SP catheterization was associated with
fewer urinary tract infections (catheters were removed after two days) [33]. The patients undergoing SP catheterization
were less uncomfortable than those who were treated with urethral catheters. 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, studies have shown that partial drainage and clamping does not
reduce these complications and may increase risk for urinary tract infection [30,34].
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 [30]. For example,
one trial found that hematuria occurred in approximately 11 percent of patients with AUR; hematuria resolved with
irrigation for almost all patients [35].
Transient hypotension After initial bladder decompression, patients may experience a transient hypotension
[30]. 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
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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 [36].
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'.)
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 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 women", section on
'Spontaneous voiding trial'.)
In other patients who have underlying etiologies that are 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 longterm 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.)
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 [37]. Hospitalization is indicated for patients who have urosepsis, have obstruction related to malignancy,
or acute myelopathy [15]. Patients with associated acute renal failure may 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'.)
SUBSEQUENT MANAGEMENT
Evaluation 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.
Benign prostatic hyperplasia (BPH) is the most common cause of AUR [2-5,15]. 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".)
The appropriate subsequent evaluation in other patients 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 "Clinical manifestations, diagnosis, and nonsurgical management of posterior vaginal defects".)
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 "Treatment
of urethral stricture disease in men" and "Urethral diverticulum in women".)
Benign prostatic hyperplasia Men with BPH (or presumed BPH) and AUR should be evaluated by a urologist.
Unless they have contraindications, they should also be started on an alpha-1-adrenergic antagonist at the time AUR is
diagnosed. This is followed by one or two voiding trials. Patients who fail voiding trials may require surgical therapy.
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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 within one
year [13,38].
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-1adrenergic blocker and a 5-alpha reductase inhibitor to delay the recurrence of AUR. (See "Medical treatment of benign
prostatic hyperplasia", section on 'Combination therapy'.)
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 [39]. 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 [40].
Several different types of alpha-1-adrenergic antagonists are available with similar mechanisms and differing side effect
profiles (table 3) [41]. Alfuzosin and tamsulosin have been evaluated in randomized, placebo-controlled trials in
conjunction with a trial without a catheter (TWOC) [42-44]. The Alfuzosin in Acute Urinary Retention trial (ALFAUR)
compared placebo with alfuzosin (10 mg once daily) in 360 men with AUR [44]. 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 [45]. 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 [46-48]. Patients need to be treated for more than one year to prevent AUR and
reduce the need for surgery. (See "Medical treatment of benign prostatic hyperplasia", section on '5-alpha-reductase
inhibitors' and "Medical treatment of benign prostatic hyperplasia", section on 'Combination therapy'.)
Trial without a catheter Initial bladder decompression and initiation of medical therapy should be followed by a
trial without a catheter (TWOC). We suggest that patients have two TWOC 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.
Reported success rates for initial TWOC in men with prostate disease with AUR have ranged from 20 to 40 percent [42].
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 [38,42].
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 [49,50]. 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 [51]. 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 [52]. (See "Transurethral procedures for treating benign
prostatic hyperplasia".)
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 [37]. 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 [37,53]. 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
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with men undergoing elective prostatectomy (relative risk 26.6 and 4.4, respectively) as well as an increased risk of
perioperative complications [37]. 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.
The use of urethral stenting provides only modest improvement and is associated with a variety of complications,
including stent migration, infection, encrustation, and calculus formation [54]. This modality is presently reserved for
patients unfit for more invasive surgical intervention [55,56].
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 "Treatment of urethral stricture disease in men")
Urethral diverticulum (see "Urethral diverticulum in women")
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Basics topic (see "Patient education: Neurogenic bladder in adults (The Basics)")
SUMMARY AND RECOMMENDATIONS
Acute urinary retention (AUR) is the most common urologic emergency. It is more common in men than women.
Benign prostate hyperplasia (BPH) is the most common underlying condition in men, but multiple etiologies may
cause AUR. Medications are frequently implicated (table 1). (See 'Epidemiology' above and 'Pathogenesis and
etiologies' above.)
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 associated abdominal
pain and may complain of symptoms of overflow incontinence. (See 'Clinical presentation' above.)
The evaluation should begin with a history and physical exam focusing on factors that help identify an etiology. A
urinalysis and culture should be sent on all patients; other labs and studies depend on the patient's presentation.
(See 'Evaluation' above.)
In patients whose history and physical examination suggest AUR, it is reasonable to proceed with catheterization,
which is both diagnostic and therapeutic. In others where the diagnosis is less clear, a bladder ultrasound may help
establish the diagnosis. (See 'Diagnosis' above.)
Initial management of AUR involves prompt bladder decompression. We suggest initial treatment with an
indwelling urethral catheter, rather than a suprapubic catheter, for most patients on first presentation. Urethral
catheterization is contraindicated in patients who have had recent urologic surgery (eg, radical prostatectomy or
urethral reconstruction). A suprapubic catheter may be indicated when obstruction precludes a urethral catheter
and is also preferred in patients who are expected to require longer-term catheterization. (See 'Acute management'
above.)
We suggest complete drainage of the bladder with initial catheterization (Grade 2B). Hematuria, transient
hypotension, and postobstructive diuresis are common, but rarely clinically significant. (See 'Rate of
decompression' above and 'Complications of decompression' above.)
The majority of patients can be managed as outpatients once bladder decompression is accomplished.
Hospitalization is indicated for patients who are uroseptic or who have obstruction related to malignancy or spinal
cord compression. Patients with acute renal failure may also require hospitalization. (See 'Indications for
hospitalization' above.)
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In men with BPH or presumed BPH, we recommend use of an alpha-1-adrenergic antagonist (eg, alfuzosin 10 mg
daily), to be initiated at the time of initial catheterization (Grade 1A). We suggest ongoing treatment with an alpha1-adrenergic antagonists and 5-alpha-reductase inhibitor to delay the recurrence of AUR (Grade 2A). (See
'Medical management' above and "Medical treatment of benign prostatic hyperplasia", section on 'Alpha-1adrenergic antagonist and 5-alpha-reductase inhibitor'.)
In men with BPH, removal of the catheter after a period of time ("trial without catheter" or TWOC) results in
successful spontaneous micturition in up to 40 percent of patients, though recurrent AUR is common. We suggest
a trial of catheter removal in one to two weeks (Grade 2C). For patients who fail the initial TWOC, we suggest a
second trial of TWOC after an additional two weeks with the catheter (Grade 2C). (See 'Trial without a catheter'
above.)
Men with BPH who fail a second TWOC may need surgical therapy. A urodynamic evaluation is suggested prior to
prostate surgery for patients who have experienced AUR. (See 'Surgical therapy' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
Topic 6883 Version 28.0
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GRAPHICS
Pharmacologic agents associated with urinary retention
Sympathomimetics
(alpha-adrenergic
agents)
Ephedrine sulfate (Marax, Tedral)

