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Keywords:

  • acute urinary retention;
  • trial without catheter;
  • alpha1-blocker;
  • benign prostatic hyperplasia;
  • alfuzosin

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Acute urinary retention (AUR) is a urological emergency characterized by a sudden and painful inability to pass urine. It represents a significant worldwide public health issue, as mortality within the year following an AUR episode appears much higher than in the general population, especially in younger patients. Management of AUR involves immediate bladder catheterization usually followed, until recently, by prostatic surgery. The greater morbidity and mortality associated with emergency surgery (within a few days after AUR), and the potential morbidity associated with prolonged catheterization (bacteriuria, fever, urosepsis) has led to an increasing use of a trial without catheter (TWOC). TWOC involves catheter removal after 1–3 days, allowing 23–40% of patients to void successfully, so that surgery can be performed at a later stage, if needed. Use of an α1-blocker before a TWOC may also be of help, as it has been demonstrated that it increases the chances of successful voiding after catheter removal. In the UK, this TWOC policy has resulted in a progressive decrease in the number of surgical procedures following a first episode of AUR, with the detriment of a slight increase in the AUR recurrence rate.

Currently, there is no consensus on the optimal management of AUR in terms of type of catheterization, duration of catheterization and management following catheterization. The Reten-World survey is aimed at assessing current practice in the management of AUR in France, Asia, Latin America, North Africa and the Middle East. Interim results based on 3785 men with AUR associated with benign prostatic hyperplasia show that a urethral catheter is inserted in most cases (87%). Following this initial step, a TWOC after a median of 3 days’ catheterization has become standard practice worldwide, with only a minority of men (6%) undergoing immediate surgery. Treatment with an α1-blocker before a TWOC improves the chances of success, regardless of the duration of catheterization. There is also evidence that prolonged catheterization (>3 days) is associated with a significantly higher rate of comorbidity and prolonged hospitalization due to adverse events. Every effort should thus be made to reduce the comorbidity and mortality associated with AUR.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Acute urinary retention (AUR) is a common urological emergency in men and is defined as a sudden and painful inability to pass urine voluntarily [1]. It is often unexpected, painful and distressing [2] and represents a significant worldwide public health issue. The annual incidence of primary AUR varies from 2.2 to 6.8 per 1000 men, according to the series [3–6]. It is the presenting feature for approximately 1 in 5 men who undergo transurethral resection of the prostate [7].

In some cases, AUR is consecutive to a triggering event and corresponds to the so-called ‘precipitated AUR’. The most common precipitating events include surgical procedures with general or locoregional anaesthesia, excessive fluid intake, bladder overdistension, urinary tract infections, prostatic inflammation, alcohol consumption or use of drugs with sympathomimetic or anticholinergic effects [8–10]. However, in most cases, no triggering event is identified and the AUR is attributed to the natural history of benign prostatic hyperplasia (BPH) (i.e. spontaneous AUR). Baseline variables that have been identified as predictors of AUR in men with BPH include old age, severe lower urinary tract symptoms (LUTS), low peak flow rate, increased postvoid residual urine (PVR), enlarged prostate and high serum prostate-specific antigen (PSA) levels [3,11]. Dynamic variables, such as LUTS or PVR deterioration or lack of treatment response to short- or long-term α1-blockade, are also associated with an increased risk of AUR [12–14]. The differentiation between spontaneous and precipitated AUR is important in practice, as BPH-related surgery is less common in cases of precipitated AUR [6]. In the UK in 2003, 1 out of 4 men underwent BPH-related surgery following a first episode of spontaneous AUR, while <1 out of 10 men with precipitated AUR underwent this procedure [6].

AETIOLOGY AND PATHOGENESIS OF AUR

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

The exact cause of AUR remains unclear but several mechanisms have been suggested (Fig. 1) [1]: (i) an increased resistance to the flow of urine, either related to mechanical obstruction (e.g. urethral stricture, clot retention) or dynamic obstruction (e.g. increased α1-adrenergic activity, prostatic inflammation); (ii) bladder overdistension (e.g. immobility, constipation, prolonged car travelling), which may be secondary to the influence of drugs (e.g. anticholinergic medication inhibiting bladder contractility, opiates or opioids decreasing the sensation of bladder fullness); and (iii) neuropathic causes (e.g. diabetic cystopathy).

image

Figure 1. Aetiology and pathogenesis of AUR. AUR, acute urinary retention.

