An Evidence-Based Approach January 2014

Volume 16, Number 1

To Emergency Department Authors

John R. Marshall, MD

Management Of
Department of Emergency Medicine, Lincoln Medical and Mental
Health Center, Bronx, NY
Jordana Haber, MD

Acute Urinary Retention Department of Emergency Medicine, Maimonides Medical Center,

Brooklyn, NY
Elaine B. Josephson, MD, FACEP
Assistant Professor of Emergency Medicine in Clinical Medicine,
Abstract Weill Cornell Medical College of Cornell University, New York, NY;
Emergency Medicine Residency Program Director, Lincoln Medical
and Mental Health Center, Bronx, NY
Approximately 10% of men in their 70s and 33% of men in their 80s
Peer Reviewers
report at least 1 episode of acute urinary retention, and this urologi-
cal emergency presents unique assessment and treatment challenges William J. Brady, MD
Professor of Emergency Medicine and Medicine, Chair, Medical
in the emergency department setting. Patients presenting with Emergency Response Committee, Medical Director, Emergency
acute urinary retention are often in severe pain and require urgent Management, University of Virginia Medical Center, Charlottesville, VA
diagnosis and prompt treatment. The differential diagnosis of acute Joseph D. Toscano, MD
urinary retention is vast, with some causes leading to permanent Chairman, Department of Emergency Medicine, San Ramon Regional
Medical Center, San Ramon, CA
impairment if not dealt with in a timely manner. Quick recogni-
CME Objectives
tion of the cause and timely bladder decompression are of utmost
importance in preventing morbidity and relieving pain. This review Upon completion of this article, you should be able to:
1. Describe the pathophysiology and complications of AUR.
analyzes the etiology, key historical and physical findings, differen-
2. Distinguish key physical examination findings, including red flags,
tial diagnosis, and diagnostic studies for acute urinary retention in that may help identify patients with AUR.
both men and women. Treatment algorithms for men and women, 3. Interpret the treatment algorithms for AUR in men and women.
current controversies regarding urinary catheter usage, and recom- Prior to beginning this activity, see “Physician CME Information” on the
mendations on criteria for disposition are also presented. back page.

Editor-In-Chief
Andy Jagoda, MD, FACEP
Professor and Chair, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, Medical
Director, Mount Sinai Hospital, New
York, NY
Associate Editor-In-Chief
Kaushal Shah, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
Editorial Board
William J. Brady, MD
Professor of Emergency Medicine
and Medicine, Chair, Medical
Emergency Response Committee,
Medical Director, Emergency
Management, University of Virginia
Medical Center, Charlottesville, VA
Peter DeBlieux, MD Medicine, George Washington
Professor of Clinical Medicine,
Interim Public Hospital Director
of Emergency Medicine Services,
Louisiana State University Health
Science Center, New Orleans, LA
Francis M. Fesmire, MD, FACEP
Professor and Director of Clinical
Research, Department of Emergency Eric Legome, MD
Medicine, UT College of Medicine,
Chattanooga; Director of Chest Pain
Center, Erlanger Medical Center,
Chattanooga, TN
Nicholas Genes, MD, PhD
Assistant Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Carolinas
Medical Center, University of North
Carolina School of Medicine, Chapel
Hill, NC
Steven A. Godwin, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Assistant
Dean, Simulation Education,
University of Florida COM-
Jacksonville, Jacksonville, FL
Gregory L. Henry, MD, FACEP
Clinical Professor, Department of
Emergency Medicine, University
of Michigan Medical School; CEO,
Medical Practice Risk Assessment,
Inc., Ann Arbor, MI
John M. Howell, MD, FACEP
Clinical Professor of Emergency
University, Washington, DC; Director
of Academic Affairs, Best Practices,
Inc, Inova Fairfax Hospital, Falls
Church, VA
Shkelzen Hoxhaj, MD, MPH, MBA
Chief of Emergency Medicine, Baylor
College of Medicine, Houston, TX
Chief of Emergency Medicine,
King’s County Hospital; Professor of
Clinical Emergency Medicine, SUNY
Downstate College of Medicine,
Brooklyn, NY
Keith A. Marill, MD
Assistant Professor, Harvard Medical
School; Emergency Department
Attending Physician, Massachusetts
General Hospital, Boston, MA
Charles V. Pollack, Jr., MA, MD,
FACEP
Professor and Chair, Department of
Emergency Medicine, Pennsylvania
Hospital, Perelman School of
Medicine, University of Pennsylvania,
Philadelphia, PA
Michael S. Radeos, MD, MPH
Assistant Professor of Emergency
Medicine, Weill Medical College
of Cornell University, New York;
Research Director, Department of
Emergency Medicine, New York
Hospital Queens, Flushing, NY
Ali S. Raja, MD, MBA, MPH
Director of Network Operations and
Business Development, Department Ron M. Walls, MD
of Emergency Medicine, Brigham
and Women’s Hospital; Assistant
Professor, Harvard Medical School,
Boston, MA
Robert L. Rogers, MD, FACEP,
FAAEM, FACP
Assistant Professor of Emergency
Medicine, The University of
Maryland School of Medicine,
Baltimore, MD
Alfred Sacchetti, MD, FACEP
Assistant Clinical Professor,
Department of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA
Robert Schiller, MD
Chair, Department of Family
Medicine, Beth Israel Medical
Center; Senior Faculty, Family
Medicine and Community Health,
Icahn School of Medicine at Mount
Sinai, New York, NY
Scott Silvers, MD, FACEP
Chair, Department of Emergency
Medicine, Mayo Clinic, Jacksonville, FL
Corey M. Slovis, MD, FACP, FACEP
Professor and Chair, Department
of Emergency Medicine, Vanderbilt
University Medical Center; Medical
Director, Nashville Fire Department and
International Airport, Nashville, TN
Stephen H. Thomas, MD, MPH
George Kaiser Family Foundation
Professor & Chair, Department of
Emergency Medicine, University of
Oklahoma School of Community
Medicine, Tulsa, OK
Professor and Chair, Department of
Emergency Medicine, Brigham and
Women’s Hospital, Harvard Medical
School, Boston, MA
Scott D. Weingart, MD, FCCM
Associate Professor of Emergency
Medicine, Director, Division of
ED Critical Care, Icahn School of
Medicine at Mount Sinai, New Attending Physician, Emergency
York, NY
Senior Research Editors
James Damilini, PharmD, BCPS
Clinical Pharmacist, Emergency
Room, St. Joseph’s Hospital and
Medical Center, Phoenix, AZ
Joseph D. Toscano, MD
Chairman, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon, CA
Research Editor
Michael Guthrie, MD
Emergency Medicine Residency,
Icahn School of Medicine at Mount
Sinai, New York, NY
International Editors
Peter Cameron, MD
Academic Director, The Alfred
Emergency and Trauma Centre,
Monash University, Melbourne,
Australia
Giorgio Carbone, MD
Chief, Department of Emergency
Medicine Ospedale Gradenigo,
Torino, Italy
Amin Antoine Kazzi, MD, FAAEM
Associate Professor and Vice Chair,
Department of Emergency Medicine,
University of California, Irvine;
American University, Beirut, Lebanon
Hugo Peralta, MD
Chair of Emergency Services,
Hospital Italiano, Buenos Aires,
Argentina
Dhanadol Rojanasarntikul, MD
Medicine, King Chulalongkorn
Memorial Hospital, Thai Red Cross,
Thailand; Faculty of Medicine,
Chulalongkorn University, Thailand
Suzanne Peeters, MD
Emergency Medicine Residency
Director, Haga Hospital, The Hague,
The Netherlands
Case Presentations
It’s a typically busy morning in your community ED.
The average wait time to be seen is 1 hour when a
66-year-old man with hypertension and high cholesterol
states that he has been unable to urinate for a few days
and now has suprapubic pain and constipation. He denies
fever and chills. He also notes that, in the past, he was
diagnosed with benign prostatic hypertrophy and has re-
quired Foley placement. It seems simple enough, and you
anticipate he will be out as soon as the Foley and leg bag
are in place. You wonder if a rectal exam is needed and
how fast his bladder can be emptied...
It’s 2:00 PM and you are about to finally grab some
lunch, but in comes a 72-year-old man with a history of
large cell lymphoma for the past 15 years. He complains of
dribbling urinary frequency, which has worsened over 1
day after being prescribed an antibiotic by his doctor for a
UTI. The nurse asks him to walk to another stretcher, and
as he gets up, he stumbles and catches himself with his
hands. As you prepare to do the bladder ultrasound, you
wonder why he stumbled...
It’s finally 6:30 PM, with just 30 minutes until relief
arrives. You are spending the last half hour of your shift
tying up the loose ends with your current patients when
a 46-year-old febrile woman with a history of active intra-
venous drug abuse and HIV comes in. She is in excruciat-
ing discomfort and tells you that she has not urinated in 2
days. You wonder if that is possible, and why...
Introduction
Acute urinary retention (AUR) is commonly seen in
the emergency department (ED), most often in older
men with benign prostatic hypertrophy (BPH).1
AUR is defined as the inability to pass urine volun-
tarily, and the distended bladder causes extreme
discomfort, often requiring immediate attention and
intervention. There are many concerning and poten-
tially dangerous causes of AUR, and the onus is on
the emergency clinician to consider these etiologies
and eliminate them before assuming that it is caused
by a benign process. Urgent treatment in the ED is
of utmost importance for acute pain management,
to prevent insult to the kidneys, and to address the
underlying causes of AUR (such as cauda equina
syndrome, stroke, tumors, etc).
In women, the most common causes of AUR
are bladder masses, gynecologic surgery, and pelvic
prolapse.2,3 Unlike the abundance of clinical studies
on older men with BPH-related AUR, women have
typically been excluded from AUR studies, and little
published data are found in the literature addressing
women with this condition. An article by Preminger
et al in 1983 emphasized the importance of assessing
for organic illness for women with AUR.4 The rela-
tively low incidence of women with AUR in the ED
combined with the paucity of published evidence
Emergency Medicine Practice © 2014 2
often leads to inconsistent and suboptimal recogni-
tion and management of female patients.
This issue of Emergency Medicine Practice pres-
ents a systematic review of the latest evidence
regarding the pathophysiology, diagnosis, and
treatment of AUR, with a focus on controversies and
advances in care.
Critical Appraisal Of The Literature
An initial search utilizing the PubMed® database
from 1960 to 2013 was performed using the search
term management of acute urinary retention, with
a total of 385 results produced. Full texts for 122
articles were reviewed, of which 69 are cited in this
review. Two Federal Aviation Administration (FAA)
guideline appendices studying the treatment of
AUR in airplane flight as well as a website on flight
safety were also reviewed. In addition, the Cochrane
Database of Systematic Reviews was searched with
regard to the treatment of AUR. In 1994, A BPH
guidelines panel published recommendations for
the diagnosis and treatment of BPH, and in 2004 the
American Urological Association published more
up-to-date guidelines in light of new evidence-based
clinical trials.6 A thorough literature review revealed
that the major focus of AUR research involves the
treatment of BPH. With the exception of general
review articles and case reports, there is little pub-
lished original research that focuses specifically on
the treatment of AUR in women, and this remains
an area in need of further research.
Epidemiology
A cohort study of 2115 men aged 40 to 79 years
reported the incidence of AUR to be between 2.2 and
6.8 per 1000 men per year (95% confidence inter-
val [CI], 5.2-8.9),7,8 with a 10-year cumulative risk
of 4% to 73% (meaning that the risk is cumulative
and increases with advancing age).8 A man’s risk
of urinary retention is directly correlated to his age,
urinary symptom severity, prostate volume, and
urinary flow rate.8 It is estimated that 1 in 10 men
aged in their 70s will experience an episode of AUR,
increasing to 1 in 3 men aged in their 80s. There is
a 20% recurrence rate within 6 months after an epi-
sode of urinary retention in patients with AUR due
to BPH and 4% recurrence in those with AUR due to
other causes.9 Female AUR is relatively uncommon,
with much variation regarding incidence and little
published data addressing occurrence rates. AUR
in women is estimated to account for only 3 out of
100,000 cases of AUR each year,2 with an incidence
estimated at around 0.07 per 1000 females.10
In certain populations, AUR may be an indicator
of potential morbidity and mortality. One systematic
review of 176,046 men aged > 45 years with a first
www.ebmedicine.net • January 2014
episode of AUR reported, in the subset of hospital-
ized men aged > 85 years, a 1-year predicted mortal-
ity rate of 33% after an episode of spontaneous AUR;
those with AUR from precipitated causes had a
1-year predicted mortality rate of 45%.7 Among men
with AUR who are admitted to the hospital, those
with comorbid disease are found to have a higher
mortality rate at both 90 days and at 1 year than
those admitted with AUR without comorbid illness.7
Although the incidence of spontaneous AUR is
well studied, there are little data on the incidence
of drug-induced AUR. Data from observational
studies suggest that up to 10% of episodes may be
attributable to the concurrent use of medications.11
In a prospective cohort of 41,276 male health profes-
sionals 45 to 83 years of age, Meigs et al studied risk
factors and found that the use of calcium channel
antagonists and anticholinergic drugs doubled and
tripled, respectively, the risk of AUR.12
In cases of AUR secondary to spinal cord com-
pression, only rarely was AUR a presenting sign or
chief complaint, but a review study of 133 patients
found that, once the diagnosis of spinal cord injury
was made, up to 39% to 43% of patients were de-
scribed as having bladder or bowel dysfunction.13
Pathophysiology
The voiding process (micturition) involves the inte-
gration of high cortical sympathetic, parasympathet-
ic, and somatic functions. Normal voiding requires
a coordinated contraction of bladder smooth muscle
(detrusor muscle) with the simultaneous lowering
of resistance at the level of sphincter smooth muscle
and striated muscle and the absence of anatomic
obstruction. Urinary retention thus results from
an increased resistance to flow via mechanical or
dynamic means, diminished neurogenic control of
detrusor muscle contractility, and the subsequent
decompensating of voiding function.14
Sympathetic innervation originating from the
T10 to L2 spinal cord is responsible for the control
of lower urinary tract and urine storage function.
Somatic innervation via the pudendal nerve (S2, S3,
and S4) maintains sensory input and pelvic muscle
tone. As the sensory impulse of bladder distention
is transmitted to cortical centers, these areas of the
brain smoothly coordinate voluntary urination.
Holding urine requires both relaxation of the detru-
sor muscle through parasympathetic inhibition and
beta-adrenergic stimulation and contraction of the
bladder neck and internal sphincter through alpha-
adrenergic stimulation. Conversely, urination oc-
curs via contraction of the bladder detrusor muscle
via cholinergic muscarinic receptors and relaxation
of both the internal sphincter of the bladder neck
and the urethral sphincter through alpha-adrener-
gic inhibition.
January 2014 • www.ebmedicine.net
The cortical control of voiding involves the
connection between the frontal cortex and the septal-
preoptic region of the hypothalamus as well as the
connections between the paracentral lobule and the
brainstem. The process involves inhibition of so-
matic neural efferent activity to the striated sphinc-
ter, inhibition of spinal sympathetic reflexes (outlet
relaxation, both internal and external sphincters),
and facilitation of efferent parasympathetic pelvic
nerves for detrusor muscle contraction.
Any factors that interfere with the neurologic
control of the voiding process can result in void-
ing dysfunction. Urinary retention is defined as
the inability to void voluntarily in spite of a full,
distended bladder. As bladder outlet obstruction
(by any means) progressively increases, the urine
stream decreases in size and strength despite force-
ful and prolonged detrusor contraction. Over long
periods of time, this mechanism results in decon-
ditioning, which leads to dimished detrusor muscle
contractility and a larger amount of residual urine
volume.14 For an illustration of the neuronal control
of micturition, see Figure 1 (page 4).
Etiology
The etiology of AUR is divided into 5 categories:
(1) pharmacologic, (2) neurologic, (3) infectious and
inflammatory, (4) obstructive, and (5) other. BPH,
which is in the obstructive category and is a primary
cause of AUR, is referred to as "spontaneous" AUR.
Other causes of AUR (eg, infection, medication side
effects, surgery, or trauma) are referred to as "pre-
cipitated" causes of AUR.15
Pharmacologic Causes
Medications may cause prolonged bladder immotil-
ity or increased sphincter tone, with resultant AUR.
These medications include anticholinergics that
inhibit detrusor muscle activity, sympathomimetic
drugs that increase alpha-adrenergic tone in the
prostate, and nonsteroidal anti-inflammatory drugs
(NSAIDs) that may inhibit prostaglandin-mediated
detrusor muscle contraction. Patients on chronic opi-
oid therapy are also at an increased risk for devel-
opment of AUR as a result of experiencing reduced
bladder-fullness sensation.11 For a list of medica-
tions associated with AUR, see Table 1, page 5.
Neurologic Causes
Neuropathic etiologies (eg, diabetic cystopathy)
are also causes of AUR. Up to 45% of patients with
diabetes mellitus and 75% to 100% of patients with
diabetic peripheral neuropathy will experience uri-
nary retention at some point in their lives.16-18 Upper
motor neuron lesions that cause a deficit above the
micturition center in the sacral cord are associated
with multiple sclerosis, trauma, Parkinson disease,
3 Emergency Medicine Practice © 2014
stroke, and neoplasms. Lower motor neuron lesions
causing bladder flaccidity with AUR include spinal
cord tumors, epidural abscesses, and trauma. One
review examined 3 cases where cord compression
as the cause of AUR was missed by the ED physi-
cian in patients with a present history of enlarged
prostate.19
AUR.21,22 One prospective study followed a cohort
of 310 men over a 2-year period and found that AUR
was caused by BPH in 53% of patients, while other
obstructive causes accounted for another 23%.23 This
is important to keep in mind, as precipitated and
spontaneous causes of AUR differ greatly in their
treatments and outcomes.

