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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

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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

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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

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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)

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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

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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)

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SPONTANEOUS AUR
• BPH
• With acute change
• Catheter
• Is it an acute increased in alpha
sympathomimetic activity?
ALFUSOZIN TRIAL
UROL 2005; 65: 83

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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

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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

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MTOPS
NEJM 2003; 349: 2387-98
CLINICAL PROGRESSION

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AUR MTOPS
YEAR 4

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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

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DUTASTERIDE BASELINE
DUTASTERIDE

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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

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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