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MANAGEMENT OF AUR

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

The immediate management of AUR involves bladder decompression by catheterization. The catheter (urethral or suprapubic) may be inserted at a general practice or hospital, with follow-up treatment varying according to local policy. Until recently, most patients underwent prostatectomy following AUR. However, surgery is associated with high risks in these patients. The UK National Prostatectomy Audit showed that compared with elective surgery for symptoms alone, emergency surgery following AUR resulted in a 3.0-fold increase in the risk of postoperative death at 30 days, a 2.5-fold increase in the risk of requiring a transfusion, a 2.0-fold increase in the risk of operative complications, and a 1.6-fold increase in postoperative complications [7]. Surgical intervention in the presence of a urinary catheter can also lead to an increased risk of sepsis, which potentially contributes to the observed increase in operative morbidity, especially in older patients [15,16].

These findings led to the increasing use of a trial without catheter (TWOC). TWOC involves removing the catheter after 1–3 days, which allows 23–40% of patients to void successfully [17–19]. The obvious benefit is that men can have their catheter removed rapidly and return home without the discomfort and potential morbidity associated with an in situ catheter. Moreover, if prostatectomy is required, this can be scheduled at a mutually convenient time for both the patient and the surgeon, which has reduced morbidity and mortality compared with an acute procedure.

ALPHA-BLOCKERS AND TWOC

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

The rationale for the use of α1-blockers before a TWOC is based on the fact that AUR related to BPH may be consecutive to a sudden stimulation of α1-adrenergic receptors, as already suggested by Caine et al. in 1975 [20]. By decreasing the high sympathetic tone at the level of the urethra and bladder neck, α1-blockers decrease bladder outlet resistance and may thus facilitate a return to normal voiding. This concept was supported by several small studies showing that α1-blockade before a TWOC may improve the TWOC success rate [19,21] and was confirmed by the large randomized, double-blind, placebo-controlled ALFuzosin in Acute Urinary Retention (ALFAUR) study [16,22].

The ALFAUR study was divided into two parts. In the first part, 360 patients with a first episode of AUR related to BPH were randomized to receive alfuzosin 10 mg once daily or placebo for 2–3 days following catheterization [16]. Significantly more patients treated with alfuzosin experienced successful voiding after catheter withdrawal compared with placebo (62% vs 48%, respectively; P = 0.02) (Fig. 2). Elderly patients (aged ≥65 years) and patients with a drained volume ≥1000 mL at the time of catheterization had a significantly greater risk of TWOC failure (odds ratios [ORs] 95% confidence interval [CI] for success over failure were 0.309 [0.182–0.514] and 0.361 [0.225–0.571], respectively) (Fig. 2). Nevertheless, even in the presence of these two factors, alfuzosin almost doubled the likelihood of a successful TWOC (OR 1.979; P = 0.0055).

image

Figure 2. ALFuzosin in Acute Urinary Retention (ALFAUR) study (part 1): Alfuzosin 10 mg OD administered for 2–3 days before a trial without catheter (TWOC) facilitates successful voiding, even in patients at high risk of TWOC failure (age ≥65 years, drained volume at catheterization of ≥1000 mL) (adapted from McNeill et al.[16]). OD, once daily.

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In the second part of the study, 165 patients with successful voiding were re-randomized to receive alfuzosin 10 mg once daily (n = 82) or placebo (n = 83) for 6 months [22]. Within the 6-month follow-up period, 24.1% of the placebo-treated patients and 17.1% of alfuzosin-treated patients required BPH-related surgery, mainly for recurrent AUR. The need for BPH-related surgery was significantly reduced by alfuzosin compared with placebo within the first 3 months (by 61% at 1 month and 52% at 3 months; both P = 0.04) but the difference was no longer significant at 6 months (29%; P = 0.20). Patients with AUR relapse or requiring BPH-related surgery were characterized by higher PSA values and post-TWOC PVR.

Clear messages were delivered by this placebo-controlled study, which was the first to be adequately powered. Firstly, it demonstrated that alfuzosin intake before a TWOC was useful in facilitating a return to normal voiding. Secondly, it showed that the need for surgery following a successful TWOC was much lower than expected, with only 24% of men in the placebo group requiring surgery during the 6-month follow-up period. Thirdly, the observation that most patients requiring surgery after a successful TWOC also had an AUR relapse emphasizes the need for a careful assessment of risk factors for an unfavourable outcome soon after a successful TWOC in a patient.

IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

α1-Blockade followed by a TWOC is now the standard of care in most UK hospitals [23]. To confirm whether the TWOC policy is beneficial in terms of reducing the need for surgery, an analysis was performed of a large database including 165 527 men admitted to National Health Service (NHS) hospitals in England from 1998 to 2003 with primary AUR (spontaneous, 65.3%; precipitated, 34.7%) [6]. Over the duration of the survey, a slight decrease was observed in the percentage of patients undergoing surgery following a first episode of AUR, both for spontaneous (32% in 1998 vs 26% in 2003) and for precipitated (7.6% in 1998 vs 5.8% in 2003) AUR. Conversely, the percentage of patients who were rehospitalized for recurrent AUR increased slightly between 1998 and 2003 (from 18% to 22% for spontaneous AUR; from 4.0% to 4.9% for precipitated AUR).

AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Another analysis of this database has just been published, and includes 176 046 men admitted to NHS hospitals between 1998 and 2005 with primary AUR. This analysis shows that mortality at 1 year was higher in cases of precipitated AUR than for spontaneous AUR (25.3% vs 14.7%) and was strongly related to both increasing age and comorbidity, as assessed using the Charlson Comorbidity Index (Fig. 3) [24]. Although the oldest age group (aged ≥85 years) showed the highest 1-year mortality rate, the age-specific relative increase in mortality compared with the general population was greatest in the younger age group (aged 45–54 years), with a 10-fold increase in mortality rate for spontaneous AUR and a 24-fold increase in mortality rate for precipitated AUR [24]. This demonstrates that men admitted to hospital for AUR represent a vulnerable group of patients. A careful assessment of health status (especially the nature and severity of comorbidities) and an optimal management of AUR in these patients is needed, regardless of age.

image

Figure 3. Age-specific mortality within 1 year after spontaneous or precipitated AUR in men with (Charlson score of 1 or more) or without comorbidity (Charlson score of 0) (adapted from Armitage et al.[24]). AUR, acute urinary retention.

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THE Reten-World SURVEY

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Currently, there is no consensus on the optimal management of AUR, in terms of type of catheterization, duration of catheterization and management following catheterization. The Reten-World survey is a prospective, cross-sectional survey designed to evaluate current practice in the management of men with AUR associated with BPH. The survey has been planned to include data from approximately 7000 men from around the world (France, Latin America, Asia, Algeria and the Middle East), representing a diverse range of healthcare systems. Results from the French survey, which included 2618 men with AUR, have already been published [10]. The new interim analysis presented below includes data from a total of 3785 men with AUR (France, n = 2618; Asia, n = 667; Latin America, n = 295; Algeria, n = 205), enrolled by 796 urologists from public (37.5%), private (46.5%) or mixed (16.0%) healthcare practices.

Of the 3785 men presenting with AUR, 2659 (70.3%) had a spontaneous AUR and 1126 (29.7%) a precipitated AUR, mainly consecutive to a surgical procedure with general or locoregional anaesthesia (11.2%) (Table 1). The incidence of spontaneous AUR and precipitated AUR varied by region (Fig. 4). The incidence of spontaneous AUR was much higher (83%) than precipitated AUR (17%) in Algeria. Conversely, Latin America showed a particularly high incidence of precipitated AUR (46%), which was in most cases consecutive to excessive alcohol intake. A previous episode of AUR was reported by 14% of men (France, 10%; Algeria, 22%; Latin America, 23%; Asia, 24%) within a median of 7 months. BPH was revealed by AUR in 36% of men (France, 33%; Latin America, 38%; Asia, 43%; Algeria, 46%).

Table 1.  Causes of AUR in 3785 men with benign prostatic hyperplasia
CauseIncidence (%)
  1. AUR, acute urinary retention; BPH, benign prostatic hyperplasia. *Febrile AUR was an exclusion criterion in the French survey.

BPH natural history (spontaneous AUR)70.3
Postoperative (with general or locoregional anaesthesia)11.2
Important alcohol intake3.5
Faecal impaction3.3
Medications (parasympatholytics, sympathomimetics, etc.)2.8
Need to postpone voiding (travelling by car, immobilization, etc.)2.4
Acute ano-rectal pain2.2
Urinary tract infection*2.0
Acute medical condition (cardiac failure, etc.)0.4
Urolithiasis0.3
Other1.6
image

Figure 4. Reten-World survey in 3785 men with AUR associated with benign prostatic hyperplasia: patients with spontaneous and precipitated AUR in France, Asia, Latin America and Algeria. AUR, acute urinary retention.

