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Acute urinary retention precipitated by antimuscarinic treatment in bladder outlet obstruction — MSRA MCQ

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HardBPHAcute urinary retention precipitated by antimuscarinic treatment in bladder outlet obstructionMSRA

A 74-year-old man with benign prostatic enlargement takes tamsulosin MR 400 micrograms daily. His voiding symptoms are well controlled, but persistent urgency and urge incontinence led to solifenacin 5 mg daily being added 3 weeks ago. He now presents with 10 hours of complete inability to pass urine and worsening suprapubic pain. He is afebrile, has no dysuria or haematuria, and urine dipstick is negative for leucocytes and nitrites. Examination shows a tender, palpable bladder. Bladder scan shows 780 mL residual urine. He is haemodynamically stable and has no neurological symptoms. What is the most appropriate management now?

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

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Correct answer: D — Immediately insert a urethral catheter, withhold solifenacin, continue tamsulosin before a later trial without catheter, and arrange urological assessment

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

This is acute urinary retention: he has complete inability to void, acute suprapubic pain, a palpable bladder and a residual volume of 780 mL. NICE recommends immediate catheterisation for acute retention; management should not be delayed for outpatient review, repeat scanning or urine culture. Solifenacin is a likely precipitant because antimuscarinics can worsen emptying in clinically significant bladder outlet obstruction and are contraindicated once urinary retention has developed. It should therefore be withheld. Tamsulosin should be continued. NICE recommends offering an alpha blocker before catheter removal in acute urinary retention, to improve the chance of a successful trial without catheter. Retention also warrants specialist assessment. A is unsafe because the 1-litre threshold relates to investigation of chronic retention, not a threshold for draining painful acute retention. B may have a role in selected chronic retention, but is not first-line management of acute painful retention. C incorrectly attributes the presentation to infection despite absent supportive features and fails to decompress the bladder. D correctly decompresses the bladder but incorrectly stops the alpha blocker, which should be used before catheter removal.

Reference: NICE CG97: Lower urinary tract symptoms in men: management — Treating urinary retention (Published 2010; last updated June 2015; last reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations Solifenacin succinate Sandoz 10 mg film-coated tablets — Summary of Product Characteristics (2023) — https://www.medicines.org.uk/emc/product/10464/smpc