Infectious Or Inflammatory Causes Other Causes

Infectious or inflammatory causes of AUR include
urethritis from a urinary tract infection (UTI),
prostatitis, severe vulvovaginitis, or viral causes (eg,
genital herpes involving the sacral nerves).20
Obstructive Causes
Obstructive causes of AUR are divided into intrinsic
causes (eg, prostatic enlargement, bladder stones),
or extrinsic causes (eg, uterine or gastrointestinal
masses). Obstructive causes in women often involve
pelvic organ prolapse (eg, cystocele or rectocele) or
malignant pelvic masses.16,17
Although there are many possible causes of
AUR, BPH remains the most common cause of
In patients during the postpartum period, the
incidence of AUR was found to be 1.7% to 17.9%.24
In a prospective study of 1000 women, it was
found that women who received epidural anesthe-
sia during labor were significantly more likely to
experience AUR than those who did not.25 In cases
where trauma is a suspected cause of AUR, etiolo-
gies to keep in mind include acute trauma to the
urethra, penis, or bladder; spinal cord injury; and
bladder/urethral rupture with associated pelvic
fracture.
Compared to chronic urinary retention, AUR
is usually painful, while more-slowly obstructing
pathological processes (ie, tumors) tend to be pain-

Figure 1. Pathophysiology Of Micturition

Bladder wall stretch Higher

Higher brain
brain centers
centers

Allow or inhibit micturition as

appropriate

Afferent impulses from stretch receptors Pontine micturition center Pontine storage centers

Promotes by acting on Inhibits by

Simple spinal reflex
all 3 spinal efferents acting on all 3
spinal efferents

Parasympathetic activity Sympathetic activity Somatic motor activity

➞

Parasympathetic activity
➞

Sympathetic activity
➞

Somatic motor activity

➞

Detrusor contracts; internal External urethral

urethral sphincter opens sphincter opens

Key:
Gray boxes: bladder
White boxes: spinal cord
Black boxes: brain Inhibits
Solid lines/arrows: nerves promoting urination Micturition
Dashed lines: nerves inhibiting urination

MARIEB, ELAINE N.; HOEHN, KATJA, HUMAN ANATOMY & PHYSIOLOGY, 8th, © 2010. Printed and Electronically reproduced by permission of
Pearson Education, Inc., Upper Saddle River, New Jersey.

Emergency Medicine Practice © 2014 4 www.ebmedicine.net • January 2014

free. Often, already established obstruction comes to
light when a superimposed acute obstruction occurs,
preventing effective urination (acute-on-chronic
urinary retention). For many patients presenting to
the ED with a first-time case of AUR, AUR is the first
symptom of underlying prostate hyperplasia. The
emergency clinician must distinguish more benign
processes from an etiology that is emergent and
requires urgent operative treatment (eg, AUR that
is caused by spinal cord compression). See Table 2
for a list of causes of AUR and Table 3 for gender-
specific causes of AUR (page 6).
Differential Diagnosis
AUR can present with very vague complaints in-
volving multiple organ systems, which can lead to
very broad differential diagnoses. Common com-
plaints may include abdominal pain or distension
that may be mistaken for conditions such as small-
bowel obstruction, organ prolapse, carcinoma, uri-
nary tract infection, or prostatitis. A presentation of
back pain may be confused with renal pathology or
spinal tumors. Commonly seen urinary complaints
(eg, frequency, dribbling) may also be manifestations
of toxin exposure or from neurological causes such
as diabetes, cerebrovascular accident, or spinal cord
compression. AUR presenting as genital pain may be
due to (or confused with) vaginal or penile carci-
noma, severe infection, trauma, testicular torsion,
or organ prolapse. Because of the large differential
diagnosis in AUR, a comprehensive history and
physical examination are indicated when evaluating
these patients.
Prehospital Care
On The Ground
Care for the patient with AUR in the prehospital set-
ting is centered on providing comfort to the patient
during transport to the ED for further evaluation.
Serious cases may involve severe pain, infection,
or autonomic hyperreflexia. Depending on local
protocols and the patient’s presentation, prehospital
management may include alleviating pain, correct-
ing hypovolemia, and relieving urinary retention by
means of Foley catheter placement.26
In The Sky
With an increase in the number of elderly individu-
als (ie, patients aged ≥ 65 years) flying on com-
mercial aircraft, there will likely be an increasing
incidence of AUR in flight. In a recent European
review of over 1000 cases of surgical and medical
emergencies in flight, AUR was not listed as a more

