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Chronic urinary retention with hydronephrosis and renal impairment — MSRA MCQ

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HardUrologyChronic urinary retention with hydronephrosis and renal impairmentMSRA

A 74-year-old man reports 6 months of progressive nocturnal enuresis, daytime frequency and a weak urinary stream. He has no dysuria, fever, loin pain or visible haematuria. He is not particularly troubled by his voiding symptoms and has delayed seeking help. Examination shows a smooth, enlarged prostate and a palpable, non-tender bladder. Urine dipstick is negative for blood, nitrites and leucocytes. Bladder scan shows a post-void residual volume of 1.3 L. Creatinine is 156 micromol/L (previously 88 micromol/L), and urgent renal ultrasonography shows bilateral hydronephrosis. What is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Catheterise the bladder and arrange urgent specialist urological assessment

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

This is chronic urinary retention rather than uncomplicated benign prostatic enlargement: the residual volume exceeds 1 L and the bladder is palpable. Crucially, retention has caused upper-tract obstruction and renal impairment, demonstrated by bilateral hydronephrosis and a substantial creatinine rise. NICE recommends catheterisation when chronic retention is associated with impaired renal function or hydronephrosis secondary to retention; retention also warrants specialist assessment. A is inappropriate because alpha-blockade may subsequently have a role in outlet obstruction, but it does not address the immediate risk of ongoing high-pressure retention and renal injury. C is unsuitable because surgery without prior catheterisation is an option only where chronic retention coexists with bothersome LUTS but there is no renal impairment or upper-tract abnormality. D applies to non-bothersome chronic retention only when the bladder has not been drained and surveillance is clinically safe; this patient has established renal and upper-tract consequences. E is plausible because intermittent catheterisation can be considered in chronic retention, particularly where long-term management is required, but immediate bladder drainage and urgent specialist assessment take priority in this high-risk presentation.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management — Recommendations (Last reviewed 19 December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations