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Lower urinary tract symptoms in men, age-related (including symptoms of benign prostatic hyperplasia/hypertrophy) - Management
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How do I manage acute urinary retention in a man?
- If this is the first episode of acute urinary retention:
- Admit the man urgently for catheterization and investigation of the cause.
- If the expertise and facilities are available, catheterize before admission.
- For an episode of recurrent acute retention, or acute-on-chronic urinary retention:
- Admit the man, or insert a urethral catheter. Discuss and decide on treatment to prevent or manage recurrent urine retention. Options include:
- An alpha-blocker (alfuzosin) — start at least 24 hours before attempting to remove the catheter. After removing the catheter, confirm over several hours that the man can void freely. Continue the alpha-blocker until the man has been fully investigated to determine the cause and to assess renal function. For detailed prescribing information, see Alpha-blockers for voiding symptoms.
- Intermittent urethral catheterization — refer the man or his carer to a continence nurse for training in catheterization.
- A long-term indwelling catheter — only if intermittent catheterization is not appropriate or practical.
Basis for recommendation
These recommendations are in line with the guideline The management of lower urinary tract symptoms in men from the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010].
Admission
- The recommendations to admit men with acute urinary retention (unless the expertise and facilities are available in primary care) is based on expert opinion in NICE referral guidelines [NICE, 2001].
Alpha-blockers
- The recommendation on offering an alpha-blocker before removal of the urinary catheter in an episode of acute retention reflects NICE guidelines [NICE, 2010].
- The NICE systematic review found four randomized controlled trials (RCTs) that provide consistent, but imprecise because the studies were small, evidence that alpha-blockers improve the chance of being able to void after removing the urinary catheter. Two of the RCTs found no significant difference in the need for recatheterization, but the studies lacked statistical power and had serious methodological limitations. One economic study conducted in the UK suggests that the use of an alpha-blocker may be cost-saving, but the study did not include a full cost-effectiveness analysis.
Intermittent or continuous urethral catheterization
- These recommendations are based on expert opinion, because NICE found no directly relevant controlled trials [NICE, 2010].
How do I manage chronic urinary retention in a man?
- Exclude non-obstructive causes of reduced urine flow (such as chronic heart failure).
- Check serum creatinine to assess renal function.
- Refer the man for specialist assessment.
- Consider seeking specialist advice about arranging imaging of the upper urinary tract and kidneys while the man is waiting to be seen.
- Management options in secondary care depend on renal function and the man's wishes, and include:
- No catheterization, but follow up with active surveillance of renal function, volume of urinary retention, and changes in imaging of upper renal tract.
- Intermittent urethral catheterization, performed by the man or his carer.
- A permanent indwelling catheter.
- Surgery to divert the urine externally (urostomy).
Basis for recommendation
These recommendations are in line with the guideline The management of lower urinary tract symptoms in men from the National Institute for Health and Clinical Excellence (NICE) [NICE, 2010].
Referral for specialist assessment
- The recommendations about referral for specialist assessment are based on expert opinion as NICE found no directly relevant clinical trials [NICE, 2010].
Assessing renal function with serum creatinine
- The indications for measuring serum creatinine (palpable bladder, nocturnal enuresis, recurrent urinary tract infection, history of renal stones) are based on expert opinion, because NICE found no studies that assessed how measuring renal function affects clinical outcomes in men with lower urinary tract symptoms (LUTS) [NICE, 2010].
- The NICE guideline development group considered serum creatinine to be the most reliable routine test for renal function. They highlighted that many laboratories report eGFR (estimated glomerular filtration rate) whenever serum creatinine is measured, and that (when required) renal function can be more accurately assessed by measuring creatinine clearance.
- The NICE guideline development group considered serum urea to be less reliable than serum creatinine for assessing renal function.
Assessing renal function and structure with radiological imaging
- The NICE systematic review found no studies that assessed how radiological imaging affects clinical outcomes in men with LUTS. The recommendations are therefore based on expert opinion [NICE, 2010].
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Alfuzosin
Age from 40 years onwards
Alfuzosin m/r tablets: 10mg once a day
Alfuzosin 10mg modified-release tablets
Take one tablet once a day.
Supply 30 tablets.
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