Table 1. Medications Associated With Acute Urinary Retention16

Classification Generic Names (Brand Names)
Antiarrhythmics Disopyramide (Norpace®, Rhythmodan®); procainamide (Pronestyl®, Procan®, Procanbid®); quinidine
Anticholinergics Atropine (Atreza®, Sal-Tropine®, AtroPen®); belladonna alkaloids; dicyclomine (Bentyl®, Byclomine®, Dibent®); flavoxate
(Urispas®); glycopyrrolate (Robinul®, Cuvposa®); hyoscyamine (Symax®, HyoMax®, Levsin®, et al); oxybutynin (Ditro-
pan®, Gelnique®, Oxytrol®); propantheline bromide; scopolamine
Antidepressants Amitryptyline (Elavil®, Amitril®); amoxapine (Asendin®, Defanyl®, Demolox®); doxepin (Sinequan®, Silenor®); imipramine
(Tofranil®); maprotiline (Ludiomil®); nortriptyline (Sensoval®, Aventyl®, Pamelor®, et al)
Antihistamines Brompheniramine (Ala-Hist®, Dimetane®, Brovex®, et al); chlorpheniramine (Chlor-Trimeton®, Antagonate®, Phenetron®,
et al); cyproheptadine (Periactin®); diphenhydramine (Unisom®, Nytol®, Benadryl®, et al); hydroxyzine (Atarax®, Hy-
pam®, Vistaril®, et al)
Antihypertensives Hydralazine (Apresoline®, Dralzine®, plus multiple combination products); nifedipine (Adalat®, Nifedical®, Procardia®)
Antiparkinsonians Amantadine (Symmetrel®); benztropine (Cogentin®); bromocriptine (Cycloset®, Parlodel®); levodopa (Sinemet®, Par-
copa®, Larodopa®); trihexyphenidyl (Artane®, Tremin®)
Antipsychotics Chlorpromazine (Promapar®, Thorazine®); fluphenazine (Permitil®, Prolixin®); haloperidol (Haldol®); prochlorperazine
(Compazine®); thioridazine (Mellaril®); thiothixene (Navane®)
Hormonal agents Estrogen; progesterone; testosterone
Muscle relaxants Baclofen (Kemstro®, Lioresal®); cyclobenzaprine (Amrix®, Flexeril®); diazepam (Valium®)
Sympathomimetics (alpha) Ephedrine; phenylephrine (Lusonal®; plus multiple combination products, eg, Dimetapp®, Neo-Synephrine®, Sudafed
PE®, et al); phenylpropanolamine; pseudoephedrine (Afrinol®, Silfedrine®, Sudafed®, et al; plus multiple combination
products)
Sympathomimetics (beta) Isoproterenol/isoprenaline (Isuprel®); metaproterenol (Alupent®); terbutaline (Brethine®, Bricanyl®)
Miscellaneous Amphetamines; carbamazepine (Carbatrol®, Epitol®,Tegretol®, et al); dopamine (Intropin®); mercurial diuretics; nonste-
roidal anti-inflammatory drugs, opioid analgesics; vincristine (Oncovin®, Vincasar®, Vincrex®, et al)

Drug brand names examples are from the Medline Plus® website, www.MedlinePlus.gov.
Adapted from Emergency Medicine Clinics of North America, Volume 19, Issue 3. Liesl A. Curtis, Teresa Sullivan Dolan, R. Duane Cespedes, Acute
Urinary Retention and Urinary Incontinence. Pages 591-620, Copyright 2001, with permission from Elsevier.

January 2014 • www.ebmedicine.net 5 Emergency Medicine Practice © 2014

common concern.27 However, the true incidence pain often radiates to the scrotum or labia. A full list
of AUR in flight may be underreported. Current of patient medications should be obtained including
guidelines provided by the aviation Medical Assis- new medications, over-the-counter medications, and
tance Act require that all United States commercial herbal remedies. When inquiring about a possible
aircraft be equipped with an automatic external toxicologic cause of AUR, regardless of the patient's
defibrillator and an emergency medical kit, but a gender, the emergency clinician should inquire about
Foley catheter is not specified.28-30 Many interna- any illicit drug usage, misuse of medications, chemi-
tional carriers do include a Foley catheter in their cal exposure, history of psychiatric illness, and suicid-
standard equipment. In the event of suspected AUR al intent or ideation. In women and men, a history of
in flight, the patient’s stability would guide manage- weight loss, bone pain, and other constitutional signs
ment. Interestingly, urinary retention is a recognized and symptoms may suggest an underlying neoplasm.
medical problem observed in both short-duration In men, a history of urinary frequency, urgency,
and prolonged space flight and research has looked hesitancy, nocturia, difficulty initiating a urinary
at a percutaneous solution.31 stream, decreased force of stream, incomplete void-
ing, or terminal dribbling may indicate an enlarged
Emergency Department Evaluation or inflamed prostate as the cause of the AUR.
Women with obstruction often complain of
History pelvic pain and abdominal pressure. A history of
The history for a patient with AUR focuses on de- dysuria, urgency, discharge, chills, fever, low back
termining which of the etiologies in the differential pain, and genital itching should be sought in order
diagnosis may be involved. The location, movement, to assess for possible infectious causes such as UTI
and radiation of the pain help to determine whether and vulvovaginitis.
the involved process is proximal or distal to the blad- The elderly patient, the nonverbal patient, or the
der. If the pain is proximal to the bladder, there is patient with dementia may not be able to divulge
often flank pain; with pain distal to the bladder, the a history and may present with only agitation and
restlessness. In these patients, family and caregivers
may provide the critical history needed to direct the
Table 2. Common Causes Of Acute Urinary evaluation. Other questions to ask include a history
Retention1 of known neurological disorders and history of prior
episodes of urinary retention.
Regardless of gender, neurologic issues should
• Benign prostatic hypertrophy
• Bladder calculi
be considered. While spinal cord injury with parapa-
• Bladder clots resis or quadraparesis is usually obvious, other enti-
• Meatal stenosis ties such as cauda equina syndrome require a higher
• Neoplasm of the bladder index of suspicion.
• Neurogenic etiologies
• Paraphimosis Physical Examination
• Penile trauma The general appearance of patients presenting to
• Phimosis
the ED with AUR varies greatly, depending on the
• Prostate cancer
etiology, age, and underlying comorbidities of the
• Prostatic trauma/ avulsion
• Prostatitis
patient. A rectal examination is important in both
• Urethral foreign body men and women. In women, a rectal examination
• Urethral inflammation should be performed to rule out rectal or uterine
• Urethral strictures prolapse. In men with BPH, the prostate may be
enlarged; however, a normal prostate examination
does not exclude BPH. The prostate in a patient with
Table 3. Gender-Specific Causes Of Acute prostate cancer is generally enlarged and nodular.
Urinary Retention1,23,33 One meta-analysis by Roehrborn et al found that
prostate volumes estimated by digital rectal ex-
Women Men
amination and measured by transrectal ultrasound
• Obstructive Causes • Obstructive Causes (TRUS) were significantly correlated (r = 0.4-0.9),
l Cystocele l BPH but it also concluded that digital rectal examination
Tumor
l l Meatal stenosis often underestimates prostate size if TRUS volume
• Infectious Causes Phimosis/ paraphimosis
l
is > 30 mL. However, digital rectal examination may
• Operative Causes Tumor
l
still help identify patients with prostates likely to
• Infectious Causes
be larger than certain cutpoints by TRUS.32 Patients
• Operative causes
with prostatitis often present with a tender, warm,
and boggy prostate. It is common practice to avoid
Abbreviation: BPH, benign prostatic hypertrophy.

Emergency Medicine Practice © 2014 6 www.ebmedicine.net • January 2014

performing digital rectal examinations in patients Clinical judgment should be used in each case to
with suspected acute bacterial prostatitis, so as not determine the significance of obtaining a chemistry
to elicit bacteremia. However, we could find no panel to evaluate renal function. Prostate-specific
significant evidence supporting this widely accepted antigen (PSA) levels are frequently elevated in the
notion and it remains an area for further study. setting of AUR;34,35 however, PSA is not a routine
In both sexes, a thorough genital/pelvic exami- ED test and will not differentiate cancer from other
nation is necessary. In men, the examination looks causes of urinary retention. Complete blood count
for phimosis or paraphimosis, lesions, and tumors as (CBC) should be considered in patients with sus-
potential causes of AUR; in women, the examination pected serious infection, hypovolemia, or hemato-
looks for lesions, tumors, uterine prolapse, cystocele, logic disorders.
enlarged uterus, or enlarged ovaries. If there is clini-
cal suspicion for neurogenic disease or a history of Imaging Studies
trauma, it is important to perform a thorough neuro- In both men and women, when obstruction is the
logical examination, focusing on strength, sensation, likely cause of urinary retention, renal ultrasound
and lower extremity reflexes. When ruling out spinal may show signs of hydronephrosis, stone, or ob-
pathology as a cause for AUR, one must assess the struction. Kidney ultrasound can evaluate for
bulbocavernosus reflex, anal reflex, sphincter tone, hydronephrosis that would indicate downstream
and perineal sensation. obstruction. (See Figure 2.) In women, pelvic ultra-
sound using the bladder sonographic window may
Diagnostic Testing
Laboratory Tests
Figure 2. Ultrasound Images Of
The paramount test in patients with AUR is the
Hydronephrosis
urinalysis. A urinalysis will reveal infection and
determine the presence of hematuria, which can be a
sign of infection, tumor, toxin, trauma, or calculi. A
The 3-cup bacterial localization study, described
initially by Mears and Stamey in 1968, has been the
classic method for diagnosis of bacterial prostatitis
in men.36 The patient is asked to retract the foreskin,
cleanse the meatus, and void, collecting the first 5 Renal parenchyma
to 10 mL of urine. This first cup represents bacte-
rial growth from the urethra. Then, the next 100 to Dilated renal pelvis
150 mL of urine is voided, and 5 to 10 mL of that is
collected in a second cup, representing the bladder
component of bacterial growth. The prostate is then
massaged until a drop of fluid is expressed, collect-
ed, and then examined by microscope. More than 10
white blood cells per high power field is abnormal
and is consistent with prostate inflammation. Lastly,
the third cup captures the first 5 to 10 mL of urine
collected after prostate massage, and this is sent B
for culture, representing a prostatic source.37 Clini-
cally, the 3-cup test has proven time-consuming and Renal parenchyma
cumbersome, and its use as a diagnostic tool is de- Dilated renal
clining. Simply obtaining urine cultures before and pelvis
after prostate massage has become a clinically useful
alternative. A 2009 retrospective study by Magri et
al of semen cultures from 1100 patients found that it
can be a useful adjunctive diagnostic tool; however,
further studies are needed to confirm these findings
and determine whether a semen culture alone may
represent a reasonable diagnostic alternative.37

Electrolytes, blood urea nitrogen, and creati-
nine levels may be obtained to evaluate for im-
paired renal function from prolonged obstruction
and potential electrolyte imbalance in those requir- Images show hydronephrosis in a 21-year-old male eventually
ing bladder irrigation. diagnosed with nephrolithiasis. Image A shows mild hydronephrosis.
Image B shows moderate hydronephrosis.

