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BMJ 2019;366:l4590 doi: 10.1136/bmj.l4590 (Published 25 July 2019) Page 1 of 6 BMJ: first published as 10.1136/bmj.l4590 on 25 July 2019. Downloaded from

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RATIONAL TESTING Investigating chronic urinary retention

Jenny Martin specialist registrar 1, Will Chandler general practitioner 2, Mark Speakman consultant urological surgeon 1

1Taunton and Somerset NHS Foundation Trust, Taunton, UK; 2French Weir , Taunton, UK

How should I assess the patient? What you need to know Patients with chronic urinary retention often do not report any • Patients with chronic retention are usually still voiding urine and it is not usually painful. Physical examination may reveal a painlessly distended or urinary symptoms, even when they present with acute kidney injury. It is not unusual for chronic urinary

• Urine dipstick, blood tests for renal biochemistry, and ultrasound retention to be identified incidentally as a very large residual http://www.bmj.com/ scanning can help differentiate low pressure chronic retention (LPCR) from the more serious but less common high pressure urinary retention volume during radiological investigations for other symptoms. (HPCR) This is common in LPCR. A minority of patients present with • Immediately refer patients with impaired renal function to secondary serious acute kidney injury, which is a surgical emergency care for further management requiring immediate urological referral. Box 1 provides an overview of initial assessment of the patient. A 68 year old man complains of worsening fatigue, nausea, and Nocturnal , if present, is the only urological symptom loss of appetite. He reports minimal urinary symptoms but has that strongly suggests HPCR rather than LPCR, other than on 29 July 2019 by Richard Alan Pearson. Protected copyright. described episodes of night time bed-wetting in recent months. symptoms or signs suggestive of acute kidney injury. Box 2 On examination, he looks generally unwell. He has no lists the and other categories of abdominal pain. His lower abdomen is dull to percussion up to drugs with anticholinergic burden, which could exacerbate the level of the umbilicus. He is still voiding urine. Urgent blood chronic retention. investigations are arranged by the general practitioner, which reveal an acute kidney injury. Chronic urinary retention is a common presentation in men in primary care. Women are less commonly affected.1 The condition is frequently not recognised, as symptoms often progress slowly and are not serious. Patients with acute urinary retention are not voiding urine and are in pain.2 In contrast, patients with chronic retention void without pain. Chronic urinary retention has two subtypes: low pressure chronic retention (LPCR) and the more serious, but less common, high pressure chronic retention (HPCR).3 The terms “high” and “low” refer to the bladder pressure at the end of voiding, but pragmatically, HPCR refers to patients with abnormal renal function and/or , and people with LPCR have normal kidney function and normal kidneys. Acute-on-chronic retention occurs when a patient with chronic retention stops voiding completely. In this article, we present an approach for non-specialists to investigate chronic urinary retention in men and identify high pressure chronic retention, which warrants immediate specialist referral.

Correspondence to M Speakman [email protected]

