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Official reprint from UpToDate®

www.uptodate.com © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Acute urinary retention

AUTHORS: Glen W Barrisford, MD, MS, MPH, FACS, Graeme S Steele, MBBCh, FCS
SECTION EDITORS: Michael P O'Leary, MD, MPH, Korilyn S Zachrison, MD, MSc
DEPUTY EDITOR: Karen Law, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Aug 2023.

This topic last updated: Sep 29, 2021.

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 issues related to evaluation and management of AUR. The diagnosis
and treatment of BPH and chronic urinary retention in women are discussed separately.

● (See "Clinical manifestations and diagnostic evaluation of benign prostatic

hyperplasia".)
● (See "Medical treatment of benign prostatic hyperplasia".)
● (See "Surgical treatment of benign prostatic hyperplasia (BPH)".)
● (See "Chronic urinary retention in females".)

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].

By 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.

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PATHOGENESIS AND ETIOLOGIES

A variety of pathophysiologic mechanisms may be responsible for the development of acute

urinary retention (AUR). Several mechanisms may occur concurrently. The most common
mechanisms are outflow obstruction, neurologic impairment, or an inefficient detrusor
muscle [9,10]. Other causes include medications, infection, and trauma.

● Outflow obstruction – Obstruction is the most common cause of AUR [11]. The flow of
urine can be impeded by mechanical factors (physical narrowing of the urethral
channel) and/or dynamic factors (increased muscle tone within and around the urethra)
[9,12,13].

• In males, the most common cause of obstruction is benign prostatic hyperplasia

(BPH) [2-5,11]. Other causes of outflow obstruction in men include constipation,
prostate or bladder cancer, urethral stricture, urolithiasis, phimosis, or paraphimosis
[4,13]. (See "Lower urinary tract symptoms in males" and "Clinical manifestations
and diagnostic evaluation of benign prostatic hyperplasia" and "Strictures of the
adult male urethra".)

• In females, obstruction is generally secondary to anatomic distortion, including

pelvic organ prolapse (eg, cystocele or rectocele), pelvic masses, or, less commonly,
urethral diverticulum [7,14-23]. (See "Pelvic organ prolapse in females:
Epidemiology, risk factors, clinical manifestations, and management", section on
'Urinary symptoms' and "Urethral diverticulum in females".)

● Neurologic impairment – AUR may develop secondary to the interruption of the

sensory or motor nerve supply to the detrusor muscle [4]. Incomplete relaxation of the
urinary sphincter mechanism (dyssynergia) can also result in elevations in both voiding
pressures and post-void residual volumes.

AUR can occur with spinal cord injuries from trauma, infarct or demyelination, epidural
abscess and epidural metastasis, Guillain-Barré syndrome, diabetic neuropathy, and
stroke [13]. AUR is typically accompanied by back pain and/or other neurologic deficits.
Patients with neurologic impairment may develop acute-on-chronic urinary retention.
(See individual topic reviews on each disorder.)

● 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)
[9,13,24-26]. This most often occurs in patients with obstructive urinary symptoms at
baseline.

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● 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.

● 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 [11,29]. 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 [1,11,29].

● Trauma – Patients with trauma to the pelvis, urethra, or penis may develop AUR from
mechanical disruption [11]. (See "Blunt genitourinary trauma: Initial evaluation and
management".)

● Other – AUR may also occur postoperatively or in the postpartum period. (See
"Overview of post-anesthetic care for adult patients", section on 'Inability to void'.)

CLINICAL PRESENTATION

Acute urinary retention (AUR) generally presents as an inability to pass urine, usually
associated with lower abdominal and/or suprapubic discomfort [13]. Affected patients are
often restless and may appear in considerable distress. In older adult patients, particularly
those with dementia or other forms of cognitive impairment, AUR may present as an acute
change of mental status [30].

These manifestations may be less pronounced when AUR is superimposed upon chronic
urinary retention. Chronic urinary retention is often painless [31]. Acute-on-chronic urinary
retention may present with overflow incontinence. The patients may complain of
incontinence rather than the inability to pass urine.

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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 females" and "Overview
of post-anesthetic care for adult patients", section on 'Inability to void'.)

EVALUATION OF SYMPTOMS

The initial evaluation of patients with symptoms suggestive of acute urinary retention (AUR)
should begin with a history and physical examination to determine the likelihood of the
disorder.