January 2014 • www.ebmedicine.net 7 Emergency Medicine Practice © 2014

show masses (such as ovarian or uterine tumors).
Bladder ultrasound can assess for free fluid in cases
of trauma, and it can assess bladder volume and
reveal the presence of urethral jets (which would
rule out upstream ureteral blockages). Bladder
ultrasound can also demonstrate urinary retention
(see Figure 3), confirm correct Foley or suprapubic
catheter placement, and can also detect the presence
of masses.
Regarding renal function testing in blood
chemistries, in an observational cohort study of 96
subjects (11 female and 85 male), Shah et al showed
that the presence of hydronephrosis on bedside ul-
trasound does not correlate with an elevated serum
creatinine; a sensitivity of 70%, a specificity of 67%,
a positive predictive value of 39%, and a negative
predictive value of 70% were found. This study
noted that, given the high prevalence of an elevated
creatinine in this cohort of subjects, emergency phy-
sicians interested in identifying creatinine elevation
in patients with AUR should maintain a low thresh-
old for testing the serum creatinine.33
In cases where masses or malignancy are suspect-
ed causes of AUR, further diagnostic study (such as
computed tomography [CT] scan) should be under-
taken to evaluate for mass or malignancy as a cause
of obstruction. When new neurological deficits are
elicited on examination in a patient with AUR, mag-
netic resonance imaging (MRI) is indicated. A lumbar
MRI is indicated for suspected disc herniation, cord
compression, and cauda equina syndrome.
Treatment
AUR should initially be managed by immediate and
complete decompression of the bladder through
urinary catheterization with a double-lumen Foley
catheter.22 (See Table 4 for a list of types of catheters
and their uses.)
Foley Placement
Two important aspects in Foley placement are
patient reassurance and patient comfort during the
procedure. In female patients, this is especially im-
portant, given the common propensity to tense the
muscles, especially if the patient has had prior expe-
riences with painful Foley insertion. In a prospective
study of 50 patients, Allardice et al examined the
importance of adequate analgesia, preparation, and
correct technique. It was found that by using these
methods, 50 consecutive male patients with a diag-
nosis of AUR were successfully catheterized by 12
different house persons.43 Often, adequate explana-
tion regarding the procedure and having the patient
exhale deeply during insertion helps greatly.
When inserting a Foley catheter, the small-
est catheter size that will allow for adequate urine
drainage should be used. Urinary catheter sizes refer
Emergency Medicine Practice © 2014 8
to the circumference of the catheter, not the diameter
of the lumen. Catheters are recorded in sizes French,
where 1 French (F) = 1 Charrière = 0.33 mm. Sizes
for adults range from 10F to 28F, with sizes 14F to
18F being the most common. Large-circumference
catheters (eg, 16F-20F) are more beneficial for drain-
ing clots, debris, mucus, etc.
After examining the urogenital area and prior to
starting the procedure, observe the patient’s over-
all condition. Palpate the suprapubic area, keeping
in mind the contraindications to Foley and Coude
catheter insertion. (See Table 5.) For patients with
recent bladder or prostate surgery where continu-
ous bladder irrigation may be necessary, consider
placement of a double or triple lumen catheter by
an emergency clinician trained in advanced catheter
techniques. See Figure 4 for a picture of types of
urinary catheters.
To facilitate passage of a Foley catheter in men,
hold the penis at a 90° angle to the stretcher and
stretch it upward to straighten the penile urethra.
As in women, ensure adequate lubrication with 1 to
2 mL of lubricant inserted into the urethral meatus.
Apply gentle continuous pressure to help open
the prostatatic sphincter, as attempting to force it
through can increase sphincter contraction, making
Foley passage difficult. While waiting for sponta-
neous urine return, a 60-mL syringe may be used
to aspirate urine; if there is still no urine return,
remove the Foley and attempt again under direct
ultrasound guidance. Ultrasound can be useful in
confirming placement as well as calculating urinary
volume (postvoid residual) prior to catheter place-
ment. Do not inflate the balloon until you have
Figure 3. Transverse View Ultrasound Image
Of A Full, Distended Bladder
Distended bladder
Bladder wall
www.ebmedicine.net • January 2014
confirmed placement with urine return. Inflate the
balloon only with sterile water to ensure the bal-
loon does not float or become lodged against the
bladder wall.1 • Precipitated acute urinary retention
If the above fails (usually due to hindrance of
passage by an enlarged prostate), placement of a
curved-tip Coude catheter (see Figure 4) by an emer-
gency clinician comfortable with advanced catheter-
ization techniques is warranted for male patients.38
The curved tip of the Coude catheter allows easier
passage over the obstruction caused by prostatic
enlargement. Despite a thorough literature search,
no studies were found on placement of Coude
catheters by emergency clinicians other than articles
recommending its use in the setting of difficult Foley
catheter placement due to an enlarged prostate. If
passage of neither catheter is successful, a urology
consult should be obtained. Criteria for ordering a
urology consult include the following:
• Urologic postoperative complications
• Failed Foley and Coude catheter placement
• Urethral stricture, meatal stenosis
Table 4. Types Of Urinary Catheters
• Single lumen: no balloon; used for in-and-out catheterization
• Double lumen: balloon-inflation lumen and draining lumen; used for
continuous catheterization
• Triple lumen: also called 3-way catheters; have draining lumen,
balloon-inflation lumen, and irrigation lumen for bladder washout;
commonly used in post-TURP patients
Abbreviation: TURP, transurethral resection of prostate.
Table 5. Indications And Contraindications
For Catheter Placement
Indications for Foley Placement
• Acute urinary retention
• Need for monitoring urine output
• Collection of urine for diagnostic purpose
• Radiographic evaluation of lower urinary tract
• Treatment of neurogenic bladder
Indications for Coude Placement
• Failed Foley placement
• Benign prostatic hypertrophy and known history of difficult catheter-
ization
Relative Contraindications to Foley Placement/Contraindications
for Coude Placement
• Abdominal or pelvic trauma with blood at urethral meatus
• Penile deformity
• High-riding prostate
• Perineal hematoma
• Known impassible catheterization
• Radiographic evidence of bladder mass/ trauma
• History of known prostate or bladder neck surgery
January 2014 • www.ebmedicine.net
• Suspected genitourinary trauma (eg, urethral
injury)
• Acute prostatitis or sepsis
• Uncontrolled hematuria
At this time, there is no current indication of
usage of a Coude catheter in women presenting with
AUR, due to lack of curvature of the urethra and
absence of a prostate.
In situations involving difficult Foley insertions
in women, the emergency clinician should first ex-
amine for ureterocele, cystocele, or signs of prolapsed
organs. Look for the urethral meatus first, instead
of attempting to put the catheter where the meatus
should be, especially in elderly women. If the vagina
is accidently catheterized, do not remove the catheter;
leave it in the vagina so that, when you start to recath-
eterize with the second tube, you will know where
not to put it. Ensure adequate lubrication by placing
lubricant on the catheter, as well as slowly injecting 1
to 2 mL into the urethral meatus. This helps provide
lubrication further up the urethra.1
Suprapubic Catheterization
Indications for suprapubic catheterization include:
(1) AUR in a patient who has contraindications for
urethral catheterization, (2) major urethral trauma
when no urologist is available, and (3) failure of
Foley and Coude catheterization in an AUR patient
without contraindications.1 Prior to performing the
procedure, ultrasound visualization of the bladder
should be performed to confirm bladder disten-
tion. Emergency clinicians should also be familiar
with the absolute and relative contraindications as
well as the indications for performing suprapubic
Figure 4. Types Of Urinary Catheters
Top: triple-lumen urinary catheter; center: double-lumen Coude cath-
eter; bottom: double-lumen urinary catheter.
9 Emergency Medicine Practice © 2014
catheterization. (See Table 6.) Also, keep in mind
that a misplaced suprapubic catheter may produce
an ileus, bleeding, hematoma, or infection.34 Us-
ing ultrasound guidance for direct visualization is
highly recommended, as shown by Aguilera et al in
a prospective study that showed 100% success rate
when ultrasound guidance was used in placing 17
suprapubic catheters in the ED.39 For instructions on
how to place a suprapubic catheter, see Table 7.
In a meta-analysis study by McPhail et al,
postabdominal surgery patients who had bladder
drainage via suprapubic catheters had a decreased
risk of bacteriuria and less discomfort than patients
who had transurethral catheterization. The supra-
pubic catheter was, overall, preferred by patients
versus transurethral catheterization.40 A Cochrane
Database review was performed to determine pa-
tient preference and policies for catheter placement
in patients with short-term voiding problems and
bladder drainage problems.41 One Cochrane article
confirmed patient preference for suprapubic cath-
eterization by concluding that in patients requiring
catheterization for up to 14 days, less bacteriuria,
less discomfort, and reduced need for recatheteriza-
tion were experienced by patients when suprapubic
catheters were used compared to when urethral
catheters were used.42
Complications Of Catheterization
Hematuria, hypotension, and postobstructive diure-
sis are all potential complications of rapid bladder
decompression in patients with AUR. Nyman et
al performed a review of the literature on urinary
decompression published from 1966 to 1996 and
found that, although evidence showed that a sudden
reduction in bladder wall tension reflexively pro-
duces vasodilatation with a concomitant decrease in
blood pressure, this occurs with no serious clinical
consequences when a patient already has a healthy
cardiovascular system. Patients without a healthy
cardiovascular system may be at risk for prolonged
hypotension following rapid bladder decompres-
sion.22 In the past, to avoid the aforementioned
sequelae, it was recommended to only gradually
decompress the bladder in treating patients with
AUR. Nyman's review cast doubt on this common
practice, finding no evidence that gradual bladder
decompression decreased the likelihood of causing
these complications, and complete and rapid empty-
ing of the bladder was recommended.22
Other complications of catheterization include
a risk of urethritis, cystitis, prostatitis, bactere-
mia, and sepsis. These risks are most prominent
in elderly patients and patients with preexisting
indwelling catheters.
Emergency Medicine Practice © 2014 10
Medical Therapies
Since 1994, there have been major changes in the
treatment of patients with urinary retention, in
particular, patients with lower urinary tract symp-
toms and BPH. Currently, the American Urologi-
cal Association guidelines treatment options for
patients with modest-to-severe lower urinary tract
Table 6. Indications And Contraindications
For Suprapubic Catheter Placement
Indications for Placement
• AUR in a patient with contraindications for urethral catheterization
• No urologist present
• Failure of transurethral catheterization in an AUR patient
Absolute Contraindications for Placement
• Gross or morbid obesity
• Pregnancy
• Bladder not palpable and/or not visible on portable ultrasound
Relative Contraindications for Placement
• Uncontrolled coagulopathy
• Pediatric cases (urologist input necessary)
• Prior abdominal or pelvic surgery (may need consult first, given the
risk of adhesion)
• Pelvic radiation
Abbreviation: AUR, acute urinary retention.
Table 7. Procedure For Placement Of A
Suprapubic Catheter
1. Identify location 2 finger-breadths above the pubic symphysis
and anesthetize with 1% lidocaine with epinephrine.
2. Insert a 22-gauge spinal needle into the midline and aimed
caudally.
3. Advance until urine is aspirated (return of air suggests bowel
penetration; movement cephalad with the needle is recom-
mended); then place a wire through the needle and remove the
needle.
4. After aspiration, make a 1-cm skin incision deep through the
subcutaneous fat.
5. Incise the fascia, ensuring a wide enough incision to allow trocar
placement
6. Inspect the trocar to make sure it can be easily removed from the
sheath.
7. Insert the trocar, with sheath, into the bladder using a “cork-
screw” motion until urine flashback is seen; advance 1 cm further
to ensure safe placement within the bladder.
8. Remove the trocar from the sheath and place the catheter down
the lumen of the sheath into the bladder.
9. Remove the tear-off strip from the sheath and remove the
sheath.
10. Inflate the balloon.
11. Suture in place.
Note: If the above catheter is not available, a central venous catheter
set may be used, with 12- to 18-inch tubing inserted into the bladder
using Seldinger technique.
www.ebmedicine.net • January 2014
symptoms associated with BPH include: (1) watch-
ful waiting, (2) pharmacotherapy with alpha block-
ers such as doxazosin or tamsulosin (which act to
relax urethral muscle), and (3) minimally invasive
therapies such as transurethral microwave thera-
py.44 Generally speaking, most patients will now
undergo medical management prior to any form
of surgical intervention. Before these changes, all
patients with hematuria were treated with surgical
intervention; today they are first offered pharmaco-
therapy. (See Table 8.)
Pharmacologic Therapies
The 2 mainstays of pharmacological treatment in
BPH-precipitated AUR are alpha 1 adrenergic-
blocking agents (such as tamsulosin) and 5-alpha
reductase inhibitors (such as finasteride). Alpha 1
adrenergic blockers work to block alpha-adrenergic
receptors in the prostate and bladder neck, thus
decreasing bladder outlet resistance and facilitating
normal micturition.17 The 5-alpha reductase inhibi-
tors act by inhibiting the formation of dihydrotes-
tosterone (the chemical responsible for androgenic
prostate growth) from testosterone by blocking the
enzyme 5-alpha reductase.15
Alpha-Adrenoceptor Antagonists
The Prospective European Doxazosin and Combi-
nation Therapy (the PREDICT study) concluded
that doxazosin is effective in improving urinary
symptoms and urinary flow rate in men with BPH
and more effective than placebo or finasteride
alone. The addition of finasteride did not provide
additional benefit to that achieved with doxazosin
alone.45 Therefore, it is common for patients with
urinary retention to be treated with the concomi-
tant use of an indwelling catheter, an alpha blocker
(such as alfuzosin, tamsulosin, or doxazosin), and
then trial without catheter.6 Adverse side effects
commonly reported with different alpha 1 blockers
include dizziness, headache, postural hypotension,
rhinitis, and sexual dysfunction, and these occur in
about 5% to 9% of patient populations.6
5-Alpha Reductase Inhibitors
The current American Urological Association guide-
lines regarding 5-alpha reductase inhibitors recom-
mend them as an effective and appropriate option
for treating men with enlarged prostates and associ-
ated lower urinary tract symptoms.44 The Proscar
Long-Term Efficacy and Safety Study (PLESS) trial,
a multicenter double-blinded, placebo-controlled
trial, studied 3000 men with enlarged prostates and
moderate-to-severe urinary symptoms over 4 years.
The patients were randomized to finasteride 5 mg/
day or placebo. Finasteride treatment resulted in
significant improvement in the symptoms scores
(-3.3 in the finasteride group compared to -1 in the
placebo group in the first year [P < .001]), and main
prostate volume decreased in the finasteride group
(-18%) in the first year. At 4 years, the risk of un-
dergoing BPH-related surgery was reduced by 55%
in the finasteride group versus the placebo group,
and the risk for experiencing AUR in the finasteride
group was reduced by 57% (P < .001).46
In the dutasteride trials, a pooled analysis of 3
similar randomized double-blind placebo-controlled
2-year clinical trials was similar to PLESS, but it
had a larger patient population (n = 4325). These
trials showed that treatment with 0.5 mg of dutas-
teride once daily reduced the risk of AUR and BPH
more than placebo. At 2 years, dutasteride therapy