Phenylephrine HCl (Neo-Synephrine)
Phenylpropanolamine HCL (Conlac)
Pseudoephedrine HCl (Sudafed, Actifed)
Sympathomimetics (betaadrenergic agents)
Isoproterenol
Metaproterenol
Terbutaline
Antidepressants
Imipramine (Tofranil)
Nortriptyline (Aventyl)
Amitriptyline (Elavil)
Doxepin (Adapin)
Amoxepine (Asendin)
Maprotiline (Ludiomil)
Antiarrhythmics
Quinidine
Procainamide
Disopyramide
Anticholinergics
(selected)
Atropine
Scopolamine hydrobromide
Clidinium bromide (Quarzan)
Glycopyrrolate (Robinul)
Mepenzolate bromide (Cantil)
Oxybutynin (Ditropan)
Flavoxate HCl (Urispas)
Hyoscyamine sulfate (Anaspaz)
Belladonna
Homatropine methylbromide
Propantheline bromide (Probanthine)
Dicyclomine HCl (Bentyl)
Antiparkinsonian agents
Trihexyphenidyl HCl (Arlane)

Benztropine Mesylate (Cogentin)
Amantadine HCl (Symmetrel)
Levodopa (Sinemet)
Bromocriptine Mesylate (Parlodel)
Hormonal agents
Progesterone
Estrogen
Testosterone
Antipsychotics
Haloperidol (Haldol)
Thiothixene (Navane)
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Thioridizine (Mellaril)
Chlorpromazine (Thorazine)
Fluphenazine (Prolixin)
Prochlorperazine (Compazine)
Antihistamines (selected)
Diphenhydramine HCl (Benadryl)

Chlorpheniramine (Chlor-Trimeton)
Brompheniramine (Dimetane)
Cyproheptadine (Periactin)
Hydroxyzine (Atarax, Vistaril)
Antihypertensives
Hydralazine (Apresoline)
Nifedipine (Procardia)
Muscle relaxants
Diazepam (Valium)
Baclofen (Lioresal)
Cyclobenzaprine (Flexeril)
Miscellaneous
Indomethacin (Indocin)
Carbamazepine (Tegretol)
Amphetamines
Dopamine
Vincristine
Morphine sulfate and other opioids
Anesthetic agents
Reproduced with permission from: Curtis LA, Dolan TS, Cespedes RD. Acute urinary retention and urinary
incontinence. Emergency Medicine Clinics of North America 2001; 19:591. Copyright 2001 Elsevier.
Graphic 75763 Version 2.0
https://www.uptodate.com/contents/acute-urinary-retention?topicKeyntion+emergency&selectedTitle=1%7E71&view=print&displayedView=full
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International Prostate Symptom Score (IPSS)

