Management of acute urinary retention

Transcription

1 Original Article MANAGEMENT OF ACUTE URINARY RETENTION FITZPATRICK and KIRBY Management of acute urinary retention JOHN M. FITZPATRICK and ROGER S. KIRBY* Mater Misericordiae Hospital and University College Dublin, Ireland, and *The Prostate Centre, London, UK Acute urinary retention (AUR) is a common urological emergency, characterized by a sudden and painful inability to pass urine. There is high variability within and among countries in its management, which can be explained not only by differences in access to care but also by a lack of harmonization and consensus on the best way to proceed. Immediate treatment consists of bladder decompression, usually by a urethral catheter, although a suprapubic catheter offers several advantages not often exploited by urologists. Until recently, secondary management consisted almost exclusively of prostatic surgery within a few days (emergency surgery) or a few weeks (elective surgery) after a first AUR episode. The greater morbidity and mortality associated with emergency surgery, and the potential morbidity associated with prolonged catheterization, has led to the increasing use of a trial without catheter; this involves catheter removal after 1 3 days, allowing the patient to void in 23 40% of cases, and surgery, if needed, at a later stage. α 1 -adrenergic blockers given before catheter removal improve the chances of success. A high prostate-specific antigen level and postvoid residual urine volume, and response to alfuzosin treatment after a first AUR episode managed conservately, may help to identify patients at risk of an unfavourable outcome. KEYWORDS BPH, acute urinary retention, progression INTRODUCTION Acute urinary retention (AUR) is a urological emergency characterized by a sudden and painful inability to pass urine [1]. It is estimated that 10% of men in their seventies and a third in their eighties will have AUR within the next 5 years [2]. AUR is an important public health issue in men with BPH, as up to a third of patients undergoing TURP present with AUR [3,4]. It also has a measurable impact on patients healthrelated quality of life, which is comparable to an attack of renal colic, and is associated with a substantial economic burden [5]. There are several possible causes of AUR: (i) a greater resistance to the flow of urine, either related to mechanical obstruction (e.g. urethral stricture, clot retention) or dynamic obstruction (e.g. increased α-adrenergic activity); (ii) bladder over-distension (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 as a result of decreased bladder fullness); and (iii) neuropathic causes (e.g. diabetic cystopathy) [6]. It was proposed that prostatic infarction might play a role in the occurrence of AUR [6], but there is evidence from recent reports that prostatic infarction is uncommon, with a prevalence closely similar in men undergoing prostate surgery for AUR or LUTS only [7 9]. Tuncel et al. [9] reported a higher incidence of prostatic inflammation in men with AUR (54.7%) than in those having LUTS only (28.9%). This corroborates recent findings that prostatic inflammation may be an important predictor of disease progression, especially the first occurrence of AUR [10]. In some cases, AUR appears consecutive to a triggering event (also called precipitated AUR), e.g a surgical procedure of any kind (in this case several factors such as pain, general or locoregional anaesthesia and immobility may have contributed to the occurrence of AUR), excessive fluid intake (especially alcohol, which acts as a sympathetic stimulator), UTI, or intake of medications with sympathomimetic or anticholinergic effects (Table 1). However, in the vast majority of cases, AUR appears simply related to the natural history of BPH (also called spontaneous AUR) [11,12]. The differentiation between spontaneous and precipitated AUR is clinically relevant, as both types of AUR differ in their outcomes. Hence, the risk of BPH-related surgery appears to be lower in case of precipitated AUR [13]. MANAGEMENT OF AUR There is a high variability within and among countries in the management of AUR in real-life practice, in terms of duration of catheterization, hospital admission, management after a failed trial without catheter (TWOC), emergency or delayed surgery [12,14,15]. This can be explained by differences in access to care but also by a lack of harmonization and consensus in the management of complications from BPH. SUPRAPUBIC VS URETHRAL CATHETERIZATION The initial management of AUR consists of immediate bladder decompression with urethral or suprapubic catheterization. In routine practice, most urologists prefer a urethral catheter. This was the case in a survey of 410 consultant urologists in the UK who were asked to complete a questionnaire into their management of AUR caused by BPH [15]. Of the 264 urologists who provided an answer, urethral catheterization was used most often (98% of cases), with suprapubic catheter only being used in failures. In another cross-sectional survey which included 2618 French men hospitalized for a first episode of AUR related to BPH, initial management consisted of urethral and suprapubic catheterization in 83% and 17%, respectively [12]. Complications may arise with either technique. In the French survey, suprapubic catheterization was associated with a higher incidence of haematuria, impossible catheterization and catheter obstruction, while urethral catheterization was associated with a higher rate of urine leak [12]. Surprisingly, suprapubic and transurethral catheterization shared the same risk of 16 JOURNAL COMPILATION 06 BJU INTERNATIONAL 97, SUPPLEMENT 2, 16

2 MANAGEMENT OF ACUTE URINARY RETENTION TABLE 1 Causes of AUR in 170 men with LUTS in Europe, Latin America, Middle-East, Asia, and Canada [14] FIG. 1. The percentage of patients hospitalized for a first episode of AUR in a real practice study conducted in Europe, Canada, Latin America, Middle-East and Asia (Alf-One). Analysis was limited to countries where patients had 10 episodes of AUR before enrolment in the study. Cause % BPH (spontaneous AUR) 64.8 Postoperative 13.1 Excessive fluid intake (alcohol) 12.5 Drugs 2.8 UTI 2.3 Urolithiasis 1.7 Acute medical condition 1.7 Post-traumatic 1.1 asymptomatic bacteriuria, lower UTI or urosepsis, which is not in agreement with previous reports [16]. Hence, Horgan et al. [16] reported that suprapubic catheterization was associated with less UTI (18% vs 40%, P < 0.05) and less urethral stricture throughout a 3-year follow-up (0% vs 17%, P < 0.01) than was urethral catheterization. Besides avoiding urethral and bladder neck damage, a suprapubic catheter also offers the advantage that the catheter can be spigoted rather than removed while undergoing a TWOC, which avoids re-catheterization in case of failure. HOSPITALIZE VS HOME WITH CATHETER After catheterization, patients may be hospitalized or sent home and reviewed in the outpatient clinic. Country-specific differences in the percentage of patients hospitalized for AUR were found in a real-life practice study conducted in various parts of the world [14]. Most men presenting with AUR were hospitalized in France (69%) and Russia (80%), where few were admitted to hospital in Mexico (22%), Denmark (25%) or the Netherlands (27%) (Fig. 1). In the recent UK survey on the management of AUR [15], most urologists (65.5%) preferred to admit their patients after catheterization, while a further 19.3% would admit only if renal function was impaired. Only a minority (9.1%) would send the patient home with a catheter. TWOC There is increasing evidence that immediate treatment by bladder decompression can effectively be followed by a TWOC, which involves removing the catheter after % of patients hospitalized for AUR % Mexico 35% Brazil 40% Argentina 25% Denmark 1 3 days, allowing the patient to void successfully in 23 40% of cases [12,17,18], and surgery, if needed, to be performed later. In the UK survey [15], 73.9% of men catheterized for AUR had a TWOC, usually after 2 days of catheterization, while only 2.9% had immediate surgery. With failure of TWOC, 68.7% were re-catheterized with delayed surgery, and 11.7% had a subsequent further TWOC later. In the French survey [12], TWOC was also standard, being used in 72.8% of cases after a median of 3 days catheterization, and this was especially the case for precipitated AUR vs spontaneous AUR (89.4% vs 66.2%, P < 0.001). Of those patients who did not have a TWOC, 17.9% had elective surgery after a median of 8 days catheterization (precipitated AUR 7.1%, spontaneous AUR 22.1%, P < 0.001) and 5.7% had immediate surgery (precipitated AUR 1.1%, spontaneous AUR 7.5%, P < 0.001). If the TWOC failed most men (57.5%) were re-catheterized and had elective surgery. However, interestingly, a third of urologists tried another TWOC later, which is over three times higher than in the UK [15]. Some factors influence the success of a TWOC; lower age (<65 years), high detrusor