A 60-year-old man comes to the emergency department due to severe abdominal pain and an inability to void urine for the past 18 hours. The patient has a year-long history of urinary hesitancy and a weak urinary stream but has always been able to urinate prior to today. He has not had fever, chills, dysuria, or recent genitourinary trauma or procedures. The patient also has a history of chronic arthritis of the lumbar spine and was recently prescribed baclofen, which has provided some pain relief. He does not use tobacco, alcohol, or illicit drugs. Temperature is 36.5 C (97.7 F), blood pressure is 145/90 mm Hg, pulse is 95/min, and respirations are 18/min. The patient appears restless and in moderate distress. Abdominal examination reveals suprapubic fullness and moderate tenderness to palpation with no guarding or rebound tenderness. An enlarged, smooth, nontender prostate is palpated by digital rectal examination; no masses or fecal impaction are present. There is no tenderness to palpation of the lower back. Abbreviated testing of strength and sensory function is normal. Laboratory results are as follows:
| Complete blood count | ||
| Hemoglobin | 13.8 g/dL | |
| Leukocytes | 6,500/mm³ | |
| Serum chemistry | ||
| Blood urea nitrogen | 40 mg/dL | |
| Creatinine | 2.9 mg/dL | |
What is the best next step in management of this patient?
This older man with a year of lower urinary tract symptoms (eg, hesitancy, weak stream) likely has benign prostatic hyperplasia. This disorder is common in men age >50 and is typically diagnosed when the prostate grows large enough to impinge the urethra, resulting in lower urinary tract symptoms. If left untreated, a minority develop progressive urethral impingement leading to bladder outlet obstruction and acute urinary retention. Risk of acute urinary retention is increased with bladder/urethral infection, genitourinary trauma, and the use of certain medications (eg, baclofen, anticholinergics).
Acute urinary retention is often suspected when a patient is unable to void and has suprapubic discomfort/fullness and renal insufficiency. Bladder ultrasound is sometimes used to confirm the diagnosis (bladder volume >300 mL), but patients with suspicious symptoms often proceed directly to urethral or suprapubic catheterization. In most cases, urethral catheterization is attempted prior to consideration of suprapubic catheterization, particularly when a reversible cause (eg, medication) is likely. Suprapubic catheterization is usually reserved for patients with a recent history of genitourinary trauma/surgery or if urethral catheterization is unsuccessful (Choice D).
(Choice A) Infusion of intravenous fluid would likely worsen the patient's current symptoms, as he is unable to void.
(Choice B) The patient has failed to void for 18 hours, is in distress, and has renal insufficiency. Voiding trials are unlikely to be successful, and delaying bladder decompression puts this patient at risk for worsened renal insufficiency.
(Choice C) Suprapubic bladder aspiration is typically used to obtain uncontaminated urine specimens from children who are not toilet trained. Adults rarely get this procedure as they are generally capable of providing clean catch urine. Although this patient is not able to urinate at this time, the first priority is to insert a catheter to decompress the bladder. If needed, urine studies can be obtained after a catheter is inserted.
Educational objective:
Patients with benign prostatic hyperplasia are at risk for acute urinary retention due to bladder outlet obstruction. Immediate bladder decompression using urethral or suprapubic catheter is required to prevent progression and acute renal failure. For most patients, urethral catheterization is attempted prior to consideration of suprapubic catheterization.