Management of acute urinary retention secondary to benign prostatic hyperplasia in the UK: a national survey

Transcription

1 Original Article MANAGEMENT OF AUR IN THE UK R. MANIKANDAN Management of acute urinary retention secondary to benign prostatic hyperplasia in the UK: a national survey R. MANIKANDAN, S.J. SRIRANGAM, P.H. O REILLY and G.N. COLLINS Stepping Hill Hospital, Urology, Stockport, Cheshire, UK Accepted for publication 5 August 2003 OBJECTIVE To analyse current practice in the management of acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH) in the UK, and to assess how much of this is evidence-based. METHODS In all, 410 consultant urologists practising in UK hospitals were sent a questionnaire about the management of AUR secondary to BPH. Data were collected on practice relating to initial management, trial without catheter (TWOC), the use of a-blockers and the followup. The need for a uniform guideline in the management of AUR secondary to BPH was also assessed. RESULTS We received 270 (66%) replies, of which six were excluded because they were from subspeciality interests (e.g. paediatric urology) or had ambiguous answers; 264 (64%) were therefore available for analysis. Urethral catheterization was the initial management of choice (98%), failing which a suprapubic catheter was inserted. Two-thirds (65.5%) admitted the patient after catheterization. Most consultants initiated a-blockers (70.5%), with 64% (118) of these using a TWOC 2 days after starting them. One failed TWOC was an indication for transurethral resection of the prostate for 192 (72.8%), with 136 (49.8%) re-admitting the patient for surgery later. Routine follow-up after a successful TWOC was advocated by 77.3%. Just over half the respondents (52.6%) felt that there was no need for uniform guidelines in the management of AUR secondary to BPH. CONCLUSION This survey identified a reasonable national uniformity in managing AUR secondary to BPH in the UK, but significant aspects of current practice are not evidence-based. KEYWORDS acute urinary retention, management, a-blocker, trial without catheter, BPH, surgery INTRODUCTION Acute urinary retention (AUR) remains the most common urological emergency and is usually caused by BPH [1]. We sought to assess the current practice in the management of AUR secondary to BPH in the UK, and to what degree this was evidence-based. METHODS Within the UK, 410 consultant urologists were sent a questionnaire about the management of AUR specifically secondary to BPH. We received 270 (65.9%) responses, of which six were excluded from the analysis because of their speciality interests (paediatric urology) or ambiguity in the answers. The remaining 264 were evaluated. RESULTS Most urologists preferred urethral catheterization as the initial management, failing which a suprapubic catheter was inserted (98%). Apart from routine blood investigations, ultrasonography (26.5%), a plain film of the abdomen (15.5%) and PSA assay (24.6%) were part of the routine assessment by some. Nearly 71% (186) started their patients on a-blockers, with 64% (118) using a trial without catheter (TWOC) 2 days after starting them; 39% (103) used a TWOC only if the residual urine volume was <1 L at the time of initial catheterization, and 77% followed patients who had had a successful TWOC. One failed TWOC was an indication for TURP for 72.8% (192) of the respondents, with 49.8% (136/233) undertaking TURP at a separate admission. A second TWOC was advocated by 31 (11.7%) and the duration of catheterization was between 2 days and 6 weeks. Of the respondents, 139 (52.6%) felt that there was no need for any uniform guidelines for managing AUR secondary to BPH. The results are summarized in Table 1. DISCUSSION AUR is characterized by a sudden inability to void that is usually but not always painful. In a community-based study from Minnesota, men aged years had a 10% chance of developing AUR in the subsequent 5 years [2]. The exact cause of AUR remains poorly