● 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 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", section on
'Clinical features' and "Spinal epidural abscess", section on 'Clinical manifestations'.)

● Physical examination – The initial physical examination should include lower

abdominal palpation. The urinary bladder may be palpable, either on abdominal or
rectal examination. Deep suprapubic palpation will provoke discomfort.

DIAGNOSIS

The diagnosis of acute urinary retention (AUR) is made by demonstrating retained urine by
either bladder ultrasound or catheterization, in the appropriate clinical setting. If the
procedure can be performed relatively quickly, a bladder ultrasound is a good first choice for
patients who are not in extreme distress, because it is noninvasive, it is more comfortable for
the patient, and bladder decompression can be avoided if results are normal.

In patients whose history and physical examination strongly suggest a diagnosis of AUR, or
those in acute distress, it is reasonable to proceed directly to catheterization, which is both
diagnostic and therapeutic, rather than waiting to obtain a bladder ultrasound. Alternatively,
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a bladder scanner can be used if immediately available. (See 'Options for bladder
decompression' below.)

A bladder volume on ultrasound ≥300 cc suggests urinary retention warranting

decompression. 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.

Upon placement of a urethral catheter, the initial amount of urine drained should be noted.
Patients with volumes <200 cc likely do not have acute urinary retention. These patients
should undergo further evaluation by a urologist in an outpatient setting.

The decision of whether to leave the catheter in is discussed below. (See 'Acute
management' below.)

POST-DIAGNOSTIC EVALUATION

In patients with acute urinary retention (AUR), the post-diagnostic evaluation focuses on
determining an etiology.

● Physical examination – In patients with AUR of unknown etiology, further physical

examination should include the following:

• Rectal examination – A rectal examination should be done in both all patients 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.

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 department with concern for urinary retention have serum chemistries and
creatinine checked. These should be checked in any patient whose history suggests
acute-on-chronic urinary retention to evaluate for renal failure.
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Other labs that may be helpful include a complete blood count (CBC) for suspected
infection. We do not check a prostate-specific antigen (PSA) as it is expected to be
elevated during an episode of AUR.

ACUTE MANAGEMENT

The initial management of acute urinary retention (AUR) is prompt bladder decompression
by catheterization, with urinalysis and culture.

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 (see 'Contraindications to urethral catheterization' below), particularly in
patients for whom AUR is expected to resolve (eg, patients with urinary tract infections or
AUR secondary to medication effect). A 14 to 18 gauge French catheter should be inserted as
first-line in most patients with AUR [11]. Indications for choosing a smaller or larger catheter
are discussed below. (See 'Difficulties with urethral catheterization' below.)

For patients with an initial urine volume of less than 200 cc, immediate catheter removal and
subsequent observation for recurrence is usually appropriate. These patients should be
evaluated for other causes of abdominal and/or suprapubic discomfort. (See "Evaluation of
the adult with abdominal pain" and "Acute pelvic pain in nonpregnant adult females:
Evaluation".)

For patients with greater than 200 cc of urine, the volume drained in the first 10 to 15
minutes should be noted and recorded as it is useful for subsequent management regarding
duration of catheter use. If this volume exceeds 400 cc, the catheter is typically left in place.
For volumes less than 400 cc, the decision to leave the catheter in place is guided by the
clinical scenario.

For patients with greater than 200 cc and less than 400 cc, the decision on catheterization
may take into account multiple factors. Patient comorbidities, mental status, ability to return
to the hospital, and numerous other factors may influence this decision to leave an
indwelling catheter.

In patients with back pain or neurologic symptoms, the presence of spinal cord compression
should be considered. Younger age, history of malignancy, or intravenous drug abuse can be
associated risk factors.

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In patients with AUR, we generally leave the catheter in place for three to five days, after
which the patient is given a voiding trial. Examples of earlier catheter removal include
postoperative patients who are initially unable to void but recover this ability within a few
hours.

Contraindications to urethral catheterization — 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. (See
'Suprapubic catheter' below.)

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 "Acute bacterial prostatitis", section on 'Nonantimicrobial
therapy'.)