pressure (>35 cmh 2 O), a drained volume of <1 L at catheterization, an identified precipitating factor (e.g. postoperative AUR) and prolonged catheterization are usually associated with a greater success rate of TWOC [19]. Nevertheless, catheterization for >3 days is associated with a significantly higher comorbidity (haematuria, urosepsis, urinary leakage around the catheter) and 69% France 27% Netherlands 80% Russia double the rate of prolonged hospitalization than in men catheterized for 3 days [12]. α-blockers AND TWOC 47% Lebanon 47% Canada The rationale for the use of α 1 -blockers before a TWOC is based on the fact that AUR related to BPH may be consecutive to a sudden stimulation of α 1 -adrenergic receptors, as already suggested by Caine et al. in 1975 []. By decreasing the high sympathetic tone at the level of the urethra and bladder neck, α 1 - adrenergic blockers decrease bladder outlet resistance and may thus have a beneficial effect on AUR. This concept was validated shortly thereafter when the administration of i.v. phentolamine and/or oral phenoxybenzamine, an irreversible antagonist of both α 1 - and α 2 -adrenoceptors, was followed by a return to normal voiding with no need for catheterization in five of eight men with AUR [21]. However, the clinical use of phenoxybenzamine was limited by the high incidence and severity of its adverse events (mainly dizziness and hypotension), as well as evidence of carcinogenicity in rats. Subsequently, several pilot studies including few patients suggested that selective α 1 - adrenergic blockers administered orally before a TWOC might also facilitate the return to normal voiding, with fewer side-effects (Table 2) [21 26]. Currently, alfuzosin is the only α 1 -adrenergic blocker to have confirmed benefit in men undergoing a TWOC in an adequately powered placebo-controlled study [27]. Hence, in the large randomized, doubleblind, placebo-controlled Alfuzosin in Acute Urinary Retention (ALFAUR) study, which JOURNAL COMPILATION 06 BJU INTERNATIONAL 17

3 FITZPATRICK and KIRBY TABLE 2 Clinical studies assessing the effect of α 1 -adrenoceptor blockers on the outcome of a TWOC in men with AUR related to BPH Study α 1 -blocker N randomized patients Duration of treatment before catheter removal Successful voiding (%) α 1 -blocker Chan et al. [21] Terazosin 25 2 h <0.01 McNeill et al. [22] Alfuzosin 81 2 days Bowden et al. [23] Tamsulosin 49 2 days NS Shah et al. [24] Alfuzosin h NS Lucas et al. [25] Tamsulosin days NS McNeill [26] Alfuzosin days NS, not significant. P enrolled 360 patients with a first episode of AUR related to BPH, alfuzosin 10 mg once daily significantly increased the rate of success of a TWOC, compared with placebo (62% vs 48% of patients, P = 0.012) [27]. Elderly patients ( 65 years) and patients with a bladder volume of 1 L at the time of AUR had a significantly greater risk of TWOC failure, with odds ratios (95% CI) of success over failure of ( ) and ( ), respectively. The multivariate analysis accounting for all these factors confirmed that alfuzosin almost doubled the likelihood of a successful TWOC, the odds ratios being 1.98 ( ; Fig. 2). The benefit of alfuzosin in facilitating a return to normal voiding was further confirmed in the French survey on the management of AUR [12]. Of the 1906 men who had a TWOC, 1505 (79%) received an α 1 -adrenergic blocker at the time of catheter removal (alfuzosin 76%, tamsulosin 6%, unspecified 18%). The TWOC success rate was significantly higher in those men receiving an α 1 -blocker (53.0% vs 39.6%, P < 0.001). BPH-RELATED SURGERY Patients (%) % Age p= % Alfuzosin 10 mg OD 65 year 36% p< % Alfuzosin 10 mg OD RetentionVolume 1000 ml FIG. 2. ALFAUR: Phase 1; results in patients with a high risk of TWOC failure. Adapted from McNeill et al. [27]. FIG. 3. ALFAUR: Phase 2; the need for BHP surgery within 6 months after a successful TWOC. Need for BPH surgery Alfuzosin 10 mg OD 61% (p=0.04) 52% (p=0.04) Time (months) 6 29% (ns) There is evidence from the National Prostatectomy Audit that urgent prostatic surgery after AUR is associated with greater morbidity and mortality than in men with elective prostatectomy for LUTS only [3]. This is in part due to a greater risk of intraoperative complications, with relative risks (RRs, 95% CI) of 1.8 ( ), bleeding requiring transfusion of 2.5 ( ), postoperative complications of 1.6 ( ) and hospital mortality within 30 days of 3.3 ( ). It is well known that bacterial colonization of a urinary catheter is significantly