understood. Some of the suggested causes are prostate infection, bladder overdistension, excessive fluid intake, alcohol consumption, a-adrenergic overactivity, sexual activity and prostatic infarction [3 6]. Risk factors include age, moderate to mild symptoms, a urinary flow rate of <12 ml/s, a prostate volume of >30 ml (on TRUS) and an increasing serum PSA level [2,7,8]. AUR can be classified as precipitated (e.g. resulting from surgery to other than the prostate, anaesthesia or medications) or spontaneous. This has implications for managing these patients, as those with spontaneous AUR may be more likely to require surgical intervention than the precipitated group [9]. Previously AUR was considered to be an absolute indication for prostatectomy [10]; since the advent of a-blockers this concept has changed. AUR results in 25 32% of men undergoing prostatectomy [11 13]. Some urologists consider the presence of previous LUTS before AUR to be a relative indication for TURP [14] BJU INTERNATIONAL 93, doi: /j x x

2 MANAGEMENT OF AUR IN THE UK Subject n (%) Initial management Urethral catheterization 260 (98) SPC 2 (1) In-and-out catheter 2 (1) After catheterization Admit patients 173 (65.5) Admit patients only if renal function deranged 51 (19.3) Send home with catheter 24 (9.1) No response or multiple answers 16 (6.1) a-blockers 186 (70.5) Finasteride only 0 Combined 6 (2.3) No medical therapy 50 (18.9) No response or multiple answers 22 (8.3) Preferred a-blocker (214 respondents) Tamsulosin 120 (56) Alfuzosin 76 (35.5) Doxazosin 4 (1.9) Indoramin 5 (2.3) No response 9 (4.2) TWOC Yes 195 (73.9) Evaluate for surgery 7 (2.7) No response 10 (3.8) Variable 52 (19.7) Days of TWOC after catheterization (Overall) 1 7 (2.7) (48.5) (14.5) 7 20 (7.8) (10.2) No response 30 (11.4) Variable 14 (5.3) If TWOC fails Try another TWOC later 31 (11.7) Re-catheterize and evaluate for TURP 181 (68.6) Surgery/self-catheterization in the interim 11 (4.2) No response 12 (4.5) Variable 29 (11) Follow-up Patients with a successful TWOC: Urodynamics 20 (8.7) Flow rate and postvoid scan 231 (88) Only postvoid scan 14 (5.3) Follow-up? Yes 204 (77.3) No 9 (3.4) Only if patients experience LUTS 39 (14.8) No response 12 (4.5) Failed TWOC - TURP same admission? (233 responses) Yes 32 (13.7) No 116 (49.8) Depends on theatre availability 78 (33.5) Variable or no response 7 (3) TABLE 1 The management of AUR secondary to BPH, before catheterization, afterward and during the follow-up For the initial management, urethral catheterization remains the standard treatment for AUR from any cause, as reflected in the survey (98%). Suprapubic catheterization (SPC) is used when this fails, but SPC has the advantages that the incidence of UTI and urethral stricture are less [15 17]. Also patients requiring a TWOC can have their catheter spigoted, and hence those failing to void do not need to be recatheterized, thus reducing further trauma. Complications of SPC including bowel perforation and dislodgement, which although infrequent must be considered [16,18]. Other factors in favour of SPC include comfort, easier management and costeffectiveness [15,16]. These have to be balanced against the fact that most patients presenting with AUR present to the Accident and Emergency department, where personnel may not be trained in SPC. This may have to be addressed if SPC is to become the initial management in AUR. After the initial management patients are either admitted, or sent home and reviewed in the outpatient clinic. In the present survey 65.5% of the respondents admitted their patients and 19.3% would admit patients only if renal factors were deranged. Evidence suggests that it is safe to send patients presenting with AUR home after catheterization and have them return later for a TURP [14]. However, this group of patients sent home are more likely to require antibiotics, perhaps explained by the longer duration of catheterization than in patients undergoing TURP during the same admission [14]. The other issue of using valuable bedspace needs to be considered. In another study, only a minority (11%) with AUR sent home immediately after catheterization found the catheter very inconvenient during their daily activities [19]. Intermittent selfcatheterization is another alternative to catheterization. This may be difficult in the emergency setting but can be used in those patients who fail a TWOC during their wait to undergo surgery, and it has been shown to be advantageous in reducing the incidence of UTI [20]. The TWOC has become standard practice in most hospitals for men in AUR with normal renal values. Only 11 of 60 patients who were followed for 6 months avoided surgery after a successful TWOC [21]. Increasing the period of drainage of the bladder before a TWOC improves the chances of success (44%, 51% 2004 BJU INTERNATIONAL 85

3 R. MANIKANDAN ET AL. and 62% success at day 0, 2 and 7, respectively) [22]. Patients with precipitated AUR have a higher chance of successful TWOC than those who had spontaneous AUR [23]. Factors associated with an unsuccessful TWOC are age >75 years, a residual drained urine volume of >1 L and a detrusor contraction of <35 cmh 2 O [24]. With the advent of a-blockers more men are having a TWOC after using an a-blocker [25 27]. The choice of a particular type of a- blocker depends on the clinicians preference; nearly 71% (186) in the present survey started their patients with AUR on a-blockers. In the study of McNeill et al. [27], 81 patients were randomized to receive either a placebo or alfuzosin, and the success rates for a TWOC were 29% (12/41) and 55% (22/40), respectively. Of those who had a successful TWOC, 32% (11/34) had a further episode of AUR at a mean of 4.1 months, although the authors failed to say what percentage of these were from the alfuzosin group. However, they suggested that patients who had subsequent AUR were those who had larger postvoid residual volumes after their successful TWOC. Whether a-blockers are successful in preventing a further episode of AUR is doubtful [25]. The follow-up is short and there are few patients in studies assessing this, and long-term studies are needed with a larger group of patients. Most (77.3%) of the respondents in the survey followed patients who had a successful TWOC; this is advisable, given that 77 85% of patients with AUR will require surgical intervention within 1 2 years after presentation [28,29]. Surgical intervention is generally considered to be the endpoint for AUR; TURP remains the reference standard for BPH. One failed TWOC was an indication for TURP according to 72.8% of the urologists surveyed. Prostatectomy undertaken in men with moderate to severe symptoms substantially reduced the risk of AUR over the subsequent 5 years [30]. The complications and risk of death at 30 days (relative risk 26.6) and 90 days (relative risk 4.4) after TURP for AUR are higher than in those who have TURP electively. The present study could not confirm that a short period of catheter drainage at home before TURP would be advantageous [14]. This survey shows that there is reasonable uniformity in the management of AUR secondary to BPH in the UK. Some areas in the management are evidence-based, including starting a-blockers and the follow-up of patients after a successful TWOC, whereas the need for admitting all patients with AUR, the route of catheterization, assessing PSA levels in AUR and the timing of a TWOC are not necessarily evidence-based. The opinions about the requirement for uniform guidelines for managing AUR secondary to BPH are divided. We propose that those patients in AUR with no significant comorbidity or deranged renal function are discharged home after catheterization, preferably by the suprapubic route. Assessing the PSA level should be avoided, a-blockers should be started and a TWOC undertaken at 1 week; as noted, the overall management must be individualized for the patient. ACKNOWLEDGEMENTS The authors thank Mrs B. Ash for helping us conduct this study. REFERENCES 1 Murray K, Massey A, Feneley RCL. Acute urinary retention-a urodynamic assessment. Br J Urol 1984; 56: Jacobsen SJ, Jacobson DJ, Girman CJ et al. Natural history of prostatism. Risk factors for acute urinary retention. J Urol 1997; 158: Caine M, Perlberg S. Dynamics of acute retention in prostatic patients and the role of adrenergic receptors. Urology 1977; 9: Spiro LH, Labay G, Orkin LA. Prostatic infarction. Role in acute urinary retention. Urology 1974; 3: Powell PH, Smith PJB, Feneley RCL. The identification of patients at risk from acute urinary retention. Br J Urol 1980; 52: Anjum I, Ahmed M, Azzopardi A, Mufti GR. Prostatic infarction/inflammation in acute urinary retention secondary to benign prostatic hyperplasia. J Urol 1998; 160: Kumar V, Marr C, Bhuvangiri A, Irwin P. A prospective study of conservatively managed acute urinary retention: prostate size matters. BJU Int 2000; 86: Meigs JB, Barry MJ, Gionvanucci E et al. Incidence rates and risk factors for acute urinary retention. The health professionals follow-up study. J Urol 1999; 162: Roehrborn CG, McConnell JD. Etiology, pathophysiology, epidemiology and natural history of benign prostatic hyperplasia. In Walsh PC, Retik AB, Vaughan ED, Wein AJ eds. Campbell s Urology. Eighth Edition, 2. Chapt 38, Philadelphia: WB Saunders, 2002: Blandy JP. Benign enlargement of the prostate gland. In Blandy JP ed. Urology. Vol. 2 Chapter 33. Oxford: Blackwell Science, 1998: Lynch TH, Waymont B, Beacock CJM et al. Follow-up after transurethral resection of prostate: who needs it? Br Med J 1991; 302: Mebust WK, Holtgrewe HL, Cockett ATK, Peters PC &, the Writing Committee. Transurethral prostatectomy: immediate postoperative complications. A co-operative study of 13 participating institutions evaluating 3885 patients. J Urol 1989; 141: Roehrborn CG, Boyle P, Bergner D et al. Serum prostate specific antigen and prostate volume predict long-term changes in symptoms and flow rate- Results of a four year, randomized trial comparing finasteride versus placebo. PLESS study group. Urology 1999; 54: Pickard R, Emberton M, Neal DE. The management of patients with acute urinary retention. Br J Urol 1998; 81: Ichsan J, Hunt DR. Suprapubic catheters. A comparison of suprapubic versus urethral catheters in the treatment of acute urinary retention. Aust NZ J Surg 1987; 57: Horgan AF, Prasad B, Waldron DJ, O Sullivan DC. Acute urinary retention. Comparison of suprapubic versus urethral catheterisation. Br J Urol 1992; 70: Abrams PH, Shah PJR, Gaches CGC, Green NA, Ashken MH. Role of suprapubic catheterization in the retention of urine. J Royal Soc Med 1980; 73: Cundiff G, Bent AE. Suprapubic catheterization complicated by bowel perforation. Int Urogynecol J Pelvic Floor Dysfunct 1995; 6: Khoubehi B, Watkin NA, Mee AD, Ogden CW. Morbidity and the impact on BJU INTERNATIONAL

4 MANAGEMENT OF AUR IN THE UK daily activities associated with catheter drainage after acute urinary retention. BJU Int 2000; 85: Patel MI, Watts W, Grant A. The optimal form of urinary drainage after acute urinary retention. BJU Int 2001; 88: Taube M, Gajraj H. Trial without catheter following acute retention of urine. Br J Urol 1989; 63: Djavan B, Shariat S, Omar M et al. Does prolonged catheter drainage improve the chance of recovering voluntary voiding after acute urinary retention of urine (AUR)? Eur Urol 1998; 33: Hastie KJ, Dickinson AJ, Ahmad R, Moisey CU. Acute retention of urine: is trial without catheter justified? J Roy Coll Surg Edinb 1990; 35: Djavan B, Madersbacher S, Klinger C, Marberger M. Urodynamic assessment of patients with acute urinary retention: is treatment failure after prostatectomy predictable. J Urol 1997; 158: Shah T, Palit V, Biyani S, Elmasry Y, Puri R, Flannigan G. Randomised, placebo controlled, double blind study of alfuzosin SR in patients undergoing trial without catheter following acute urinary retention. Eur Urol 2002; 42: Kim HL, Kim JC, Benson DA, Bales GT, Gerber GS. Results of treatment with tamsulosin in men with acute urinary retention. Tech Urol 2001; 7: McNeill SA, Daruwala PD, Mitchell IDC, Shearer MG, Hargreave TB. Sustainedrelease alfuzosin and trial without catheter after acute urinary retention: a prospective placebo controlled trial. BJU Int 1999; 84: McNeill SA. Does acute urinary retention respond to alpha-blockers alone? Eur Urol 2001; 39 (Suppl. 