Difficulties with urethral catheterization — Some patients may have an obstruction

that does not readily allow passage of the catheter. A partially obstructing urethral or
prostatic scar may be present if the patient has had a prior transurethral procedure (eg,
transurethral resection of the prostate), or pelvic trauma or radiation [10]. 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 or injury, 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'.)

If attempts to pass a catheter are not successful, urgent urology consultation may be an
option for bedside flexible cystoscopy with either dilatation of a stricture or passage of a
wire over which a urinary catheter may be placed [10].

Complications of urethral catheters are discussed separately. (See "Complications of urinary

bladder catheters and preventive strategies", section on 'Urethral catheters'.)

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. Suprapubic tubes can be placed in either the
operating room, the emergency department, or occasionally an outpatient clinic. However,
patient factors (age, health, medications, body mass index, prior surgical history, etc) may
preclude placement outside of the operating room.

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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, this treatment can make subsequent SP placement more difficult or even
dangerous due to bladder decompression. If an appropriately trained medical professional
will be 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 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. They also have the advantage of allowing assessment of the patient's
ability to void before removing the catheter, they may be associated with fewer infections
than an indwelling urethral catheter [32], and are less uncomfortable than urethral
catheters. Lastly, SP catheters in men avoid the risk of subsequent urethral stricture, a
common complication in men requiring long-term urethral catheterization [33].

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, partial drainage and clamping does not reduce these complications and
may increase risk for urinary tract infection [31,34-36].

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 [31]. For example, one trial found that hematuria occurred in approximately
11 percent of patients with AUR; hematuria resolved with irrigation for almost all
patients [37].

● Transient hypotension – After initial bladder decompression, patients may experience

a transient hypotension [31]. 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 defined as a diuresis that persists after
decompression of the bladder. A postobstructive diuresis is primarily a problem with

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chronic, not acute, urinary retention and usually represents an appropriate attempt to
excrete excess fluid retained during the period of obstruction [38].

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'.)

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 [39]. Hospitalization is indicated for patients
who have urosepsis, have obstruction related to malignancy, or acute myelopathy [11].
Patients with associated acute renal failure 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'.)

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 that
condition has been treated 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 females",
section on 'Spontaneous voiding trial'.)

In other patients who have underlying etiologies 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 long-term clean intermittent catheterization (CIC) or
SP placement. (See "Placement and management of urinary bladder catheters in adults",
section on 'Clean intermittent catheterization' and 'Suprapubic catheter' above.)

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The duration of catheterization in men with benign prostatic hyperplasia is discussed below.
(See 'Trial without a catheter' below.)

Clean intermittent catheterization — CIC has fewer complications compared with

indwelling urethral and SP 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 [40].

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 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'.)

SUBSEQUENT MANAGEMENT

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.

The appropriate subsequent evaluation of patients without benign prostatic hyperplasia

(BPH) 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 "Posterior vaginal defects (eg, rectocele): Clinical manifestations,
diagnosis, and nonsurgical management".)

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 "Strictures of
the adult male urethra" and "Urethral diverticulum in females".)

Benign prostatic hyperplasia — BPH is the most common cause of AUR [2-5,11]. 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

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acute management with bladder decompression. (See "Clinical manifestations and

diagnostic evaluation of benign prostatic hyperplasia".)

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 experienced a recurrence within one year
[25,41].

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-1-adrenergic blocker and a 5-alpha reductase
inhibitor to delay the recurrence of AUR.

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
[42]. 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 [43].

Several different types of alpha-1-adrenergic antagonists are available with similar

mechanisms and differing side effect profiles ( table 3) [44]. Alfuzosin and tamsulosin have
been evaluated in randomized, placebo-controlled trials in conjunction with a trial without a
catheter (TWOC) [45-47]. The Alfuzosin in Acute Urinary Retention trial (ALFAUR) compared
placebo with alfuzosin (10 mg once daily) in 360 men with AUR [47]. 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 [48]. 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 [49-51]. Patients need to be
treated for more than one year to prevent AUR and reduce the need for surgery.

Trial without a catheter — Initial bladder decompression and initiation of medical therapy
should be followed by a TWOC. We suggest that patients have two trials 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.

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In our office, a voiding trial starts with catheter removal early in the morning, either at home
or in the office. Patients are encouraged to hydrate aggressively and to return to the office in
the early afternoon for a postvoid residual (PVR). A PVR over 400 cc is generally considered a
failure, under 200 cc would be a success, and PVRs between 200 to 400 cc result in a risk
benefit discussion of options. If the patient is unable to void or if they are voiding with high
PVRs, they are offered instruction in clean intermittent catheterization. If they are unable or
unwilling to do this, a catheter is placed.

