Chronic Urinary Retention in Men: How We Deﬁ Ne It, and How Does It Affect Treatment Outcome BJUIBJU INTERNATIONAL Carlo L.A

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Chronic urinary retention in men: How we deﬁ ne it, and how does it affect treatment outcome BJUIBJU INTERNATIONAL Carlo L.A. Negro and Gordon H. Muir Department of Urology, King’ s College Hospital, London, UK Accepted for publication 18 January 2012

Urinary retention describes a bladder that What ’s known on the subject? and What does the study add? does not empty completely or does not Chronic urinary retention (CUR) is a poorly defi ned entity, as the key element of empty at all. Historically, urinary retention defi nition, signifi cant postvoid residual urine volume (PVR), has not a worldwide and has been classifi ed as either acute or moreover evidenced-based defi nition. There is no agreement on which is the threshold chronic the latter is generally classifi ed as value to defi ne a signifi cant PVR and different society produced guidelines with high pressure or low pressure according to different thresholds ranging from 300 mL to 1000 mL. Diagnosis is diffi cult, and the bladder fi lling pressure on urodynamic. management has not been defi ned yet. There is a lack of studies on the best A MEDLINE ® search for articles written in management of these patients, as this group of patients has always been considered English and published before January 2010 at high risk of failure. Only one study compares conservative with the surgical was done using a list of terms related to management but it is not a randomised controlled trail. urinary retention: ‘ urinary retention ’ , ‘ chronic urinary retention ’ and ‘ PVR ’. This review offers a systematic appraisal of the most recent publications on CUR. It Chronic urinary retention (CUR) is defi ned indicates the absence of a real worldwide agreed defi nition, as the two keys element by the International Continence Society as of it are not satisfactorily defi ned yet: signifi cant PVR, is suffering from a lack of ‘ a non-painful bladder, which remains evidenced-based defi nition, and percussable or palpable bladder is a very nebulous palpable or percussable after the patient concept as it is not a criteria of certainty as different individual variables affect it. This has passed urine ’. Abrams was the fi rst to has an important effect on management which is not structured. Most of the trials choose a residual urine volume > 300 mL involving benign prostatic hyperplasia treatments (either medical or surgical) tend to to defi ne CUR as he considered it the exclude this group of patients, which is a clinically important group, comprising up to minimum volume at which the bladder a quarter of men undergoing TURP in the UK. becomes palpable suprapubically. The UK National Institute for Health and Clinical Excellence lower urinary tract symptoms improve precision. As defi ning CUR is who are unable to void. This confusion (LUTS) guidelines defi ne CUR as a postvoid diffi cult, structured management is leads to an inability to design and interpret residual urine volume (PVR) of > 1000 mL. challenging. Nearly all prospective trials studies; indeed most prospective trials No studies have specifi cally addressed the exclude men with CUR from analysis, simply exclude these patients. There is a problem of quantifying the minimum possibly anticipating a poor outcome and a clear need for internationally accepted amount of urine present in the bladder high risk of complications. However, men defi nitions of retention to allow both to defi ne CUR. Nor did we fi nd any with CUR are a clinically important group, treatment and reporting of outcomes in publications objectively assessing at what comprising up to 25% of men undergoing men with LUTS, and for such defi nitions to amount of urine a bladder can be palpable. transurethral resection of the prostate. be used by all investigators in future trials. The ability to feel a bladder may rely on Defi nition of CUR is imprecise and variables (i.e. medical skills and patient arbitrary. Most studies seem to describe the KEYWORDS habitus). There is a marked variability of condition as either a PVR of > 300 mL in PVR, so the test should be repeated to men who are voiding, or > 1000 mL in men urinary retention , LUTS , PVR , male