greater after 3 days of catheterization and can result in major morbid events such as fever and possible progression to bacteraemia/septicaemia [4,12]. Furthermore, there is a greater incidence of septicaemia in men with bacteriuria and undergoing surgery [28]. Thus treatment measures that can avoid urgent surgery or allow elective surgical intervention without the presence of a urinary catheter are important in managing AUR. A TWOC combined with α 1 -adrenergic blockade represents such a measure. This is further confirmed by the results of the second phase of the ALFAUR study [29], in which 165 patients with successful voiding were rerandomized to receive alfuzosin 10 mg once daily (82) or placebo (83) for 6 months. Within the 6-month follow-up 24.1% of the placebotreated patients and 17.1% of alfuzosintreated patients required BPH surgery, mainly for recurrent AUR. The need for BPH-related surgery was significantly less with alfuzosin 18 JOURNAL COMPILATION 06 BJU INTERNATIONAL

4 MANAGEMENT OF ACUTE URINARY RETENTION than with placebo during the first 3 months of treatment, although the difference was no longer significant at 6 months (Fig. 3). Several possible comments are possible based on these results. First, the need for surgery after a successful TWOC is much lower in ALFAUR (one out of 4 men in the placebo arm) than was previously thought to be the case, with a recurrence of AUR in 50 70% of men within the first week and with >90% of men requiring surgery in the long term [18,30,31]. Second, the observation that most of the patients who required surgery after a successful TWOC had also an AUR relapse, emphasizes the need for a careful assessment of risk factors of unfavourable outcome soon after a successful TWOC. Two of these have been clearly identified in a multivariate analysis of the ALFAUR study: a high postvoid residual urine volume after the TWOC and a high PSA level [29]. The results of the Alf-One study also suggest that lack of symptomatic improvement with alfuzosin in the follow-up of a first AUR episode managed conservatively is also a strong predictor of AUR relapse and need for BPH surgery [unpublished data]. Interestingly, these risk factors also predict the occurrence of AUR and BPH-related surgery in men with symptomatic BPH [32 34]. Prostatectomy may thus be considered at an early stage in those men who have a high risk of surgery. CONCLUSIONS There is high variability within and among countries in the management of AUR in routine practice, which can be explained by a lack of harmonization in the management of BPH complications. The immediate treatment is bladder decompression using urethral or suprapubic catheterization, which is often followed by hospitalization. Until recently, secondary management consisted exclusively of BPH surgery, within a few days after AUR (emergency), or within a few weeks (elective), the patient returning home with a catheter in the interval. There is evidence that urgent prostatic surgery after AUR is associated with greater morbidity and mortality than delayed prostatectomy, and the potential morbidity usually associated with prolonged catheterization has led to the increasing use of TWOC in the last few years. The ALFAUR study showed that a significant percentage of patients presenting with AUR do not have surgery, justifying the use of TWOC. Alfuzosin 10 mg once daily facilitated catheter removal and therefore allows surgery, if needed, to be elective. That study also showed that PSA level and the postvoid residual volume may be considered as risk factors for recurrence of AUR, and need to be considered as potential indicators of surgery after a successful TWOC. Moreover, the Alf- One study showed that the response to alfuzosin treatment is also an important predictor of AUR and BPH-related surgery. These factors may help to select patients at risk of AUR relapse and surgery, to optimize their management. CONFLICT OF INTEREST John M. Fitzpatrick has received a fee for speaking at a symposium from Sanofi Aventis. REFERENCES 1 Emberton M, Anson K. Acute urinary retention in men: an age old problem. BMJ 1999; 318: Jacobsen SJ, Jacobson DJ, Girman CJ et al. Natural history of prostatism: risk factors for acute urinary retention. J Urol 1997; 158: Pickard R, Emberton M, Neal DE. The management of men with acute urinary retention. National Prostatectomy Audit Steering Group. Br J Urol 1998; 81: Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. 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