Table 8. Pharmacologic Therapies Used For Spontaneous Acute Urinary Retention In The
Emergency Department
Class of Drug Generic Name/ Dosing
Alpha blockers • Tamsulosin: 0.4-0.8 mg daily
• Alfuzosin: 10 mg PO once daily
• Doxazosin: 1-8 mg PO once daily
• Terazosin: 1-10 mg PO once daily
• Silodosin: 8 mg PO once daily;
decrease to 4 mg PO once daily if
CrCl is < 50 mL/min
• Prazosin: 1-2 mg PO twice daily†
5-alpha reductase • Finasteride: 5-mg tablets
inhibitors • Dutasteride: 0.5-mg capsules
Mechanism of Action Indications
Alpha 1 adrenergic Patients with spontaneous
blockade, thus increasing AUR regardless of prior
urinary flow rate history of usage (unless
contraindicated*)
Decreases the formation Patients with spontaneous
of testosterone into dihy- AUR who are currently
drotestosterone, reducing on or have previously
prostate growth taken 5-alpha reductase
inhibitors for BPH (unless
contraindicated*)
Side Effects*
Postural hypotension,
headache, dizziness,
fatigue, nausea, constipa-
tion
Impotence, decreased
libido, decreased ejacula-
tory volume, testicular
pain, rash, pruritus

*For full list of side effects and contraindications please visit www.FDA.gov/Drugs/
†
Not approved by the United States Food and Drug Administration for this use.
Abbreviation: AUR, acute urinary retention; BPH, benign prostatic hypertrophy; CrCl, creatinine clearance; PO, per os (by mouth).
Sources: www.FDA.gov, www.merckmanuals.com

January 2014 • www.ebmedicine.net 11 Emergency Medicine Practice © 2014

 Clinical Pathway For The Treatment
Of Acute Urinary Retention In Women

Perform history and physical examination

Physical findings of Signs of urethral or • Recent gynecological or

No sign of obstruction
vesicular lesions, bladder trauma obstetric surgery
infection, or severe pain or
• Rectal mass, ure-
terocele, or cystocele
present

Treat pain and underlying • Place ultrasound-guid-

Perform ultrasound Consult urology
cause ed suprapubic catheter*
• Consult obstetrics/gy-
necology

Distended bladder
Reassess ability to void NO Assess other causes Admit
present?

NO YES

Insert single- or dual-

Able to void?
lumen Foley catheter

YES

Arrange disposition Successful? NO Consider using a smaller

accordingly Foley catheter or more
experienced operator
YES

Is there presence of 1 or
more?:
• Severe infection Order urinalysis, consider Urology consult service
• Significant comorbidity ordering BUN, creatinine, YES Successful? NO
present?
• Impaired renal function and CBC
• Neurological deficits NO YES
• Catheter complication

NO YES • Place ultrasound-guid-

Consult urology
ed suprapubic catheter*
(Class II)
Admit • Admit
Able to void? NO

YES

* Contraindications should be assessed prior to suprapubic catheter

• Discharge home insertion, and it should only be attempted by or in the presence of a
• Treat or discontinue offending agent urologist or by a provider only when consult service unavailable.
• Arrange appropriate follow-up Abbreviations: BUN, blood urea nitrogen; CBC, complete blood count.

See class of evidence definitions on page 14.

Emergency Medicine Practice © 2014 12 www.ebmedicine.net • January 2014

 Clinical Pathway For The Treatment
Of Acute Urinary Retention In Men

Perform history and physical examination

Enlarged prostate History of urethral

Nonenlarged Signs of urethral Recent urological
present stricture or known
prostate present or bladder operation
impassible Foley
trauma (ie, TURP)
catheter

• Place ultrasound-guided suprapubic catheter*

Perform ultrasound (Class I) Consult urology
(Class II)
• Consult urology

Distended bladder?
Admit
YES NO

Insert Foley Assess other

catheter (class I) causes

NO Consider using smaller Foley NO

Successful? Insert Coude catheter
catheter or more experienced Successful?
(Class I)
operator
YES

Order urinalysis (Class I), YES YES Successful?

consider ordering BUN,
creatinine, and CBC NO

Is there presence of 1 or more?: Urology consulta-

• Severe infection Consult urology YES tion service
YES Admit
• Significant comorbidity present?
• Impaired renal function
NO
• Neurological deficits
• Voiding pres-
• Catheter complication
ent: discharge
• Etiology other than BPH NO Precipitated YES • Place ultra-
home, discon-
cause likely? tinue offending sound-guided
agent, treat suprapubic
other precipitat- catheter*
ing cause (Class II)
• Leave Foley in (Class I) • Voiding absent: • Admit
• Place a hip bag admit
NO
• Arrange follow-up
• Prescribe alpha blocker (Class I)
• Discharge home * Contraindications should be assessed prior to suprapubic catheter insertion and it should only
be attempted by or in the presence of a urologist or by a provider only when consult service is
unavailable.
Abbreviations: BPH, benign prostatic hypertrophy; BUN, blood urea nitrogen; CBC, complete
blood count; TURP, transurethral resection of prostate.
See class of evidence definitions on page 14.