Reported success rates for initial TWOC in men with prostate disease with AUR have ranged
from 20 to 40 percent [45]. 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 [41,45].

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 [52,53]. 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 [54]. 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 [55]. (See "Surgical treatment of benign prostatic hyperplasia (BPH)".)

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 [39]. 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 [39,56]. 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 with men undergoing elective prostatectomy (RR 26.6 and 4.4,
respectively) as well as an increased risk of perioperative complications [39]. Some, but not

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all of this excess risk could be explained by older age, larger prostate size, and higher
comorbidity in the men with AUR.

Urethral stenting is no longer used as it provided only modest improvement in symptoms

and was associated with a variety of complications including: stent migration, encrustation,
infection, and calculus formation [57]. As a result, this is no longer used. Prostatic urethral
lift (Urolift) has become an attractive, minimally invasive, low-risk surgical procedure
associated with improvement in urinary symptoms and preservation of ejaculatory function
[58,59].

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 "Strictures of the adult male urethra")
● Urethral diverticulum (see "Urethral diverticulum in females")

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Benign prostatic
hyperplasia".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topic (see "Patient education: Neurogenic bladder in adults (The Basics)")

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SUMMARY AND RECOMMENDATIONS

● Common causes – Acute urinary retention (AUR) is the most common urologic
emergency and is seen more often in men than women. Benign prostate hyperplasia
(BPH) is the most common underlying condition in men, but there are many possible
etiologies. Medications are frequently implicated ( table 1). (See 'Epidemiology' above
and 'Pathogenesis and etiologies' above.)

● Clinical presentation – 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 abdominal pain but may
complain of symptoms of overflow incontinence. Persons with dementia or other forms
of cognitive impairment may present with an acute change in mental status. (See
'Clinical presentation' above.)

● Diagnosis – The diagnosis is made by demonstrating retained urine by either bladder

ultrasound or catheterization. If the procedure can be performed relatively quickly, a
bladder ultrasound is a good first choice for patients who are not in extreme distress,
because it is noninvasive, it is more comfortable for the patient, and bladder
decompression can be avoided if results are normal. In patients whose history and
physical examination strongly suggest a diagnosis of AUR, it is reasonable to proceed
directly to catheterization, which is both diagnostic and therapeutic. (See 'Diagnosis'
above.)

● Acute bladder decompression – Initial management of AUR consists of prompt

bladder decompression usually with an indwelling urethral catheter. Urethral
catheterization is contraindicated in patients who have had recent urologic surgery (eg,
radical prostatectomy or urethral reconstruction). A suprapubic catheter may be
necessary when obstruction precludes a urethral catheter and is also preferred in
patients who are expected to require longer-term catheterization. (See 'Acute
management' above.)

● Limited need for hospitalization – The majority of patients can be managed as

outpatients once bladder decompression is accomplished. Hospitalization is indicated
for patients with urosepsis, acute renal failure, or obstruction related to malignancy or
spinal cord compression. (See 'Indications for hospitalization' above.)

● Ongoing medical treatment – In men with BPH or presumed BPH, treatment also
includes an alpha-1-adrenergic antagonist (eg, alfuzosin 10 mg daily) initiated at the
time of initial catheterization. Ongoing combination treatment is generally necessary to

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prevent recurrence of AUR. (See 'Medical management' above and "Medical treatment
of benign prostatic hyperplasia".)

● Catheter removal – In men with BPH, removal of the catheter after a period of time
after initiation of medical treatment ("trial without catheter" or TWOC) results in
successful spontaneous micturition in up to 40 percent of patients, although recurrent
AUR is common. We suggest a trial of catheter removal in one to two weeks. For
patients who fail the initial TWOC, we advise a second trial of TWOC after an additional
two weeks with the catheter. (See 'Trial without a catheter' above.)

• Men with BPH who fail a second TWOC may need surgical therapy. A urodynamic
evaluation is advised prior to prostate surgery for patients who have experienced
AUR. (See 'Surgical therapy' above.)

Use of UpToDate is subject to the Terms of Use.