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Box 1: What to cover on history and examination with elevated creatinine and decreased estimated glomerular BMJ: first published as 10.1136/bmj.l4590 on 25 July 2019. Downloaded from filtration rate. Patients with LPCR have normal or stable renal Lower urinary tract symptoms function. Request an urgent assessment of renal biochemistry • Voiding symptoms—hesitancy, straining, poor and/or intermittent stream to identify the patients with HPCR so that prompt action can • Storage symptoms—frequency, , urgency +/− urgency be taken. A full blood count is useful to exclude infection and incontinence chronic anaemia. We do not recommend a specific • (night time bed wetting) antigen blood test in the first line assessment of urinary Relevant medical history retention, as kidney injury, the insertion of a urinary , and retention itself can all produce a spurious elevated result. • Urinary tract infections, haematuria, urinary tract stones (urolithiasis) • Previous instrumentation of urinary tract—catheter or prostate surgery Ultrasound • Comorbid medical conditions • If available in primary care, a simple post-void bladder scan can quantify the residual bladder volume. This can be variable Drug history with residual volumes of 300 mL to >3 L being measured. In a • Relevant urological medications—alpha blockers/5-alpha fit patient with no symptoms and who is clinically well, a routine reductase/ bladder scan in a few weeks would be reasonable. In an unwell • Medications with anticholinergic or sympathomimetic properties (box patient with normal renal function, request an urgent ultrasound. 2) Patients with urinary retention and abnormal renal function on • Anticoagulants/antiplatelets blood tests should be referred to a specialist as a same day • Drugs affecting renal function surgical emergency. General and A renal tract ultrasound is recommended in all patients with • Signs of peripheral oedema, uraemia, , cardiac failure chronic urinary retention. It is a simple intervention that • Palpable or percussable bladder differentiates between HPCR and LPCR Request this urgently • External genitalia and digital rectal examination in men with new onset abnormal renal function. Men with HPCR often have evidence of unilateral or bilateral hydronephrosis, a distended urinary bladder, and excessive post-micturition residual volumes. Men with LPCR may have a distended bladder Box 2: Anticholinergic drugs and other drugs with an anticholinergic burden that can cause urinary retention and large residual volume but they do not have hydronephrosis. http://www.bmj.com/ • (Enablex) Figure 1 presents an algorithm for investigation of chronic • Fesoterodine (Toviaz) urinary retention. The guideline from the National Institute for • Flavoxate (Urispas) Health and Care Excellence on lower urinary tract symptoms • (Ditropan, Ditropan XL) in men provides further detail but accepts that many of these • (Vesicare) recommendations are based on the expert opinion of the guideline development group, because no relevant studies were • (Detrol, Detrol LA) found that assessed how measuring renal function, serum • Trospium (Sanctura, Sanctura XR) creatinine, and radiological imaging affects clinical outcomes on 29 July 2019 by Richard Alan Pearson. Protected copyright. Drugs with anticholinergic properties in men with lower urinary tract symptoms. Antidepressants, , antiparkinsonian drugs, antispasmodic/muscle relaxant drugs, antipsychotics, bronchodilators, analgesics (, fentanyl, Specialist investigations morphine) Urodynamic pressure flow studies may be performed in Identifying a distended urinary bladder during physical secondary care to help predict the outcome after prostatic examination will determine the next step in the management surgery, but do not influence the early management of chronic process. Palpation of the bladder can be difficult, particularly retention. Cross sectional imaging such as computed tomography in larger patients. Percussion of the bladder can be more reliable (CT) scanning is not normally indicated, but can sometimes be because of the clear contrast between the resonant upper helpful in the differential diagnosis of bilateral hydronephrosis. abdomen due to bowel gas and the dull lower abdomen due to Figure 2 shows a CT scan of patient with findings of bilateral the fluid in the distended bladder. hydronephrosis and urinary retention. In patients with voiding difficulties, examine the penis for a of the foreskin and the urethral meatus for stenosis. How is it managed? A rectal examination is recommended to assess the consistency Box 3 lists criteria to guide referral of patients for further of the prostate and possible risk of prostate . specialist management. What is the next investigation? Basic tests Urine dipstick Proteinuria and non-visible haematuria may indicate signs of acute kidney injury suggesting HPCR. The presence of leucocytes and nitrites may indicate concurrent urine infection.