January 2014 • www.ebmedicine.net 13 Emergency Medicine Practice © 2014

reduced the risk of BPH-related surgery by 48% and
AUR by 57% compared to placebo (P < .001).47
In both the finasteride and dutasteride trials,
drug-related sexual adverse events (such as de-
creased libido, impotence, ejaculatory disorders,
gynecomastia, and rash) occurred more frequently
in the 5-alpha reductase inhibitor groups than in the
placebo groups. In both finasteride and dutasteride,
the onset of adverse effects appeared in the first
year, and there was no evidence of increased ad-
verse effects compared to placebo after the first year
of therapy. Both agents appeared to be reasonably
safe and well tolerated.48
Combination Therapy Trials
The Medical Therapy of Prostatic Symptoms Study
(MTOPS) was a long-term, double-blind trial that
compared the effects of placebo, doxazosin, finaste-
ride, and combination therapy on measures of the
clinical progression of BPH over 4 years.49 The trial
followed 3047 men at 17 clinical centers between
1993 and 1998. Men aged ≥ 50 years with a symptom
score of 8 to 30 and a maximum urinary flow rate
between 4 and 15 mL/sec with a voiding volume of
at least 125 mL were included in the study. Exclu-
sion criteria included men with prior medical and/
or surgical intervention for BPH, patients who
were hypotensive while supine, and those with a
PSA > 10 mg/mL. The results of this study showed
that combination therapy with both doxazosin and
finasteride was safe and reduced the risk of overall
clinical progression of BPH significantly more than
treatment with either drug alone. In all groups,
the risk of AUR increased with increasing PSA
levels.49 Furthermore, the Combination of Avodart
and Tamsulosin (CombAT) trial was a multicenter
randomized double-blind study of clinical outcomes
in 4844 men with symptomatic BPH who received
either tamsulosin 0.4 mg, dutasteride 0.5 mg, or a
combination of both. After 4 years, the study found
that the incidence of AUR or BPH-related surgery
was higher in men treated with tamsulosin than in
Class Of Evidence Definitions
Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II
• Always acceptable, safe • Safe, acceptable
• Definitely useful • Probably useful
• Proven in both efficacy and effectiveness
Level of Evidence:
Level of Evidence: • Generally higher levels of evidence
• One or more large prospective studies • Nonrandomized or retrospective studies:
are present (with rare exceptions) historic, cohort, or case control studies
• High-quality meta-analyses • Less robust randomized controlled trials
• Study results consistently positive and • Results consistently positive
compelling
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2014 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.
Emergency Medicine Practice © 2014 14
those treated with dutasteride or combined therapy
(P < .001). Prevention of AUR secondary to BPH
may be achieved by long-term treatment (4-6 years)
with dutasteride, finasteride, or a combination of fin-
asteride and doxazosin.46,47,50 The current American
Urological Association guidelines only recommend
using the 5-alpha reductase inhibitors (finasteride
and dutasteride) in men with considerable prostate
enlargement on digital rectal examination.
Antibiotics
In addressing the case for giving antibiotics, it is
important to first recognize what is being treated.
If only a catheter has been placed and there is no
suspicion for concomitant infection, prophylac-
tic antibiotics should not be initiated unless the
patient is pregnant or preoperative, as antibiotics
have been found to promote organism resistance.51
A Cochrane review article found that silver alloy-
impregnated urethral catheters were associated with
decreased rates of UTI versus standard catheters.41
In suspected acute or chronic bacterial prostatitis,
a 4- to 6-week course of a fluoroquinolone (such as
levofloxacin) is the first-line treatment. Adjunctive
therapy for prostatitis includes alpha blockers, 5-al-
pha reductase inhibitors, and NSAIDs.52
Controversies And Cutting Edge
Rapid Versus Gradual Decompression
Addressing the complications of hematuria, postob-
structive diuresis, and hypotension after rapid blad-
der decompression, Nyman et al found no evidence
to support the practice of gradual bladder decom-
pression (clamping after a 705-mL urine output) in
order to prevent complications. They concluded that
the potential complications of rapid bladder empty-
ing were rarely clinically significant, and they empha-
sized the importance of supportive care for all AUR
patients, with particular attention paid to the special
needs of elderly, cardiovascularly compromised, and
hypovolemic patients.22
Class III Indeterminate
• May be acceptable • Continuing area of research
• Possibly useful • No recommendations until further
• Considered optional or alternative treat- research
ments
Level of Evidence:
Level of Evidence: • Evidence not available
• Generally lower or intermediate levels • Higher studies in progress
of evidence • Results inconsistent, contradictory
• Case series, animal studies, • Results not compelling
consensus panels
• Occasionally positive results
www.ebmedicine.net • January 2014
 Mustonen et al further supported the impor-
tance of urgent decompression in a prospective
study of 25 patients. They concluded that AUR
caused decreased renal blood flow (increase in resis-
tive index) as measured by renal Doppler ultra-
sound. In two-thirds of patients, blood flow returned
to normal with treatment of the precipitating factor
of AUR. However, in the remaining one-third of pa-
tients, at 1 month and 6 months, blood flow was still
decreased, thus stressing the importance of timely
decompression and urgent treatment of the AUR
precipitating factor.53
Trial Without Catheter Following Acute
Urinary Retention
The answer to the question, "How long should the
catheter stay in?" remains elusive. A 1982 prospec-
tive study of 107 patients by Breum et al found
that up to 70% of men had a recurrent episode of
AUR within 1 week if the bladder was drained
only initially on presentation.54 A 1989 random-
ized control trial by Taube et al of 60 patients, with
times of catheter removal of 0, 24, or 48 hours, found
that there was no correlation between the time of
catheter removal and the likelihood of spontane-
ous voiding.55 In 2006, in an observational study
of 2618 patients, Desgrandchamps et al found that
men with BPH and AUR catheterized for ≤ 3 days
had greater success with spontaneous voiding than
those catheterized for > 3 days.56 The 2003 American
Urological Association guidelines recommend at
least 1 attempt at voiding after catheter removal in
a BPH patient before considering surgical interven-
tion.44 In a 2006 prospective cross-sectional survey of
6074 patients, Fitzpatrick et al showed that pro-
longed catheterization (> 3 days) did not influence
trial without catheter success, but it was associated
with increased morbidity.57 A 2004 and 2005 pro-
spective study showed that men with BPH have a
greater chance of a successful voiding trial without
catheter at 2 to 3 days if they are treated with alpha-
adrenergic blockers for 3 days, starting at the time of
catheter insertion.58,59
The PLESS study classified patients into 2
groups: ”spontaneous“ AUR and ”precipitated“
AUR. Patients with spontaneous AUR had no evi-
dence of precipitating factors other than BPH, while
patients with precipitated AUR (in addition to BPH)
had clinical evidence of other precipitating factors
such as: (1) UTI, (2) preceding surgery, (3) predis-
posing medication exposure, or (4) inciting medical
event. Outcomes showed that patients with spon-
taneous AUR had a higher rate of recurrent spon-
taneous AUR and a greater need for BPH surgery
than patients with precipitated AUR (in whom trial
without catheter immediately after bladder drainage
can be attempted).46
January 2014 • www.ebmedicine.net
Pre-Foley Insertion Balloon Testing
Whether it is necessary to test the balloon for
patency prior to urethral catheterization remains
uncertain. Pretesting the balloon ensures it is sym-
metrical, that it inflates without leaking, and that it
deflates. Negative effects of balloon testing include
balloon cuffing, the formation of ridges or creases,
and the possibility of urethral trauma and balloon
entrapment.60,61
A review of practice guidelines by Barnes et al
looked at 3 catheters in a laboratory setting and 4 in
a clinical setting and found a substantial increase in
resultant diameter with pretesting (inflation and de-
flation), which could make catheter placement more
difficult.60 Moreover, a review article found that the
collapse of the balloon during inflation and deflation
results in ridges or cuff formation, which can result
in urethral trauma and make atraumatic removal of
the catheter difficult or even impossible.61 Another
conclusion of this article was that there is a growing
(but still limited) evidence base for managing pa-
tients with Foley catheters, leaving many questions
unanswered. Until these and other questions are
answered, recommendations are to carefully apply
clinical guidelines, regularly review existing evi-
dence, and ensure that institutional protocols follow
the manufacturers' guidelines.61-63
Future areas of research in this area could
include cost and prevalence studies, studies on
adequate volumes of prefill, “gravity drainage”
versus manual aspiration, slow versus fast catheter
removal, and usage of silicone versus latex catheters.
Managing The Entrapped Foley Catheter
One potential complication of Foley catheter remov-
al is entrapment of the catheter as a result of balloon
malfunction, a faulty valve mechanism, malfunction
of the inflation channel, or crystallization of fluid
within the balloon. This often becomes evident as a
failure to deflate despite manipulation and repeated
attempts at fluid aspiration. Often, this phenomenon
is due to cuffing, which happens after complete
removal of fluid contents from the catheter balloon.
This cuff can attach on to soft tissue within the blad-
der or urethra. This can be avoided by 2 techniques.
The first techniques is by very slow deflation of the
catheter balloon or by passive deflation with the sy-
ringe. The second technique is instilling 0.5 to 1 mL
of water back into the balloon after complete evacu-
ation of fluid contents from the balloon, eliminating
the already-formed balloon cuff and smoothing the
retaining ridge.63
If the Foley still cannot be removed after follow-
ing the above procedures, the next step is to confirm
placement in the bladder, using bedside ultrasound,
and then to cut the balloon port proximal to the
inflation valve. A review by Hollingsworth et al of 13
patients with Foley balloon malfunction found that
15 Emergency Medicine Practice © 2014
this technique was successful in 31% of their cases.65
If this method fails, there is, most likely, a more distal
obstruction that may be fixed by inserting a fine-
gauge guidewire through the inflation channel. If the
blockage persists after guidewire insertion, the next
step is to thread a 22-gauge central venous catheter
over the wire and remove it when the catheter tip is
in the balloon, allowing for drainage.64 This technique
was successful in 15% of Hollingsworth et al’s cases.65
If all of these methods are unsuccessful, the
balloon may be dissolved chemically using 10 mL
of mineral oil and waiting 15 minutes. This can be
repeated only once, if needed. The most extreme
and final methods described in the literature involve
active rupture of the Foley balloon with a sharp in-
strument. These numbered 31% of Hollingsworth et
al’s cases. Some approaches include transabdominal,
transvaginal, transperineal, and transrectal punc-
ture of the catheter balloon using ultrasonography.
Due to the risk of bladder rupture and severe pain,
hyperinflation of the balloon with either air or saline
is not recommended.64
Disposition
AUR patients with concomitant infection, signifi-
cant comorbid illnesses, impaired renal function,
neurological deficits, or complications of catheter-
ization require emergent urological consultation
and likely admission. 66 as an outpatient.
Because of the 70% recurrence rate of spontane-
ous AUR in patients with BPH, the catheter should
be left in place at discharge from the ED. One retro-
spective review of 1257 patients found that 90% of
patients with AUR in the ED are discharged home
with a catheter in place to await further intervention
from a urologist in an outpatient setting.67
Return parameters (such as fever, penile pain,
repeated vomiting, abdominal pain, and catheter
blockage) as well as instructions on hip/leg bag and
Foley care, should be discussed and verbalized by
the patient. In patients discharged with indwell-
ing catheters, prophylactic antibiotics should not
be initiated, as they have been found to promote
organism resistance (unless the patient is pregnant
or preoperative).51 Among patients discharged with
indwelling catheters, bacteriuria often develops, but
it is typically asymptomatic.51
Regarding pharmacological treatment, an alpha
blocker (such as tamsulosin) should be started in
patients with AUR secondary to BPH prior to dis-
charge from the ED not only because of improved
urinary symptoms and flow rate, but because of the
increased chance of successful voiding at days 2 to 3.
Remember to explain the increased risks of ortho-
static hypotension with the use of alpha blockers,
especially in the elderly.
Emergency Medicine Practice © 2014 16
Prevention of AUR recurrences over 4 to 6 years
in men with BPH may also be achieved by long-
term management with finasteride in patients with
enlarged prostates on clinical examination; however,
we recommend that this medication be started by a
physician who can provide follow-up.
Lastly, because of the increased risk of morbid-
ity (as shown by Fitzpatrick et al) and the poorer
success rates for spontaneous voiding (as shown by
Desgrandchamps et al), urge patients to consult a
urologist within 3 days. At this follow-up appoint-
ment, the need for further urodynamic studies,
laboratory studies such as PSA levels, and addi-
tional pharmacotherapy (such as 5-alpha reductase
inhibitors) may be discussed with the patient.32
AUR secondary to precipitated causes are at lower
risk of recurrence and, thus, might benefit from
trial without catheter in the ED directly after blad-
der drainage. See Table 9 for recommendations on
outpatient treatment and follow-up for patients dis-
charged from the ED who present with AUR.
Complications of chronic catheter placement
include UTI, ureteral stones, trauma, and stricture,68
and these complications have been independently
associated with an increased risk of mortality.67
However, it is still important to keep in mind that
