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Sun 0945-acute-urinary-retention- -park

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  • 1. 5/23/2014 1 ACUTE URINARY RETENTION Joel Teichman MD FRCSC Professor, Dept. Urologic Sciences UBC St. Paul’s Hospital FAX 604-806-8666 jteichman@providencehealth.bc.ca Faculty/Presenter Disclosure • Faculty: Joel Teichman MD FRCSC • Relationships with commercial interests: – Grants/Research Support: Cook Urological – Speakers Bureau/Honoraria: Ortho Women’s and Health – Consulting Fees: Boston Scientific CFPC CoI Templates: Slide 1
  • 2. 5/23/2014 2 Disclosure of Commercial Support • This program has received no financial support • This program has received no in-kind support • Potential for conflict(s) of interest: – None CFPC CoI Templates: Slide 2 Mitigating Potential Bias • Not applicable. CFPC CoI Templates: Slide 3
  • 3. 5/23/2014 3 OBJECTIVES • List 3 medications that can precipitate AUR • Describe how MS can cause AUR • Describe how alpha-blockers and 5AR reduce AUR • List two indications for Urology referral INTRODUCTION • AUR most significant complication of BPH • AUR accounts for 25-30% of indications for TURP • AUR is poorly defined • Multiple etiologies
  • 4. 5/23/2014 4 CLASSIFICATION • Spontaneous AUR – Due to the bladder • Bladder decompensation, neurogenic – Due to the bladder outlet • infarction, BPH, acute bacterial prostatitis, stricture • Precipitated AUR – Due to the bladder • Anesthesia, anticholinergics, pain – Due to the bladder outlet • Sympathomimetics, catheterization TAKE-HOME POINT • AUR is usually a combination of static (BPH) and dynamic (acute change)
  • 5. 5/23/2014 5 WHO IS AT RISK? • Older males (BPH) • Middle aged females (MS) • Others (older males with a URI, or surgery) EPIDEMIOLOGY Eur Urol 2005; 47: 494 • Increases with age • Large prostate • Increased PSA • LUTS • Low Qmax
  • 6. 5/23/2014 6 AUR DEFINITION • Inability to urinate • Increased residual volume – > 300 cc – Associated with clinical problems (pain, hematuria, UTI, renal compromise, bothersome LUTS) PRECIPITATED AUR • 40% of cases • What has suddenly changed? • Drugs (antimuscarinics, antipsychotics, narcotics, alpha sympathomimetics) • Acute change (pelvic surgery, diuresis) • Neurologic event (SCI, CVA, multiple sclerosis)
  • 7. 5/23/2014 7 SPONTANEOUS AUR • BPH • With acute change • Catheter • Is it an acute increased in alpha sympathomimetic activity? ALFUSOZIN TRIAL UROL 2005; 65: 83
  • 8. 5/23/2014 8 MTOPS NEJM 2003; 349: 2387-98 • N=3047 subjects • Mean followup 4.5 years • Double-blind, RCT • Placebo, doxazosin, finasteride, combination • > 50 years • AUASS 8-30 • Qmax 4-15 cc/sec • Exclusions: prior surgery, SBP<90, PSA>10 MTOPS NEJM 2003; 349: 2387-98 • Primary: clinical progression – AUASS 4 points – AUR – Renal insufficiency – Recurrent UTI – incontinence • Secondary: AUASS, Qmax, PSA, surgery
  • 9. 5/23/2014 9 MTOPS NEJM 2003; 349: 2387-98 MTOPS NEJM 2003; 349: 2387-98 0 10 20 30 40 50 60 70 80 90 Age White PVR Placebo Doxazosin Proscar Combo
  • 10. 5/23/2014 10 MTOPS NEJM 2003; 349: 2387-98 CLINICAL PROGRESSION
  • 11. 5/23/2014 11 AUR MTOPS YEAR 4
  • 12. 5/23/2014 12 DUTASTERIDE BMJ 2013; 346: 2109 • 1617 subjects • Placebo vs dutasteride • 4 years • Clinical progression (4 pt, AUR, UTI, surgery) TAKE HOME POINT Eur Urol 2006; supp 5: 628 • Size matters! • AUR more likely for large prostate • AUR risk increases as age and size increase • Highest risk for men with large prostates • 81% risk reduction of AUR combo, 68% risk reduction finasteride alone
  • 13. 5/23/2014 13 DUTASTERIDE BASELINE DUTASTERIDE
  • 14. 5/23/2014 14 REDUCE NEJM 2010; 362: 1192 • N=6729, 4 years, 50-75, biopsy negative • RCT double blind • Prostate cancer incidence reduced 23% • AUR incidence reduced 77% • Gleason 8-10 controversy TAKE HOME • AUR risk reduction 80% on dutasteride • Benefits continue for up to 4 years
  • 15. 5/23/2014 15 WATCH OUT FOR… • MS variable presentation • 10% of women with MS present with acute voiding dysfunction • 10-30% of MS patients present with AUR or impaired bladder emptying • Prostate cancer • Bladder CIS • Hematuria and unresolved AUR warrant Urology referral! STRATEGY AUR Catheter Reduce precipitants Alpha blockers Successful voiding Alpha-blockers 5AR No neurologic BPH TURP Neurologic Confounding Urodynamics