Blood investigations Patients with HPCR develop symptoms and signs of acute kidney injury and typically have abnormal renal biochemistry

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Box 3: When to refer Additional educational resources BMJ: first published as 10.1136/bmj.l4590 on 25 July 2019. Downloaded from

Referral for inpatient secondary care Guidelines are provided by the National Institute of Health and Care Excellence (NICE)9 in the UK, and by the European10 and American11 • Immediate (same day) urological associations: – all patients with suspected HPCR with renal impairment https://www.nice.org.uk/guidance/CG97 – any patients with evidence of urinary tract sepsis https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-the- • Urgent Management-of-Non-neurogenic-Male-LUTS-2018-large-text.pdf – all patients with suspected HPCR with radiological hydronephrosis https://www.auanet.org/guidelines/benign-prostatic-hyperplasia-(bph)- but normal renal function guideline – patients with acute on chronic urinary retention who cannot be Further clinical scenarios are provided by NICE for the management of catheterised in the community acute and chronic retention: https://cks.nice.org.uk/luts-in-men#!scenario: • Referral to outpatient urological specialist care 4 – Patients with LPCR with lower urinary tract symptoms or recurrent urinary tract infections following blood investigation and ultrasound of the urinary tract Outcome Low pressure chronic retention Blood investigations showed a creatinine of 660 µmol/L and an A conservative watch and wait approach, with symptomatic estimated glomerular filtration rate 18 mL/min. The patient’s management in primary care, may be considered if the patient general practitioner contacted the on-call team directly has mild urinary symptoms in the context of normal renal at his local hospital to arrange an urgent admission. At the function. Catheterisation can be avoided in asymptomatic hospital, he was catheterised and 1200 mL was drained. A patients with a high post-micturition residual volume with scan revealed bilateral hydronephrosis. normal renal function and no hydronephrosis, but should be In the following 24 hours he had substantial diuresis, voiding kept under observation if their residual volume is more than 3.5 L, and over the next three days his creatinine fell in stages about 500 mL. Discuss treatment options with the patient to to 180 µmol/L. He was discharged home with an indwelling understand their preferences and tailor the management catheter for weekly creatinine estimations. Once his renal approach. Consider discontinuing medications that may be function had normalised, he underwent a transurethral resection causing retention. of the prostate six weeks later. He is now voiding well with few urinary tract symptoms. Outpatient follow-up and repeat assessment of post-void residual 4 http://www.bmj.com/ volume is appropriate in patients with LPCR Alpha blockers Rational testing into practice with or without 5-α reductase inhibitors may improve the Think about the last time you referred a patient presenting with chronic urological symptoms. Clean intermittent self-catheterisation is urinary retention to a specialist. Did you request an ultrasound and renal a good technique for managing lower urinary tract symptoms function blood tests? How would you investigate these patients before and recurrent .5 Bladder outlet surgery referral? (eg, transurethral resection of the prostate, which is appropriate Have you had patients who were still voiding with low pressure chronic retention who were catheterised in the community unnecessarily? Based for patients with LPCR if they have bothersome lower urinary on reading this article, how would you alter your management approach tract symptoms) cannot always restore normal bladder and explain to your patient? on 29 July 2019 by Richard Alan Pearson. Protected copyright. compliance and contractility in men with LPCR. Preoperative clean intermittent self-catheterisation may improve surgical 6 outcomes. How patients were involved in the creation of this article