early removal of urinary catheters is associated with
a higher risk of recurrent AUR, so catheters should
remain in place until the patient can visit a urologist
Summary
AUR in men is a very common syndrome that is
frequently diagnosed and managed in the ED. While
there is a vast array of published material on the
incidence, etiology, and treatment of AUR in men,
with the exception of few case reports, there is very
little published on the treatment of women with
Table 9. Recommendations On Outpatient
Treatment And Follow-Up For Patients
Discharged From The Emergency
Department With Either Spontaneous Or
Precipitated AUR
Sources of AUR
AUR Therapies Benign Prostatic Precipitated Causes
Hypertrophy
Medications Prescribe alpha block- Prescribe antibiotics,
ers if needed
Catheters Leave in place Remove, if passed
voiding trial in ED
Follow-up See urologist within 3 At discretion of ED
days clinician
Abbreviations: AUR, acute urinary retention; ED, emergency
department.
www.ebmedicine.net • January 2014
AUR, and this remains a small but important area
for research.
Due to the wide variety of symptoms for sus-
pected AUR in the ED, a careful history and physical
examination are vital. In men and women, thorough
genital, pelvic, and rectal examinations are needed
to assess for emergent precipitators of AUR. Ultra-
sound may be used diagnostically and therapeuti-
cally in aiding invasive catheter placement, and
also as a cost-saving measure. While most labora-
tory studies may be ordered at the discretion of the
emergency clinician, most patients may only require
urinalysis. Once AUR is identified, patients should
be treated with prompt and total bladder decom-
pression, with utilization of a Coude catheter if a
Foley catheter cannot be passed.
When considering patient admission versus
discharge, the emergency clinician should consider
patient comorbidities and precipitating factors.
In precipitated cases of AUR, the catheter can be
removed and a voiding trial performed prior to
discharge from the ED. When BPH is the cause, the
urinary catheter should be left in, an alpha blocker
prescribed, and urology consultation arranged
within 3 days. As always, patient and family educa-
tion, with discharge instructions for Foley care and
leg bag emptying, are of the utmost importance.
Time- And Cost-Effective
Strategies
• In patients with no comorbidities where BPH is
the likely etiology of AUR, the only laboratory
study necessary is a urinalysis.
• Asymptomatic bacteriuria in patients with
chronic indwelling catheters is common and
does not need further intervention or antibiotic
treatment.
• Utilize ultrasound for Foley, Coude, and supra-
pubic catheter placement to avoid costly compli-
cations.
• Remember that guidelines state that men with
mild lower urinary tract symptoms can be fol-
lowed expectantly with watchful waiting rather
than rushing to surgical intervention.
• Urgent attention to bladder decompression of
extremely uncomfortable patients may result
in less need for hospital resources, such as pain
medications.
• Using ultrasound to diagnose AUR in a patient
with abdominal pain may obviate the need for
more expensive diagnostic testing (such as CT
scan).
January 2014 • www.ebmedicine.net
Case Conclusions
In the case of the 66-year-old man with hypertension and
high cholesterol, after you performed a thorough head-to-
toe examination and a complete history, you performed a
rectal examination, which showed good rectal tone with
an enlarged, smooth prostate. You used bedside ultra-
sound to evaluate the bladder and saw a full, distended
bladder with an approximate volume of 1100 mL. Urgent
bedside complete bladder decompression was performed
with a 16F dual-lumen Foley catheter, and urine was sent
for urinalysis and culture. The patient’s symptoms im-
proved, his vital signs remained stable, and the urinalysis
returned as normal. You arranged a urology follow-up
appointment in 3 days, had the Foley bag changed to a
hip bag, and gave the patient care and changing instruc-
tions. You prescribed him a 2-week course of doxazosin
and discharged him home with return instructions if his
condition worsened.
In your second case, the 72-year-old man, a quick
physical examination revealed only a distended bladder.
A urethral catheter was placed, and 700 mL of urine was
obtained, with much relief for the patient. Not forget-
ting the patient’s presentation and his stumble while
changing stretchers, you decided to perform a thorough
neurological examination, and you found nearly absent
rectal tone and absence of sensation and vibration below
T11. Urgent MRI confirmed your diagnosis of spinal
cord compression. You consulted neurosurgery, and the
patient was admitted for decompressive laminectomy
and eventual chemotherapy.
In the third case, the 46-year-old febrile woman with
HIV, after taking her history and giving her a thorough
physical examination, you performed a rectal examina-
tion, which showed good rectal tone and no evidence of
obstruction. You then performed a pelvic examination
(with a chaperone present), and it showed vesicular le-
sions suggestive of herpes. Adequate pain control was
achieved. Ultrasound showed a fully distended bladder.
You gave the patient acetaminophen, IV acyclovir, and IV
fluids, and you started cardiorespiratory monitoring. You
performed complete bladder decompression using a 16F
Foley and sent the urine for urinalysis and culture. The
urinalysis returned positive for white blood cells, so you
gave her IV ceftriaxone and admitted her to medicine for
IV antibiotics, IV fluids, and antivirals.
17 Emergency Medicine Practice © 2014
 Risk Management Pitfalls For Acute Urinary Retention
1. “My female patient was having difficulty
urinating, so I assumed that it was a UTI and
omitted the pelvic exam.”
A thorough pelvic examination is important
in ruling out uterine prolapse or other organ
obstruction as a cause of AUR in women.
2. “I treated this patient in the ED for AUR and
removed his Foley prior to his discharge, but
he is back again today!”
Up to 70% of men with AUR due to BPH will
have recurrence if the bladder is drained only
during the ED visit and the catheter is removed
prior to discharge.
3. “I went to place a suprapubic catheter in my
patient and aspirated air.”
Remember the potential bad outcomes involved
with a misplaced suprapubic catheter and
the importance of using ultrasound during
placement and for confirmation of successful
Foley, Coude, and suprapubic catheter insertion.
4. “The nurse kept telling me that the patient had
severe low back pain. It was busy in the ED, so
I gave him 2 Percocets and 4 mg of IV mor-
phine before I assessed him. It turned out all
that he needed was bladder decompression.”
Urgent bladder decompression is the definitive
treatment for AUR, and it treats pain and saves
money on unnecessary testing. Also, treating the
patient’s pain acts to improve his ED experience.
5. “The resuscitation was busy, and I couldn’t
find saline, so I injected air into the Foley bal-
loon. Now it doesn’t work.”
Injecting air into the Foley balloon may cause
it to sit inappropriately within the bladder,
interfering with its function.
6. “I placed a Foley in an elderly gentlemen with
AUR and discharged him home. Now he has
returned with paraphimosis.”
Remember to reduce the foreskin in
uncircumcised patients, as it may cause
paraphimosis.
Emergency Medicine Practice © 2014 18
7. “I did a CT scan on a patient with abdominal
pain. It showed a markedly full, distended
bladder. Maybe I should have done an ultra-
sound first.”
A thorough history and physical examination
is needed to differentiate AUR as a cause of
abdominal distension and pain, and bedside
ultrasound may be used to confirm the diagnosis
instead of other costly diagnostic modalities.
8. “The patient seemed reliable, and I assumed
he would follow up at the urology clinic. Little
did I know that they didn’t have any appoint-
ments for 3 months!”
Remember the importance of prompt
urological follow-up and the complications of
chronic catheter usage. It is essential to ensure
that the patient does actually have follow-up
prior to discharge.
9. “I removed the fluid from the Foley balloon,
and now it will not come out.”
There is a risk of balloon cuffing when fluid is
removed too quickly from the catheter balloon.
Consider instilling 0.5 to 1 mL of water into the
balloon to smooth the already-formed cuffs.
10. “I sent home an elderly patient with tamsulo-
sin and an indwelling catheter, but she came
back after passing out at home.”
Though prescribing alpha blockers is
recommended, orthostatic hypotension is a
common side effect in patients taking these
medications. Adequate instruction on the side
effects of all medications prescribed must be
given to the patient and family. Tamsulosin
may be taken at night to reduce the impact of
side effects.
www.ebmedicine.net • January 2014
 tatic hyperplasia. Finasteride Long-Term Efficacy and Safety
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Prospective European Doxazosin and Combination Therapy
(PREDICT) trial. Urology. 2003;61(1):119-126. (Prospective
double-blind placebo-controlled trial; 1095 patients)
46. Roehrborn CG, Bruskewitz R, Nickel JC, et al. Sustained
decrease in incidence of acute urinary retention and surgery
with finasteride for 6 years in men with benign prostatic
hyperplasia. J Urol. 2004;171(3):1194-1198. (Retrospective
analysis of PLESS study)
47. O’Leary MP, Roehrborn C, Andriole G, et al. Improvements
in benign prostatic hyperplasia-specific quality of life with
dutasteride, the novel dual 5-alpha-reductase inhibitor. BJU
Int. 2003;92(3):262-266. (Prospective randomized controlled
studies; 4325 patients)
48. Nickel JC, Gilling P, Tammela TL, et al. Comparison of
dutasteride and finasteride for treating benign prostatic
hyperplasia: the Enlarged Prostate International Comparator
Study (EPICS). BJU Int. 2011;108(3):388-394. (Review)
49.* McConnell JD, Roehrborn CG, Bautista OM, et al. The
long-term effect of doxazosin, finasteride, and combination
therapy on the clinical progression of benign prostatic hy-
perplasia. N Engl J Med. 2003;349(25):2387-2398. (Prospective
double-blind, placebo-controlled trial; 3047 men)
50. Roehrborn CG, Barkin J, Siami P, et al. Clinical outcomes
after combined therapy with dutasteride plus tamsulosin or
either monotherapy in men with benign prostatic hyper-
plasia (BPH) by baseline characteristics: 4-year results from
the randomized, double-blind Combination of Avodart and
Tamsulosin (CombAT) trial. BJU Int. 2011;107(6):946-954.
(Prospective randomized controlled trial; 4844 patients)
51. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases
Society of America guidelines for the diagnosis and treat-
ment of asymptomatic bacteriuria in adults. Clin Infect Dis.
2005;40(5):643-654. (Review)
52. Murphy AB, Nadler RB. Pharmacotherapy strategies in
chronic prostatitis/chronic pelvic pain syndrome man-
Emergency Medicine Practice © 2014 20
agement. Expert Opin Pharmacother. 2010;11(8):1255-1261.
(Review)
53. Mustonen S, Ala-Houhala IO, Vehkalahti P, et al. Kidney ul-
trasound and Doppler ultrasound findings during and after
acute urinary retention. Eur J Ultrasound. 2001;12(3):189-196.
(Prospective study; 25 patients)
54. Breum L, Klarskov P, Munck LK, et al. Significance of acute
urinary retention due to intravesical obstruction. Scand J Urol
Nephrol. 1982;16(1):21-24. (Prospective study; 107 patients)
55.* Taube M, Gajraj H. Trial without catheter following acute
retention of urine. Br J Urol. 1989;63(2):180-182. (Prospective
study; 60 patients)
56. Desgrandchamps F, De La Taille A, Doublet JD. The man-
agement of acute urinary retention in France: a cross-section-
al survey in 2618 men with benign prostatic hyperplasia. BJU
Int. 2006;97(4):727-733. (Prospective cross-sectional survey;
2618 patients)
57. Fitzpatrick JM, Desgrandchamps F, Adjali K, et al. Man-
agement of acute urinary retention: a worldwide survey
of 6074 men with benign prostatic hyperplasia. BJU Int.
2012;109(1):88-95. (Prospective cross-sectional survey; 6074
patients)
58. McNeill SA, Hargreave TB. Alfuzosin once daily facilitates
return to voiding in patients in acute urinary retention. J
Urol. 2004;171(6 Pt 1):2316-2320. (Prospective study; 360
patients)
59. Lucas MG, Stephenson TP, Nargund V. Tamsulosin in the
management of patients in acute urinary retention from
benign prostatic hyperplasia. BJU Int. 2005;95(3):354-357.
(Prospective multicenter study; 149 men)
60. Barnes KE, Malone-Lee J. Long-term catheter management:
minimizing the problem of premature replacement due to
balloon deflation. J Adv Nurs. 1986;11(3):303-307. (Review of
evidence-based practice guidelines)
61. Cochran S. Care of the indwelling urinary catheter: is
it evidence based? J Wound Ostomy Continence Nurs.
2007;34(3):282-288. (Review article of practice guidelines)
62. Smith JM. Indwelling catheter management: from habit-
based to evidence-based practice. Ostomy Wound Manage.
2003;49(12):34-45. (Review)
63. Gonzalgo ML, Walsh PC. Balloon cuffing and management
of the entrapped Foley catheter. Urology. 2003;61(4):825-827.
64. Shapiro AJ, Soderdahl DW, Stack RS, et al. Managing
the nondeflating uretral catheter. J Am Board Fam Pract.
2000;13(2):116-119. (Literature review)
65. Hollingsworth M, Quiroz F, Guralnick ML. The manage-
ment of retained Foley catheters. Can J Urol. 2004;11(1):2163-
2166. (Review of 13 cases)
66. Roehrborn CG. Acute urinary retention: risks and manage-
ment. Rev Urol. 2005;7 Suppl 4:S31-S41. (Review)
67. Modi P, Pleat J, Cheetham P, et al. A 23-year review of the
management of acute retention of urine: progressing or
regressing? Ann R Coll Surg Engl. 2000;82(5):333-335. (Retro-
spective review; 1257 patients)
68. Drinka PJ. Complications of chronic indwelling urinary
catheters. J Am Med Dir Assoc. 2006;7(6):388-392. (Review)
69. Kunin CM, Douthitt S, Dancing J, et al. The association be-
tween the use of urinary catheters and morbidity and mortal-
ity among elderly patients in nursing homes. Am J Epidemiol.
1992;135(3):291-301. (Prospective study; 1540 patients)
www.ebmedicine.net • January 2014
CME Questions
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5. In treating spontaneous AUR in the ED after
Foley insertion, one should do which of the
following?
a. Decompress the entire bladder and leave the
Foley in.
b. Decompress the entire bladder and remove
the Foley.
c. Only partially decompress the bladder and
leave the Foley in.
d. Only partially decompress the bladder and
remove the Foley.
6. Which of the following are contraindications to
Foley placement?
a. Postoperative urological patient with known
bladder neck or prostate surgery
b. Known impassible Foley insertion
c. Radiographic evidence of bladder trauma
d. Scrotal/perineal hematoma
e. All of the above