INTRODUCTION • Ability of patient to release any urine • Urodynamic ﬁ ndings (high or low (complete or partial). pressure). The term ‘ urinary retention ’ may describe a • Duration (acute or chronic). bladder that empties incompletely or not at • Symptoms (painful or silent). However, in clinical practice the term all. Urologists commonly subdivide retention • Mechanism (obstructive or ‘ chronic retention ’ is often used to describe episodes by any or all of the following: non-obstructive). a constellation of the above descriptions,

and is frequently used in research and transient voiding diffi culty, e.g. after surgery bladders ’. Intuitively percussion is unlikely to clinical studies, despite no standardisation of for stress incontinence, and implies a differentiate from intra-abdominal or pelvic its defi nition. signifi cant residual urine; a minimum fi gure sold masses (as attested to by anecdotes of of 300 mL has been previously mentioned attempted suprapubic catheterisation of Urinary retention is objectively measured as [ 1 ] . pelvic tumours.) Thus, while a standard the volume of either the postvoid residual approach, transabdominal bladder urine volume (PVR) or the bladder in men Despite these defi nitions, there is little examination has little or no evidence to who cannot urinate. There is no actual evidence to support the objective ability to support its use in diagnosis. numerical value or relative increase in the diagnose either AUR or CUR by physical volume of PVR that has been universally examination without imaging. The AURO Guidelines on BPH [ 6 ] defi ne as accepted or adopted into current practice. pathological a PVR of ‘ more than one third CUR may occur in diverse patient of total bladder capacity ’ , but with evidence The condition of urinary retention is often populations, including patients with detrusor level IV. The European Association of associated with LUTS, urinary infections and underactivity, detrusor hyperactivity with Urology, AUA and NICE guidelines on LUTS bladder stones. Elevated intravesical impaired contractility or neurogenic bladder do not defi ne threshold values for pressures may lead to hydronephrosis and conditions and of BOO. pathological PVR, and the NICE guidelines renal failure. do not suggest PVR assessment in the initial Abrams et al . [ 2 ] were the fi rst to choose a evaluation of male LUTS. PVR of > 300 mL to defi ne CUR, considering MATERIALS AND METHODS it the minimum volume at which the There is no consistent evidence that PVR is bladder becomes palpable suprapubically; directly related to the degree of bother, nor A MEDLINE ® search for articles written in this seems a widely accepted, although there is an association between PVR

English and published before January 2010 unvalidated, defi nition of CUR. maximum urinary fl ow rate (Qmax ). A high was done using a list of terms related to PVR has been linked to prostate volume [ 7 ] , urinary retention: ‘ urinary retention ’ , However, while some investigators have and to the degree of intravesical prostatic ‘ chronic urinary retention ’ and ‘ PVR ’. Articles defi ned CUR as a PVR of > 300 mL [ 3 ] , protrusion [ 8 ] . not directly relevant to urinary retention or others have defi ned it as > 400 mL [ 4 ] , PVR in males without neurological bladder or have given it no defi nite number at Rule et al . [ 9 ] have shown that PVR dysfunction were excluded. We then used all [ 5 ] . Most authors still seem to use a increases with age. In a random sample of the bibliographies of these sources to PVR of 300 mL as a defi nition for CUR community dwelling men (529 men aged expand our search. in men who are not in total retention, 40– 79 years) followed with a sonographic even in those works investigating the PVR and voided volume every 2 years for up outcomes of surgery. The UK National to 12 years (median fi ve examinations), the DEFINITION Institute for Health and Clinical Excellence median annual change (slope) for PVR was (NICE) LUTS guidelines defi ne CUR as PVR + 2.2% (P = 0.03) and for voided volume was Historically, urinary retention has been of > 1000 mL. – 2.1% (P < 0.01). There was considerable classifi ed as either acute or chronic. Acute variability in PVR slopes. A rapid increase in urinary retention (AUR) is characterised by a There is considerable confusion! PVR slope (greater than 80th percentile) was sudden onset, often painful and usually more likely in men with a baseline IPSS of requiring intervention to relieve symptoms. > 7 (age-adjusted odds ratio 1.6, 95% CI The ICS defi nes AUR as ‘ a painful, palpable DIAGNOSIS OF CUR 1.0– 2.5). There was less variability in voided or percussable bladder, when the patient is volume slopes. Rapidly deteriorating PVR unable to pass any urine ’ [ 1 ] . Although AUR No studies have specifi cally addressed the was more likely in elderly men and in those is usually painful, pain may not be a problem of quantifying the minimum with a baseline PVR of > 50 mL. The authors presenting feature, e.g. when due to amount of urine present in the bladder concluded that although it is highly variable, prolapsed intervertebral disc or after to defi ne CUR. Nor did we fi nd any there is progressive bladder dysfunction in regional anaesthesia. The retention volume publications objectively assessing at what community dwelling men as they age. In should be signifi cantly greater than the amount of urine a bladder can be palpable. addition, signs and symptoms attributed to expected normal bladder capacity, although The ability to feel a bladder may rely on BPH were modest predictors of the again this is not standardised. Trigger variables including medical skills and patient development of bladder dysfunction. factors, e.g. surgery, UTI, excessive fl uid habitus: in the obese patient neither intake or medications, can induce percussion or palpation may determine if There is a marked intra-individual variability precipitated AUR. the bladder is full or empty. Furthermore of PVR, so the test should be repeated to Abrams et al . [ 2 ] , in their work, wrote that improve precision, particularly if the fi rst Chronic urinary retention (CUR) is defi ned they ‘ gained the impression, that patients PVR is signifi cant and suggests a change in by the ICS as ‘ a non-painful bladder, which with low-pressure fi lling had bladders that the treatment plan. remains palpable or percussable after the were diffi cult to defi ne on abdominal patient has passed urine ’ [ 1 ] . Such patients palpation, whereas patients with high- Dunsmuir et al . [ 10 ] showed great PVR may be incontinent. The term CUR excludes pressure fi lling had tense, readily palpated variation in repeated measurement. They