Questions
to be
Not at all
answered
1. Over the
Less
than 1
Less
than
time in
5
half the
time
About half
the time
More than
half the
Almost
always
time
past month,
how often
have you had
a sensation of
not emptying
your bladder
completely
after you
finished
urinating?
2. Over the
past month,
how often
have you had
to urinate
again less
than 2 hours
after you
finished
urinating?
3. Over the
past month,
how often
have you
found you
stopped and
started again
several times
when you
urinated?
4. Over the
past month,
how often
have you
found it
difficult to
postpone
urination?
5. Over the
past month,
how often
have you had
a weak
urinary
stream?
6. Over the
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past month,
how often
have you had
to push or
strain to
begin
urination?
7. Over the
0 (none)
1 (1 time)
2 (2 times)
3 (3 times)
4 (4 times)
past month,
how many
times did you
most typically
get up to
5 (5 or
more
times)
urinate from
the time you
went to bed
at night until
the time you
got up in the
morning?
Sum of numbers (AUA symptom score):
Total score:
0 to 7: Mild symptoms
8 to 19: Moderate symptoms
20 to 35: Severe symptoms
Mixed Quality of
life due to
urinary
symptoms
If you were
to spend the
rest of your
life with your
urinary
Delighted
Pleased
about
equally
Mostly
Mostly
satisfied
satisfied
and
unsatisfied
dissatisfied
Unhappy
Terr
condition the
way it is now,
how would
you feel
about that?
Modified with permission from: Barry MJ, Fowler FJ Jr, O'Leary MP, et al. The American Urological
Association Symptom Index for Benign Prostatic Hyperplasia. J Urol 1992; 148:1549. Copyright 1992
Lippincott Williams & Wilkins.
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Alpha-1-receptor antagonist for BPH*

Dose titration schedule to reduce orthostatic effects [1]
Terazosin standard (appropriate for most patients)
Days 1 to 3
1 mg
Days 4 to 14
2 mg
Weeks 2 to 6
5 mg
Weeks 7 and thereafter
10 mg
Terazosin rapid (for selected patients)

Days 1 to 3
1 mg
Days 4 to 14
2 mg
Weeks 2 to 3
5 mg
10 mg
Doxazosin (immediate release)

Days 1 to 3
1 mg
Days 4 to 14
2 mg
Weeks 2 to 6
4 mg
8 mg
Doxazosin (extended release preparation only)

Days 1 to 21
4 mg
Week 4 and thereafter
8 mg
Uroselective Alpha-1 receptor antagonists [2]

Alfuzosin
Initial and maintenance
10 mg
Tamsulosin
0.4 mg
If inadequate response after 2-4 weeks
0.8 mg
Silodosin
8 mg
BPH: benign prostatic hyperplasia.

* Titrate dose as tolerated and as needed for effect. Oral administration for all medications is once daily at
bedtime. Peak effect of a given dose on BPH symptoms may not be fully evident until 4 to 6 weeks. If
therapy is interrupted for three or more days, reinitiate at lowest dose and re-titrate according to schedule.
Due to lower risk of orthostatic hypotension and syncope, uroselective agents do not require gradual dose
titration. Oral administration for all medications is once daily at bedtime.
1. Data from: US FDA approved product information accessed at
http://dailymed.nlm.nih.gov/dailymed/about.cfm and Lee, M Management of benign prostatic hyperplasia
chap 87 in Pharmacotherapy 7th ed Dipiro, JT, Talbert, RL, Yee, GC et al. 2008; McGraw Hill Medical.
2. Data from: US FDA approved product information accessed at
http://dailymed.nlm.nih.gov/dailymed/about.cfm.
Page 13 of 14
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Contributor Disclosures
Glen W Barrisford, MD, MS Nothing to disclose. Graeme S Steele, MBBCh, FCS Nothing to disclose. Michael P
O'Leary, MD, MPH Nothing to disclose. Robert S Hockberger, MD, FACEP Nothing to disclose. Jonathan Grayzel,
MD, FAAEM Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of
evidence.
Conflict of interest policy
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