Benign Prostatic Hyperplasia 2: The Case of Mr. Presley's Urinary Retention
Mr. Presley presents to the emergency department in urinary retention. You are expected to direct the evaluation, education, and management of this patient.
LEARNING OBJECTIVES for The Case of Mr. Presley's Urinary Retention
Describe the natural history of BPH
List the risk factors for acute urinary retention in a patient with BPH
List the important components of the history and physical examination when evaluating a patient with BPH
List the indications for treatment of BPH
Describe when a patient with BPH should be referred to a urologist
Mr. Presley Presents to the Emergency Department - 1
The screams of "treat me nice" could be heard all over the Emergency Department as a 68-year old brown-eyed handsome man was led to a room. He was gyrating his hips in the most unusual and offensive manner as he yells "I want to pee free." The doctor approaches the room to find out what all the fuss is about. "There is a whole lot of shaking going on," says Mr. Presley, "but I still have not been able to urinate for the last 18 hours." He reported that his urinary flow has not been good for years, but about 24 hours ago, his stream was reduced to a dribble, causing his suede shoes to be ruined. For the last 18 hours, though, he has not been able to urinate at all and a strong pain has developed in his lower abdomen. Mr. Presley's past medical history is notable for previous diagnoses of BPH, alcoholic hepatitis, and lumbar strain. He denies taking any medication or using any recreational drugs. Physical examination reveals normal genitalia, a prostate which is 4 cm in breadth, smooth and non-tender with no nodules, and a distended bladder which is palpable half-way up to the umbilicus What are possible factors which might trigger urinary retention in a male? (please check all appropriate answers)
a. prostatitis b. intravenous narcotics c. diphenhydramine (Benadryl) d. ranitidine (Zantac) e. pseudoephedrine (Sudafed) f. oxybutynin (Ditropan) g. drinking binge
Mr. Presley Presents to the Emergency Department - 2
While two nurses attempt to stop his pelvis from moving, the doctor inserts a Foley catheter amid rants of "don't be cruel." His bladder is drained of 700cc of clear yellow urine, much to Mr. Presley's relief. "Thank you very much," he exclaims. His creatinine level is measured at 1.4 mg/dl. What is the most appropriate next step in his treatment? (please select the best single answer)
a. Start an alpha-blocker and refer to a urologist to give a voiding trial in 3-7 days b. Refer to a urologist for scheduling of a TURP c. Place a supra-pubic tube d. Start finasteride and refer to a urologist to give a voiding trial in 3-7 days
Mr. Presley Follows-up with the Urologist
Mr. Presley follows up with the urologist 7 days later. She instills sterile saline into his bladder through the catheter, and once he feels the need to urinate, she removes the catheter. Mr. Presley is able to successfully empty 90% of the instilled volume. His urologist is pleased that he has passed the voiding trial, recommends that he continue the alpha-blocker therapy, warns him against potential triggers to urinary retention and sets up an appointment for return visit to her clinic in two months. She lets him know that if he goes into urinary retention again, he may need to undergo a procedure to reduce the obstruction from benign prostatic hyperplasia.
Mr. Presley responds that he will keep her instructions always on his mind, says "thank you very much," and leaves the building...smiling.
Take-Home Messages from the The Case of Mr. Presley's Urinary Retention
Multiple factors can precipitate acute urinary retention, including infection, sympathomimetics, anti-cholinergics, alcohol and narcotics.
Acute urinary retention should be treated immediately with catheter decompression. If this is the first episode of retention, use of an alpha-blocker followed by a voiding trial in 3-7 days may enable up to 50% of men to avoid surgery for obstructive BPH.
All patients in urinary retention should be referred to a urologist for follow-up.
Checking serum creatinine in patients with urinary retention is important in order to rule-out serious obstructive uropathy.
Recurrent urinary retention is an indication for a surgical procedure such as a TURP to remove the obstructive benign prostatic hyperplasia.