measured the pre- and post-micturiction The development of bladder wall thickening catheterization for outcomes, but exposes volume in 40 volunteers awaiting TURP. with trabeculations from smooth muscle patients to surgical and anaesthetic risks, Residual volumes ranged from 48 to hypertrophy and connective tissue infi ltrates without real benefi ts. In a retrospective 690 mL. One-third of the patients showed appears responsible for increased bladder series Thomas et al . [ 17 ] traced all fairly constant PVRs (variation < 120 mL) but pressures in men with high-pressure CUR neurologically intact men aged > 18 years at two-thirds showed a wide variation [ 12 ] . Increased bladder pressure can lead to presentation, with a diagnosis of DUA. In all, (150 – 670 mL). There was wide variation functional obstruction at the vesico-ureteric 224 men were initially diagnosed with DUA; between individuals (57%; CI 93 – 252 mL) junction or VUR. Of men with CUR those 87 (39%) of these died in the interim and and within individuals (42%; CI 55 – 228 mL). with a lower bladder capacity have worse 22 had a TURP, with a mean follow-up after The group showing the most conserved renal function [ 13 ] . surgery of 11.3 years. There were no range of PVR (a variation in range of reductions in any symptoms. There was a < 120 mL) were analysed separately and MANAGEMENT small but signifi cant reduction in the BOO showed small to moderate PVRs (mean PVR index, but this did not translate into an ≈ 100 mL). Even in this group, the intra- As CUR is poorly defi ned, structured improved fl ow rate. Comparison with 58 individual variation was signifi cant management is challenging. Very few age-matched patients with DUA who (55 – 188 mL). At larger PVRs, the intra- studies have tried to defi ne best practice. remained untreated showed no signifi cant measure variability increased, a common Nearly all prospective trials exclude men advantage of surgical intervention in the feature of many biological measurements. with CUR from analysis, possibly long-term; on the contrary, there was more This suggests that an isolated measurement anticipating a poor outcome and a high risk CUR in those who had had surgery. They of PVR is likely to be a poor diagnostic test. of complications [ 14 ] . Despite this exclusion, concluded there were no long-term men with CUR are a clinically important symptomatic or urodynamic gains from CLASSIFICATION group, comprising up to a quarter of men TURP in men shown to have DUA, but this undergoing TURP [ 15 ] . In particular there is study did not actually address the specifi c CUR is generally classifi ed as: still a debate about the best management problem of CUR. and the right timing: which if any surgery, 1. high pressure when to operate, and is preoperative Djavan et al . [ 18 ] on the contrary, showed 2. low pressure urodynamic evaluation mandatory? that patients with urinary retention, aged ≥ 80 years, with a retention volume of This classifi cation was introduced by Abrams Of the limited data available, most studies > 1500 m, no evidence of instability and