Two patients who presented with chronic retention to our hospital reviewed High pressure chronic retention this paper. The patient with LPCR confirmed how he had few symptoms and that his condition was picked up on a gall bladder scan. The second patient Immediate referral to secondary care and early catheterisation had been unwell with malaise due to renal dysfunction for some time. He felt in a specialist unit is recommended for patients with suspected more awareness is needed of this condition in primary care to foster early diagnosis and appropriate management. We have accordingly highlighted HPCR if they have evidence of renal dysfunction and/or these presentations in the article. We thank these patients for their input. hydronephrosis on ultrasound. Patients may develop haematuria following bladder decompression. Patients may pass many litres of urine in the days following catheterisation, but there is no evidence to support the historical technique of catheter clamping The patient described in the vignette is fictitious. No patient consent required] and slow decompression.7 Close monitoring for post obstructive Competing interestsThe BMJ has judged that there are no disqualifying financial diuresis is done by assessing weight, fluid input/output, lying ties to commercial companies. The authors declare the following other interests: and standing , and and electrolyte levels none. daily until normalised. Intravenous fluids are not usually Further details of The BMJ policy on financial interests is here: https://www.bmj. required, except in few patients who develop pathological com/about-bmj/resources-authors/forms-policies-and-checklists/declaration- diuresis. competing-interests HPCR patients should not undergo a trial without catheter before Provenance and peer review: commissioned; externally peer reviewed. a definitive intervention (such as surgery) has been performed. Most patients notice excellent outcomes from bladder outlet 1 Mevcha A, Drake MJ. Etiology and management of urinary retention in women. Indian J Urol 2010;26:230-5. 8 surgery, because most maintain contractile function. 2 Negro CL, Muir GH. Chronic urinary retention in men: how we define it, and how does it Preoperative urological drug therapy is not necessary. Rarely, affect treatment outcome. BJU Int 2012;110:1590-4. 10.1111/j.1464-410X.2012.11101.x 22452619 a long term catheter may be indicated in a patient with HPCR 3 George NJ, O’Reilly PH, Barnard RJ, Blacklock NJ. High pressure chronic retention. Br who is unfit for surgery. Med J (Clin Res Ed) 1983;286:1780-3. 10.1136/bmj.286.6380.1780 6407564 4 Bates TS, Sugiono M, James ED, Stott MA, Pocock RD. Is the conservative management of chronic retention in men ever justified?BJU Int 2003;92:581-3. 10.1046/j.1464-410X.2003.04444.x 14511038 5 Ghalayini IF, Al-Ghazo MA, Pickard RS. A prospective randomized trial comparing transurethral prostatic resection and clean intermittent self-catheterization in men with

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chronic urinary retention. BJU Int 2005;96:93-7. 9 National Institute for Health and Care Excellence. Male LUTS Guideline 2015. https:// BMJ: first published as 10.1136/bmj.l4590 on 25 July 2019. Downloaded from 10.1111/j.1464-410X.2005.05574.x 15963128 www.nice.org.uk/guidance/CG97 6 Jones C, Hill J, Chapple CGuideline Development Group. Management of lower urinary 10 Gravas S, Cornu JN, Drake MJ, etal . Guidelines on the management of non-neurogenic tract symptoms in men: summary of NICE guidance. BMJ 2010;340:c2354. male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO). EAU 10.1136/bmj.c2354 20484350 Guide-lines Office, 2018, http://uroweb.org/guideline/treatment-of-non-neurogenic-male- 7 Boettcher S, Brandt AS, Roth S, Mathers MJ, Lazica DA. Urinary retention: benefit of luts/. gradual bladder decompression - myth or truth? A randomized controlled trial. Urol Int 11 Foster HE, Barry MJ, Gandhi MC. Surgical management of lower urinary tract symptoms 2013;91:140-4. 10.1159/000350943 23859894 attributed to benign prostatic hyperplasia. 2018. https://www.auanet.org/guidelines/benign- 8 Abrams PH, Dunn M, George N. Urodynamic findings in chronic retention of urine and prostatic-hyperplasia-(bph)-guideline their relevance to results of surgery. Br Med J 1978;2:1258-60. Published by the BMJ Publishing Group Limited. For permission to use (where not already 10.1136/bmj.2.6147.1258 709305 granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions http://www.bmj.com/ on 29 July 2019 by Richard Alan Pearson. Protected copyright.

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Figures BMJ: first published as 10.1136/bmj.l4590 on 25 July 2019. Downloaded from http://www.bmj.com/ on 29 July 2019 by Richard Alan Pearson. Protected copyright.

Fig 1 An approach to catheterisation in men with chronic urinary retention

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Fig 2 CT scan of high pressure chronic retention (HPCR) showing a very distended bladder and bilateral hydronephroses http://www.bmj.com/ on 29 July 2019 by Richard Alan Pearson. Protected copyright.

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