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Chronic urinary retention with hydronephrosis and renal impairment, likely secondary to bladder outlet obstruc

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HardLUTSChronic urinary retention with hydronephrosis and renal impairment, likely secondary to bladder outlet obstruction from benign prostatic enlargementMSRA

A 74-year-old man is reviewed in general practice with 6 months of worsening frequency, urgency and nocturnal enuresis. He also reports a weak stream, hesitancy and a sensation of incomplete emptying. He has taken tamsulosin MR 400 micrograms daily for 8 weeks with little benefit. Urine dipstick is negative for blood, nitrites, leucocytes, glucose and protein. DRE demonstrates a smoothly enlarged prostate. A bladder scan performed after he voids 180 mL shows a post-void residual volume of 1.2 L. His eGFR has fallen from 76 to 43 mL/min/1.73 m² over 4 months, and urgent renal ultrasound demonstrates bilateral hydronephrosis without ureteric calculi. What is the most appropriate immediate management?

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Correct answer: C — Arrange urethral catheterisation today and urgent urological assessment

Explanation lettering: E = shown as A · A = shown as B · B = shown as C · C = shown as E

This man has chronic urinary retention with upper tract consequences, rather than uncomplicated overactive bladder. The key discriminators are the very large post-void residual volume (1.2 L), nocturnal enuresis suggesting chronic overflow, new renal impairment and bilateral hydronephrosis. NICE recommends catheterisation when chronic urinary retention has caused impaired renal function or hydronephrosis. He also requires urgent urological assessment to establish and manage the underlying outlet obstruction and assess renal recovery. A is attractive because urgency and frequency are storage symptoms, and NICE permits anticholinergic treatment for overactive bladder. However, his marked retention and likely clinically significant bladder outlet obstruction make solifenacin inappropriate: urinary retention is a contraindication and bladder outflow obstruction carries further retention risk. C may ultimately be appropriate for progression-risk reduction in benign prostatic enlargement, but finasteride has no role as sole immediate treatment of established high-pressure retention. D is insufficiently urgent: specialist flow rate and post-void residual measurement are useful diagnostically, but the diagnosis already includes retention with renal tract compromise. E addresses nocturia but delays decompression of an obstructed urinary tract.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Published 2010; last updated June 2015; surveillance reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Published 2010; last updated June 2015; surveillance reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Solifenacin 10 mg Film-Coated Tablets — Summary of Product Characteristics (2021) — https://www.medicines.org.uk/emc/product/11139/smpc