et al . [ 2 ] and it is based on urodynamic suggest surgery is the treatment of choice maximal detrusor pressure of < 28 cmH2 O, ﬁ ndings in patients with a PVR of > 300 mL. to avoid permanent indwelling or are at high risk of treatment failure. He In this study, patients were described as intermittent catheterisation. suggested that the detrusor may recover in high or low pressure based on bladder patients younger than 80 years after pressure ﬁ lling; those with a bladder end The CLasP study [ 16 ] showed that low power surgery, suggesting that prostatectomy

fi lling pressure of < 25 cmH2 O were laser coagulation therapy (30 W 980 nm should still be performed in this group even described as ‘ low pressure ’ , while those with Bard UrolaseTM ) and TURP were effective for if preoperative urodynamics suggest an higher end fi lling pressures were classifi ed relieving LUTS, improving Qmax and health- unfavourable outcome. as ‘ high pressure ’. In two groups the mean related quality of life (HRQL), and decreasing (range) pressure increases on fi lling were PVR. Resection was better than laser therapy Monoski et al . [ 19 ] evaluated the utility of respectively 11 (0 – 25) cmH2 O and 82 according to all primary outcomes and preoperative urodynamics as a predictor of

(40 – 148) cmH2 O, with highly variable but signifi cantly better for overall success, with surgery outcome in catheterised men, and insignifi cant differences in total bladder 91% of the men who underwent resection found that impaired detrusor contractility volume or PVR. There was a statistical achieving a successful or very successful (IDC) and detrusor overactivity (DO) helped association between enuresis and high- outcome compared with 63% of those who to predict outcome. Even though almost all pressure bladder fi lling. The two groups also received laser therapy. However, laser cases men improved their voiding function and tended to have different symptoms, the involved signifi cantly fewer treatment HRQL after surgery, those patients without low-pressure group complaining of complications and a signifi cantly shorter DO or IDC had most improvement. This was hesitancy, slow stream, and a feeling of hospital stay. None of the patients included particularly evident 1 month postoperatively incomplete emptying, while the high- had had urodynamic evaluation before when considering the IPSS for patients with pressure group also complained of urgency. surgery. Later laser cohort studies with more and without DO and the IPSS, Qmax , and PVR An association between upper urinary tract effective generators and techniques show in patients with and without IDC. However, dilatation and high pressure CUR was noted. outcomes similar to TURP, but prospective despite the increased risk of re-operation in comparative studies tend exclude patients in this group, most men (63%) gained The main clinical impact of this work is that retention. signifi cant benefi t. Therefore, preoperative around half the men with CUR have IDC is not a contraindication to performing increased serum creatinine or upper urinary Some authors argue that in CUR, in surgery. tract dilatation, it seems generally accepted particular with low-pressure retention, there that this is more common in high-pressure is detrusor underactivity (DUA). It has been Conservative management, in particular CUR [ 11 ] . suggested that surgery is no better than clean intermittent self-catheterisation (CISC),

