Acute GP service

Guidelines for the management of acute retention in men

 

Definition

 

Painful inability to pass urine.

Short duration

Palpable bladder/Bladder scan >500mls

 

Immediate management

 

Gentle passage of full length urethral catheter, preferably 14 or 16Ch. A larger and therefore stiffer catheter may pass through enlarged prostate more easily. 

 

Do not inflate balloon unless catheter in to hilt without resistance and urine draining freely (gentle pressure on bladder may help to flush instillagel from lumen). If pain during balloon inflation the catheter is incorrectly positioned, deflate immediately.

 

Replace foreskin if present.

 

Record volume of urine drained. This is crucial to planning future management.

 

Catheter clamping during drainage of large volumes is unnecessary 

 

Ensure appropriate catheter management system in place and manageable by patient.

 

Consider acute admission if:

 

• Suspicion of high pressure retention/renal impairment and therefore at risk of post obstructive diuresis

• Bed wetting/nocturnal incontinence

• Symptoms/signs of fluid overload/uraemia eg ankle swelling/orthopnoea/PND/raised JVP etc

• Impaired renal function

• Systemically unwell

• Problematic bleeding. If large residual may get decompression bleeding which is usually self limiting.

• Suspicion of acute cauda equina compression

 

 

 

Post catheterisation care

 

Clinical review within 24hrs/next working day

Check renal function

Digital rectal examination – prostate size, ?malignancy 

(N.B. PSA can be significantly raised by catheterisation – up to 50-100. For indications for PSA testing please see RMS guidelines.) May need repeating at 6 weeks if elevated)

Prescription for alpha blocker +/- Finasteride if indicated. See below.

 

Arrange district nurse support/follow up.

 

Trial without catheter (TWOC)

 

Contraindications

renal impairment that improves with catheter

drained volume more than 1litre (TWOC will likely be unsuccessful)

options: TURP if fit enough 

Long term catheter

Intermittent self catheterisation

 

More likely to be successful if:

few preceding LUTS (see RMS guidelines)

treatment naïve

reversible precipitant eg UTI, constipation, anaesthesia, drugs etc

start alpha blocker (Tamsulosin or Alfuzosin) for at least 48hrs prior to TWOC and finasteride if large prostate (bigger than a plum/30cc). 

 

Less likely to be successful if: 

gradual deterioration in preceding symptoms

already onTamsulosin and Finasteride

no precipitant

elderly

 

Post TWOC

If successful continue Tamsulosin/Finasteride for long term. 

If unsuccessful repeat TWOC at 2 weeks. 

If still unsuccessful continue Finasteride if considering TURP – reduces intraoperative bleeding.

Options: TURP if fit enough 

Long term catheter

Intermittent self catheterisation