7. Which of the following catheters is character-

ized by having a curved tip, balloon inflation
1. What is the most common cause of AUR in lumen, and draining lumen, and is commonly
women? used for continuous catheterization?
a. Medications a. Single-lumen Foley
b. Bladder masses and pelvic prolapse b. Double-lumen Foley
c. Trauma c. Triple-lumen Foley
d. UTI d. Coude catheter
2. Relaxation of the detrusor muscle to hold urine 8. Which of the following is an absolute contrain-
involves which of the following? dication for suprapubic catheter placement?
a. Parasympathetic inhibition of the detrusor a. Pregnancy
muscle b. Uncontrolled coagulopathy
b. Parasympathetic stimulation of the detrusor c. Pediatric cases
muscle d. Prior abdominal or pelvic surgery
c. Beta-adrenergic inhibition of the detrusor
muscle 9. Which of the following is not an indication for
d. Alpha-adrenergic inhibition of the detrusor urology consult?
muscle a. Genitourinary trauma
b. Failed Foley and Coude catheter placement
3. In addressing AUR in special patients, such as c. Uncontrolled hematuria
the elderly, one must keep in mind which of d. Transient hypotension after bladder
the following: decompression
a. Vital signs may not be actual predictors of
pathology 10. Which medication improves the likelihood of
b. Patients in this category may be unable to spontaneous voiding after catheter removal?
complain of discomfort a. Cyclobenzaprine
c. Obtaining collateral information may be b. Finasteride
helpful in determining history of present c. Tamsulosin
illness d. Ciprofloxacin
d. All of the above

4. Which part of the physical examination is es-

sential in women presenting with AUR?
a. Rectal exam
b. Genital/pelvic exam
c. Both a and b
d. Neither a nor b

January 2014 • www.ebmedicine.net 21 Emergency Medicine Practice © 2014


This Month in EM Practice
Guidelines Update: Current
Guidelines For The Evaluation
And Management Of
Heart Failure
The January/February 2014 issue of EM
Practice Guidelines Update reviews 2 recently
updated guidelines on the evaluation and
management of heart failure: the European
Society of Cardiology guideline, a 2012
update of their 2008 publication; and
the joint American College of Cardiology
Foundation/American Heart Association
guideline, a 2013 update of their 2009
publication. Trevor Lewis, MD; Deb Diercks,
MD; and Sigrid Hahn, MD have reviewed
these 2 updated guidelines and offer
summary and comment on what emergency
clinicians need to know about treating
patients with heart failure in the ED.
Although heart failure is a chronic condition,
the emergency clinician must be well-versed
in acute and chronic treatments and novel
concepts for early detection.
Some of the recommendations discussed in
this issue include:
• Chest x-ray, natriuretic peptide
measurements, and ECG in the ED offer
diagnostic options.
• Prompt treatment in the ED with IV
diuretics has been shown to reduce
morbidity in hemodynamically stable
patients.
• Vasodilators may be used as an adjunct
to diuretics to reduce dyspnea.
This online issue offers 2 hours of CME credit.
Be sure to log on to www.ebmedicine.net
to download your free subscription to
EM Practice Guidelines Update. Not sure
how to access your account? Call us at
1-800-249-5770 and we'll be glad to help
you get started.
Emergency Medicine Practice © 2014 22
Get 4 Hours Stroke CME Credit From
The July and August 2013 Issues Of
EM Practice Guidelines Update
The July and August issues of our online journal
supplement, EM Practice Guidelines Update, are
devoted to stroke topics, and each offers 2 hours
of Stroke CME credit. All subscribers to Emergen-
cy Medicine Practice automatically receive free
subscriptions to EM Practice Guidelines Update;
to access the articles, simply log in to your
www.ebmedicine.net account (or give us a call
and we’ll help you get your account set up).
The July issue reviews the 2009 guideline on
transient ischemic attack (TIA) and the revised
American Heart Association/American Stroke
Association (AHA/ASA) “tissue-based” diagnosis
of TIA. Jonathan Edlow, MD, of Harvard Medical
School, offers a guest editorial on the evolu-
tion of effective emergency care options for
TIA patients, and Editor-in-Chief Sigrid Hahn,
MD reviews and comments on portions of the
guideline relevant to emergency clinicians. Read
the issue online at: www.ebmedicine.net/TIA.
The August 2013 issue reviews 2 different
guidelines published in 2013 on acute ischemic
stroke and the use of intravenous t-PA (tissue
plasminogen activator) from: (1) the American
College of Emergency Physicians jointly with
the American Academy of Neurology, and (2)
the AHA/ASA. Christopher Hopkins, MD of the
University of Florida College of Medicine-Jackson-
ville, the guest editor, provides an assessment of
these controversial new guidelines, which have
been 8 years in development. Read this issue
online at: www.ebmedicine.net/Stroke.
www.ebmedicine.net • January 2014
 Coming Soon In
Emergency Medicine Practice
Cardiovascular Toxicity:
Management Of Digoxin,
Calcium-Channel Blocker, And
Beta Blocker Toxicity
AUTHORS:
WESLEY PALATNICK, MD, FRCPC
Professor and Program Director, Emergency Medicine
Residency, University of Manitoba; Attending
Physician, Department of Emergency Medicine,
Health Sciences Centre, Winnipeg, Manitoba, Canada
TOMISLAV JELIC, MD
Department of Emergency Medicine, University of
Manitoba, Winnipeg, Canada
The prevalence of cardiovascular disease is
increasing due to the aging population, and
cardiovascular medications, especially beta blockers
and calcium-channel blockers, are now some of the
most-prescribed therapeutic agents on the market.
As a result of this growing use and availability, there
has been a rise in the numbers of toxic exposures.
The 2011 annual report of the American Association
of Poison Control Centers found that cardiovascular
medications accounted for 102,766 exposures, which
was 3.74% of all exposures reported, and nearly 11%
of the fatalities.
Identifying patients exhibiting toxic effects of
these agents and their appropriate management
may be difficult. With the advent of newer
treatment modalities and controversies in others,
management can be complex. Standard Advanced
Cardiovascular Life Support (ACLS) protocols used for
the resuscitation of patients in cardiac arrest may
be insufficient due to the physiologic changes that
occur with poisoning with these agents, and often,
specific and specialized treatments are necessary.
This issue of Emergency Medicine Practice presents
the current evidence on best-practice diagnosis
and management of beta blocker, calcium-channel
blocker, and digoxin toxicity.
January 2014 • www.ebmedicine.net
Risk Stratification And Clinical
Decision-Making For
Syncope In The Emergency
Department
AUTHORS:
SUZANNE Y.G. PEETERS, MD
Emergency Medicine Residency Director, Haga
Hospital, The Hague, The Netherlands
J. STEPHEN HUFF, MD, FACEP
Associate Professor of Emergency Medicine and
Neurology, University of Virginia, Charlottesville, VA
AMBER E. HOEK, MD
Emergency Medicine Residency Director, Haga
Hospital, The Hague, The Netherlands
SUSAN M. MOLLINK, MD
Emergency Medicine Residency, Haga Hospital, The
Hague, The Netherlands
Accounting for 1% to 3% of all emergency department
visits, syncope is defined as a transient loss of
consciousness due to transient global cerebral
hypoperfusion, with rapid onset and spontaneous and
complete recovery. Although syncope is a symptom
with a wide range of possible underlying causes,
the most effective diagnostic tools in evaluating a
patient with syncope are the history and physical
examination. Studies show that if a nonstructured
evaluation is performed, the cause of syncope will be
unidentified in 50% of patients, resulting in high costs
and low diagnostic yield; however, if standardized
clinical evaluations are used, the diagnostic yield
increases up to 76%. Several decision rules for syncope
have been developed, and although none are sensitive
and specific enough to use in the ED setting, they give
a good overview of existing risk factors that predict
short-term adverse events. This issue of Emergency
Medicine Practice presents the best available evidence
for diagnosis and risk stratification for syncope and
provides guidance in differentiating patients who
can be safely discharged and those who need to be
hospitalized.
23 Emergency Medicine Practice © 2014
 Physician CME Information
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Emergency Medicine Practice © 2014 24 www.ebmedicine.net • January 2014