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27. Verhamme KM, Sturkenboom MC, Stricker BH, Bosch R. Drug-induced urinary retention:
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28. Raz S, Zeigler M, Caine M. Pharmacological receptors in the prostate. Br J Urol 1973;
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29. Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am
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30. Blackburn T, Dunn M. Cystocerebral syndrome. Acute urinary retention presenting as

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31. Nyman MA, Schwenk NM, Silverstein MD. Management of urinary retention: rapid
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33. Horgan AF, Prasad B, Waldron DJ, O'Sullivan DC. Acute urinary retention. Comparison of
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35. Gibson KE, Neill S, Tuma E, et al. Indwelling urethral versus suprapubic catheters in
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2019; 102:219.

36. Buehrle DJ, Clancy CJ, Decker BK. Suprapubic catheter placement improves antimicrobial
stewardship among Veterans Affairs nursing care facility residents. Am J Infect Control
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37. Boettcher S, Brandt AS, Roth S, et al. Urinary retention: benefit of gradual bladder
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38. Foster MC, Upsdell SM, O'Reilly PH. Urological myths. BMJ 1990; 301:1421.
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40. Patel MI, Watts W, Grant A. The optimal form of urinary drainage after acute retention
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41. Klarskov P, Andersen JT, Asmussen CF, et al. Symptoms and signs predictive of the
voiding pattern after acute urinary retention in men. Scand J Urol Nephrol 1987; 21:23.

42. Caine M, Pfau A, Perlberg S. The use of alpha-adrenergic blockers in benign prostatic
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43. Fisher E, Subramonian K, Omar MI. The role of alpha blockers prior to removal of
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45. Fitzpatrick JM, Kirby RS. Management of acute urinary retention. BJU Int 2006; 97 Suppl
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46. Lucas MG, Stephenson TP, Nargund V. Tamsulosin in the management of patients in
acute urinary retention from benign prostatic hyperplasia. BJU Int 2005; 95:354.
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in the management of acute urinary retention: results of a double-blind placebo-
controlled study. Urology 2005; 65:83.

49. McConnell JD, Bruskewitz R, Walsh P, et al. The effect of finasteride on the risk of acute
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338:557.

50. McConnell JD, Roehrborn CG, Bautista OM, et al. The long-term effect of doxazosin,
finasteride, and combination therapy on the clinical progression of benign prostatic
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51. Bruskewitz R, Girman CJ, Fowler J, et al. Effect of finasteride on bother and other health-
related quality of life aspects associated with benign prostatic hyperplasia. PLESS Study
Group. Proscar Long-term Efficacy and Safety Study. Urology 1999; 54:670.
52. Taube M, Gajraj H. Trial without catheter following acute retention of urine. Br J Urol
1989; 63:180.

53. Djavan B, et al. Does prolonged catheter drainage improve the chance of recovering
voluntary voiding after acute urinary retention of urine (AUR)? Eur Urol 1998; 33:110.
54. Desgrandchamps F, De La Taille A, Doublet JD, RetenFrance Study Group. The
management of acute urinary retention in France: a cross-sectional survey in 2618 men
with benign prostatic hyperplasia. BJU Int 2006; 97:727.

55. Wasson JH, Reda DJ, Bruskewitz RC, et al. A comparison of transurethral surgery with
watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans
Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J
Med 1995; 332:75.
56. Higgins PM, French ME, Chadalavada VS. Management of acute retention of urine: a
reappraisal. Br J Urol 1991; 67:365.

57. Isotalo T, Talja M, Välimaa T, et al. A pilot study of a bioabsorbable self-reinforced poly L-
lactic acid urethral stent combined with finasteride in the treatment of acute urinary
retention from benign prostatic enlargement. BJU Int 2000; 85:83.
58. Pushkaran A, Stainer V, Muir G, Shergill IS. Urolift - minimally invasive surgical BPH
management. Expert Rev Med Devices 2017; 14:223.