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TYPE OF CATHETERIZATION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Most urologists preferred urethral catheterization (France, 83%; Algeria, 95%; Asia, 95%; Latin America, 97%). A suprapubic catheter was inserted in 12% of cases, nearly exclusively in France. ‘In and out’ catheterization was uncommon (0.8%). In terms of comorbidity, urethral and suprapubic catheterization showed a similar incidence of complications (urethral catheter, 28.2%; suprapubic catheter, 29.4%; P = 0.60). However, suprapubic catheterization was associated with a significantly higher incidence of gross haematuria (15.9% vs 10.1%; P < 0.001) and prolonged hospitalization due to complications (8.9% vs 5.5%; P = 0.005), while urethral catheterization was associated with a significantly higher rate of urine leak (5.5% vs 2.0%; P < 0.001). Interestingly, there was no difference between the two types of catheterization regarding the risk of asymptomatic bacteriuria, lower urinary tract infection or urosepsis.

HOSPITALIZATION FOR AUR

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Hospitalization for AUR differed widely between regions, which probably reflects differences in local infrastructure and available healthcare facilities. France had the highest rate of hospitalization for AUR (100%), followed by Asia (34%), Latin America (12.4%) and Algeria (4%). The overall mean duration of the hospital stay was 7 days.

MANAGEMENT AFTER CATHETERIZATION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Following initial catheterization, the majority of patients (76%) underwent a TWOC after a median of 3 days, 16% had prolonged catheterization (median of 10 days) followed by surgery, 6% had immediate surgery (within a median of 4 days) and 2% had a urethral stent or an indwelling catheter inserted. There was a slightly more aggressive approach to the treatment of spontaneous AUR compared with precipitated AUR (Fig. 5). Patients with spontaneous AUR were less likely to undergo a TWOC (70.6%) and were more likely to have either deferred (19.6%) or immediate (7.8%) BPH-related surgery than those with precipitated AUR (89.5%, 6.8% and 2.3%, respectively; P < 0.001 for all).

image

Figure 5. Reten-World survey in 3785 men with AUR associated with benign prostatic hyperplasia: management after catheterization analysed by AUR type. AUR, acute urinary retention; TWOC, trial without catheter.

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TWOC OUTCOME

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Of the 2811 men who underwent a TWOC, the trial was successful in more than half of cases (precipitated AUR, 60.2%; spontaneous AUR, 55.5%; P = 0.02). Eighty-two percent of patients had received an α1-blocker (alfuzosin, 70%; tamsulosin, 13%; doxazosin or terazosin, 5%; unspecified, 12%) before catheter removal. Overall, the TWOC success rate was greater in men who received an α1-blocker before catheter removal than in those who did not (59.6% vs 46.3%, respectively; P < 0.001), regardless of the duration of catheterization (Fig. 6).

image

Figure 6. Reten-World survey: influence of catheter duration on TWOC success in 2811 men who underwent a TWOC. *Alfuzosin 70%, tamsulosin 13%, doxazosin or terazosin 5%, unspecified α1-blocker 12%. TWOC, trial without catheter.

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Univariate regression analysis showed that α1-blocker treatment before a TWOC, age <70 years, precipitated AUR (rather than spontaneous AUR), mild LUTS, prostate size ≤50 g, a drained volume at catheterization of <1000 mL and a duration of catheterization >3 days were associated with an increased TWOC success rate. Multivariate regression analysis including all these parameters, with the exception of LUTS severity and prostate size (due to a high rate of missing data), confirmed that treatment with an α1-blocker before a TWOC significantly increased the likelihood of a successful TWOC (OR [95% CI], 1.58 [1.28–1.96]; P < 0.0001). Men catheterized for >3 days had a slightly greater chance of TWOC success than those catheterized for ≤3 days (59.6% vs 56.4%; OR [95% CI], 1.21 [1.03–1.43]; P < 0.05) but this marginal benefit was accompanied by the detriment of higher comorbidity (see below). Age ≥70 years, drained volume at catheterization ≥1000 mL and spontaneous AUR were associated with higher rates of TWOC failure.

MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Of the 1601 patients who had a successful TWOC, the majority continued on α1-blockade treatment while being followed up regularly (82%); 24% would have a surgical procedure performed if needed and 7% underwent elective BPH-related surgery within a median of 15 days after catheter removal. Again, men with spontaneous AUR were more likely to undergo a BPH-related surgery than men with precipitated AUR.