6): Klarskov P, Andersen JT, Asmussen CF et al. Symptoms an signs predictive of the voiding pattern after acute urinary retention in men. Scand J Urol Nephrol 1987; 21: Flanigan RC, Reda DJ, Wasson JH et al. 5-Year outcome of surgical resection and watchful waiting for men with moderately symptomatic benign prostatic hyperplasia: a department of veterans affairs cooperative study. J Urol 1998; 160: 12 7 Correspondence: R. Manikandan, Stepping Hill Hospital, Urology, Stockport, Cheshire, UK. armanikan@aol.com Abbreviations: AUR, acute urinary retention; TWOC, trial without catheter; SPC, suprapubic catheterization. APPENDIX The management of AUR (secondary to BPH) (Please tick the appropriate box) (1) Initial management of AUR a) Urethral catheterization b) Supra pubic catheterization c) Suprapubic catheterization if urethral catheterization fails d) In and out catheter (2) Post-catheterization management. Do you: a) admit the patient b) admit patient only if U&Es and serum creatinine raised c) catheterize and send patient home and bring for TWOC later. (3) Medical therapy. Do you: a) start patient on a-blockers b) start patient on finasteride c) start patient on a combination of a- blockers and finasteride d) No medical therapy started (4) Preferred a-blocker a) Phenoxybenzamine b) Indoramin c) Terazosin d) Doxazosin e) Alfuzosin f) Tamsulosin g) No particular preference (5) Do you start antibiotics in patients presenting with AUR? a) Yes - routinely b) Only if UTI suspected c) Single-shot antibiotic only before catheterization d) No (6) Initial investigations at presentation (apart from routine bloods, FBC & U&E) a) Ultrasonography. Yes/No b) X-ray KUBU Yes/No c) PSA Yes/No d) Any other investigations - please specify (7) For the TWOC. Do you: a) do a TWOC in all patients? (if yes please answer 8a) b) a TWOC only if urinary residual <1 L? c) a TWOC after giving an a-blocker? (if yes please answer 8b) d) evaluate the patient for surgical treatment? (TURP) e) other - please specify (8a) If only a TWOC is preferred, how many days after catheterization would you advise TWOC? a g) 1 7 or h) Other (please specify) (b) If you use a TWOC with an a-blocker, how many days after catheterization would you advise TWOC? a g) 1 7 or h) Other (please specify) (9) If the TWOC fails, would you? a) try another TWOC after () days/weeks b) re-catheterize and evaluate for surgery (TURP) c) evaluate for surgery and clean intermittent self-catheterization in the meantime. d) advice clean intermittent selfcatheterization with medical therapy and review later. e) other (please specify) (10) Do you investigate patients who have had a successful TWOC further with urodynamics? a) Yes b) No (11) Do you investigate patients who have had a successful TWOC with a flow rate or postvoid scan? a) Yes, both flow rate and postvoid scan b) Only flow rate c) Only postvoid scan d) No (12) When patients have a TWOC, what percentage would you expect to be successful? a) 10% b) 20% c) 30% d) 40% e) 50% f) Other (please specify) 2004 BJU INTERNATIONAL 87

5 R. MANIKANDAN ET AL. (13) Do you follow-up patients who have had a successful TWOC? a) Yes routinely. b) No. c) Only if patients have further LUTS. (14) If patients are offered TURP after a failed TWOC, is it done during the same admission? a) Yes. b) No - patient sent home and TURP at a separate admission. c) Depends on theatre availability. (15) Do you think that there should be a uniform guideline in the management of AUR (apart from special cases, e.g. associated constipation)? a) Yes b) No Thank you very much for your valuable time and help BJU INTERNATIONAL