59. Magistro G, Stief CG, Woo HH. Mini-Review: What Is New in Urolift? Eur Urol Focus 2018;
4:36.
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Topic 6883 Version 50.0

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GRAPHICS

Pharmacologic agents associated with urinary retention

Sympathomimetics Ephedrine sulfate (Marax, Tedral)

(alpha-adrenergic agents)
Phenylephrine HCl (Neo-Synephrine)

Phenylpropanolamine HCL (Conlac)

Pseudoephedrine HCl (Sudafed, Actifed)

Sympathomimetics (beta- Isoproterenol

adrenergic agents)
Metaproterenol

Terbutaline

Antidepressants Imipramine (Tofranil)

Nortriptyline (Aventyl)

Amitriptyline (Elavil)

Doxepin (Adapin)

Amoxepine (Asendin)

Maprotiline (Ludiomil)

Antiarrhythmics Quinidine

Procainamide

Disopyramide

Anticholinergics Atropine
(selected)
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)

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Levodopa (Sinemet)

Bromocriptine Mesylate (Parlodel)

Hormonal agents Progesterone

Estrogen

Testosterone

Antipsychotics Haloperidol (Haldol)

Thiothixene (Navane)

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

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American Urological Association (AUA) urinary symptom

score/International Prostate Symptom Score (IPSS)

Less Less
Questions More than
than 1 than About half Almost
to be Not at all half the
time in half the the time always
answered time
5 time

1. Over the 0 1 2 3 4 5
past month,
how often
have you
had a
sensation of
not
emptying
your bladder
completely
after you
finished
urinating?

2. Over the 0 1 2 3 4 5
past month,
how often
have you
had to
urinate
again less
than 2 hours
after you
finished
urinating?

3. Over the 0 1 2 3 4 5
past month,
how often
have you
found you
stopped and
started
again
several
times when
you
urinated?

4. Over the 0 1 2 3 4 5
past month,
how often
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have you
found it
difficult to
postpone
urination?

5. Over the 0 1 2 3 4 5
past month,
how often
have you
had a weak
urinary
stream?

6. Over the 0 1 2 3 4 5
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) 5 (5 or

past month, more
how many times)
times did
you most
typically get
up to 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

Quality of Delighted Pleased Mostly Mixed - Mostly Unhappy

life due to satisfied about dissatisfied
urinary equally
symptoms satisfied

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and
unsatisfied

If you were 0 1 2 3 4 5
to spend the
rest of your
life with your
urinary
condition
the way it is
now, how
would you
feel about
that?

The AUA symptom score and the IPSS use the same questions and scale. The IPSS additionally
includes the last disease-specific quality of life question.

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.

Graphic 57680 Version 11.0

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Alpha-1-receptor antagonist for BPH*

[1]
Dose titration schedule to reduce orthostatic effects

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

Weeks 4 and thereafter 10 mg

Doxazosin (immediate release)

Days 1 to 3 1 mg

Days 4 to 14 2 mg

Weeks 2 to 6 4 mg

Weeks 7 and thereafter 8 mg

Doxazosin (extended release preparation only)

Days 1 to 21 4 mg

Week 4 and thereafter 8 mg

¶[2]
Uroselective alpha-1 receptor antagonists

Alfuzosin

Initial and maintenance 10 mg

Tamsulosin

Initial and maintenance 0.4 mg

If inadequate response after two to four weeks 0.8 mg

Silodosin

Initial and maintenance 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 four to six weeks. If therapy is interrupted for three or more days, reinitiate at lowest dose
and re-titrate according to schedule.

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¶ 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.

Graphic 60702 Version 5.0

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Contributor Disclosures
Glen W Barrisford, MD, MS, MPH, FACS No relevant financial relationship(s) with ineligible companies
to disclose. Graeme S Steele, MBBCh, FCS No relevant financial relationship(s) with ineligible
companies to disclose. Michael P O'Leary, MD, MPH No relevant financial relationship(s) with
ineligible companies to disclose. Korilyn S Zachrison, MD, MSc Grant/Research/Clinical Trial Support:
American College of Emergency Physicians [Stroke quality improvement]; CRICO [Headache
management]; Massachusetts General Hospital Executive Committee on Research [Prehospital stroke
decision modeling]; National Institutes of Health/National Institute of Neurological Disorders and
Stroke [Telestroke, telehealth, prehospital stroke care, COVID and thromboembolic risk]. Speaker's
Bureau: Efficient CME [Honorarium]. Other Financial Interest: Journal of the American Heart
Association [Associate Editor]. All of the relevant financial relationships listed have been
mitigated. Karen Law, MD No relevant financial relationship(s) with ineligible companies 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
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