MANAGEMENT OF PATIENTS AFTER A FAILED TWOC

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

Of those 1201 patients who failed a TWOC, 54.1% underwent elective BPH-related surgery after a median of 7 days’ recatheterization (spontaneous AUR, 58.2%; precipitated AUR, 45.7%; P < 0.001), 38% underwent a second TWOC after a median of 7 days’ recatheterization, 2.4% had an indwelling catheter, 1% had a stent inserted and 4.5% underwent another approach. If performed, a second TWOC was successful in only 136 men (30.7%).

CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

The Reten-World survey has also shown that the risk of catheter-related complications is related to the duration of catheterization (Table 2). Catheterization for >3 days compared with ≤3 days was associated with a significantly higher incidence of complications such as gross haematuria, asymptomatic bacteriuria, lower urinary tract infection, urosepsis, urine leak and catheter obstruction. In addition, prolongation of hospitalization for adverse events occurred in significantly more patients with longer duration catheterization (>3 days) than in those who had shorter duration catheterization (≤3 days) (19.8% vs 13.3%, respectively; P = 0.007). As the benefits associated with a catheter duration >3 days appear very marginal in terms of TWOC success (59.6%) compared with a shorter catheter duration (56.4%), it is thus our belief that all efforts should be made to reduce the duration of catheterization in order to reduce comorbidity.

Table 2.  Reten-World survey – Catheterization for >3 days is associated with increased comorbidity
Outcome≤3 days (n = 1013)>3 days (n = 2491)P value
At least 1 adverse event during catheter period, n (%) 177 (17.5)825 (33.1)<0.001
Gross haematuria, n (%) 68 (6.7)309 (12.4)<0.001
Asymptomatic bacteriuria, n (%) 52 (5.1)343 (13.8)<0.001
Lower urinary tract infection, n (%) 19 (1.9)140 (5.6)<0.001
Urosepsis, n (%)  7 (0.7) 39 (1.6) 0.03
Urine leak, n (%) 32 (3.2)145 (5.8)<0.001
Catheter obstruction, n (%)  7 (0.7) 69 (2.8)<0.001
Other adverse events, n (%) 23 (2.3) 58 (2.3) 0.92
Prolongation of hospitalization due to adverse event, n (%) 45 (13.3)158 (19.8) 0.007
Prolongation of hospitalization, median days [range]  5 [1–21]  7 [1–45] 

CONCLUSIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES

AUR represents a significant worldwide public health issue, as mortality within the first year following an AUR episode is much higher than in the general population, especially in younger patients. Currently, there is no consensus on the optimal management of AUR in terms of type of catheterization, duration of catheterization or management following catheterization. Preliminary results of the Reten-World registry based on 3785 men with AUR show that most urologists insert a urethral catheter (87%). Following this initial step, a TWOC after a median of 3 days’ catheterization has become standard practice worldwide (76% of cases), while 16% had prolonged catheterization followed by surgery and only 6% underwent an immediate surgical procedure. Treatment with an α1-blocker before a TWOC consistently improves the chances of successful catheter removal, regardless of the duration of catheterization. There is also evidence that prolonged catheterization (>3 days) is associated with a significantly higher rate of comorbidity and a prolonged hospital stay due to adverse events. The final results of this large worldwide survey will further identify current practices in the treatment of men with AUR and will support optimization of the management of this distressing condition.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. AETIOLOGY AND PATHOGENESIS OF AUR
  5. MANAGEMENT OF AUR
  6. ALPHA-BLOCKERS AND TWOC
  7. IMPACT OF TWOC POLICY ON THE MANAGEMENT OF AUR IN ENGLAND
  8. AGE-SPECIFIC MORTALITY FOLLOWING AUR IN ENGLAND
  9. THE Reten-World SURVEY
  10. TYPE OF CATHETERIZATION
  11. HOSPITALIZATION FOR AUR
  12. MANAGEMENT AFTER CATHETERIZATION
  13. TWOC OUTCOME
  14. MANAGEMENT OF PATIENTS AFTER A SUCCESSFUL TWOC
  15. MANAGEMENT OF PATIENTS AFTER A FAILED TWOC
  16. CATHETERIZATION FOR >3 DAYS IS ASSOCIATED WITH INCREASED COMORBIDITY
  17. CONCLUSIONS
  18. CONFLICTS OF INTEREST
  19. REFERENCES