can be used as an adjuvant to transurethral men who are voiding, or > 1000 mL in men Evidence-based guidelines for the surgery. who are unable to void. The place of management of lower urinary tract ultrasound, abdominal palpation and symptoms related to uncomplicated Ghalayini et al . [ 4 ] performed one of the catheterisation in diagnosis remain poorly benign prostatic hyperplasia in Italy: very few randomised trials in patients with defi ned. This confusion leads to an inability updated summary . Curr Med Res Opin retention. Included were 41 men scheduled to design and interpret studies; indeed most 2007 ; 23 : 1715 – 32 for TURP with LUTS, an IPSS of > 7, BPE and prospective trials simply exclude these 7 Kolman C , Girman CJ , Jacobsen SJ , a persistent PVR of > 300 mL. The patients patients. Lieber MM . Distribution of post-void were randomised into two treatment residual urine volume in randomly groups; the fi rst had TURP after stabilising There is a clear need for standardised selected men . J Urol 1999 ; 161 : 122 – 7 renal function (usually by indwelling internationally accepted defi nitions of 8 Chia SJ , Heng CT , Chan S et al . catheterisation), and the second was taught retention to allow both treatment and Correlation of intravesical prostatic CISC. Men in both groups were reviewed at reporting of outcomes in men with LUTS, protrusion with bladder outlet 3 and 6 months. Of the 41 patients, 17 were and for such defi nitions to be used by all obstruction . BJU Int 2003 ; 91 : 371 – 4 randomised to immediate TURP and 24 to investigators in future trials. 9 Rule AD , Jacobson DJ , McGree ME , CISC. There was a signifi cant improvement Girman CJ , Lieber MM , Jacobsen SJ . in IPSS and HRQL at 6 months in both CONFLICT OF INTEREST Longitudinal changes in post-void groups (P < 0.001). In the CISC group, there residual and voided volume among was a signifi cant improvement in voiding None declared. community dwelling men . J Urol 2005 ; and end-fi lling pressures, indicating recovery 174 : 1317 – 22 of bladder function (P < 0.001 for each). The REFERENCES 10 Dunsmuir WD , Feneley M , Corry DA , study emphasises the usefulness of CISC in Bryan J , Kirby RS . The day-to-day ensuring the recovery of bladder function in 1 Abrams P , Cardozo L , Fall M et al ., variation (test-retest reliability) of men with CUR. Both CISC and immediate Standardisation Sub-committee of the residual urine measurement . Br J Urol TURP were effective for relieving LUTS and International Continence Society. The 1996 ; 77 : 192 – 3 resulted in a better HRQL. standardisation of terminology of lower 11 O ’ Reilly PH , Brooman PJ , Farah NB , urinary tract function: report from the Mason GC . High pressure chronic Many studies suggest that patients in CUR Standardisation Sub-committee of the retention. Incidence, aetiology and sinister will benefi t from disobstructive surgery, International Continence Society . implications . Br J Urol 1986 ; 58 : 644 – 6 whether with TURP or laser prostatectomy, Neurourol Urodyn 2002 ; 21 : 167 – 78 12 Jones DA , Gilpin SA , Holden D , even if the results in terms of IPSS, HRQL, 2 Abrams PH , Dunn M , George N . Dixon JS , O ’ Reilly PH , George NJ .

Q max and PVR may be inferior compared with Urodynamic fi ndings in chronic Relationship between bladder those not in retention. Surgery may be more retention of urine and their relevance to morphology and long-term outcome of effective in patients with high-pressure CUR results of surgery . Br Med J 1978 ; 2 : treatment in patients with high pressure than those with low-pressure CUR, with 1258 – 60 chronic retention of urine . Br J Urol high-pressure fi lling patients achieving good 3 Kaplan SA , Wein AJ , Staskin DR , 1991 ; 67 : 280 – 5 bladder emptying by normal detrusor Roehrborn CG , Steers WD . Urinary 13 Styles RA , Neal DE , Griffi ths CJ , contraction [ 2 ] . retention and post-void residual urine in Ramsden PD . Long-term monitoring of men: separating truth from tradition . bladder pressure in chronic retention of In summary, urodynamics are optional: J Urol 2008 ; 180 : 47 – 54 urine: the relationship between detrusor although they help predict postoperative 4 Ghalayini IF , Al-Ghazo MA , Pickard activity and upper tract dilatation . J Urol symptoms, even men with poor detrusor RS . A prospective randomized trial 1988 ; 140 : 330 – 4 function will usually void well after surgery. comparing transurethral prostatic 14 Doll HA , Black NA , McPherson K , Primary CISC is an interesting and under- resection and clean intermittent Williams GB , Smith JC . Differences in researched alternative. self-catheterization in men with chronic outcome of transurethral resection of urinary retention . BJU Int 2005 ; 96 : the prostate for benign prostatic CONCLUSIONS 93 – 7 hypertrophy between three diagnostic 5 Thomas AW , Cannon A , Bartlett E , categories . Br J Urol 1993 ; 72 : 322 – 30 In men with LUTS, high PVRs increase the Ellis-Jones J , Abrams P . The natural 15 Emberton M , Neal DE , Black N et al ., risk of developing renal failure and a history of lower urinary tract The National Prostatectomy Audit. complete inability to void. In men with an dysfunction in men: the infl uence of The clinical management of patients inability to void, a very high PVR may detrusor underactivity on the outcome during hospital admission . Br J Urol reduce the chance of a good symptom after transurethral resection of the 1995 ; 75 : 301 – 16 response to surgery but does not predict prostate with a minimum 10-year 16 Gujral S , Abrams P , Donovan JL et al . failure to void without a catheter. urodynamic follow-up . BJU Int 2004 ; 93 : A prospective randomized trial 745 – 50 comparing transurethral resection of the However, the defi nition of CUR is imprecise 6 Spatafora S , Conti G , Perachino M , prostate and laser therapy in men with and arbitrary. Most studies seem to describe Casarico A , Mazzi G , Pappagallo GL , chronic urinary retention: the CLasP the condition as either a PVR of > 300 mL in AURO.it BPH Guidelines Committee. Study . J Urol 2000 ; 164 : 59 – 64

17 Thomas AW, Cannon A, Bartlett E, EDITORIAL COMMENT understand which patients may benefi t from Ellis-Jones J, Abrams P. The natural endoscopic relief of BOO and clinical studies history of lower urinary tract CHRONIC URINARY RETENTION IN MEN: suggest that an elevated PVR with a weak dysfunction in men: minimum 10-year CAN WE DEFINE IT, AND DOES IT AFFECT detrusor is associated with an increased risk urodynamic follow-up of untreated TREATMENT OUTCOME of poor outcome after TURP. The clinical detrusor underactivity. BJU Int 2005; 96: issue is in detrusor function, something that 1295–300 The subject of chronic urinary retention we usually quantify in terms of pressure 18 Djavan B, Madersbacher S, Klingler C, (CUR) is of interest, as there is not even rather than in the amount of work the Marberger M. Urodynamic assessment evidence that we need such a defi nition and muscle is able to perform. What we really of patients with acute urinary retention: we could probably live with the current need is a clinical translation of ‘ bladder is treatment failure after prostatectomy defi nitions of acute urinary retention (AUR) decompensation ’ , that is a measure in terms predictable? J Urol 1997; 158: 1829–33 and postvoid residual urine volume (PVR). of muscle contractility. In patients with an 19 Monoski MA, Gonzalez RR, Sandhu JS, The fi ne threshold between elevated PVR elevated PVR, the clinical question is Reddy B, Te AE. Urodynamic predictors and CUR is unclear and is not necessarily whether the detrusor muscle still functions of outcomes with photoselective laser linked to the presence of complications. or not. In cases of good contractility, surgery vaporization prostatectomy in patients Terminology is of utmost importance both in will restore normal voiding dynamics, in with benign prostatic hyperplasia and practice and research. The lack of a good cases of a very week detrusor relief of BOO preoperative retention. Urology 2006; defi nition of CUR makes epidemiological may not improve voiding function. From a 68: 312–7 studies impossible. The current ICS teleological standpoint, AUR is a protective defi nition: ‘ a non-painful bladder, which condition. In patients with benign prostatic Correspondence: Carlo L.A. Negro, remains palpable or percussable after the obstruction, AUR may occur when the Department of Urology, King’s College patient has passed urine. Such patients may detrusor is still able to produce elevated Hospital, Denmark Hill, London SE5 9RS, UK. be incontinent ’. Is a remnant from a pressure values, although these may be e-mail: [email protected], carlo. pre-ultrasound era and should probably be lower than those required to open the [email protected] reconsidered. bladder neck and initiate voiding.

Abbreviations: PVR, postvoid residual urine We certainly need a consensus on ‘ acute The mini review from Negro and Muir is volume; (A)(C)UR, (acute) (chronic) urinary urinary retention ’ because this is a condition of interest because it raises an important retention; NICE, National Institute for that present in Emergency Rooms. We know issue and hopefully will foster discussion

Health and Clinical Excellence; Qmax, how to deﬁ ne PVR, although we do not on it. maximum urinary ﬂow rate; HRQL, have a clear threshold beyond which the health-related quality of life; DUA, detrusor condition becomes problematic and it is underactivity; IDC, impaired detrusor associated with an increased risk of Andrea Tubaro , contractility; DO, detrusor overactivity; CISC, complications in the non-neurogenic adult Department of Urology, La Sapienza clean intermittent self-catheterisation. male. From a clinical standpoint, we need to University of Rome, Rome, Italy