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Chronic urinary retention secondary to presumed bladder outlet obstruction — MSRA MCQ

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ModerateLUTSChronic urinary retention secondary to presumed bladder outlet obstructionMSRA

A 75-year-old man is reviewed for 14 months of progressively worsening weak stream, hesitancy, intermittency and nocturia. He also has a persistent sensation of incomplete emptying but no dysuria, fever, visible haematuria or loin pain. He has not previously received treatment for LUTS. His urine dipstick is negative for blood, nitrites and leucocytes. Digital rectal examination shows a smooth, enlarged prostate. His bladder is palpable after voiding. Post-void residual volume is 1.25 L on two measurements. Serum creatinine is 154 micromol/L (eGFR 39 mL/min/1.73 m²), having been 88 micromol/L (eGFR 72 mL/min/1.73 m²) 9 months earlier. Renal ultrasound shows bilateral hydronephrosis. He is haemodynamically stable and is able to perform clean intermittent self-catheterisation if required. What is the most appropriate immediate management?

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

Reveal the answer and explanation

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

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

This man has chronic urinary retention: he has a residual volume exceeding 1 litre and a palpable bladder. Crucially, he also has deterioration in renal function and bilateral hydronephrosis attributable to lower urinary tract dysfunction. NICE recommends catheterisation for chronic urinary retention when renal impairment or hydronephrosis is present. Specialist urological assessment is then required to establish the cause and plan definitive management, which may include intermittent catheterisation, outlet surgery or longer-term drainage depending on bladder function and fitness. A and B may have a role in uncomplicated bothersome LUTS due to benign prostatic enlargement, but medical treatment alone is inappropriate where obstructive uropathy is already evident. C is inappropriate because surgery without prior catheterisation is considered only for chronic retention with bothersome LUTS when there is no renal impairment or upper-tract abnormality. E is appropriate for non-bothersome chronic retention that has not been drained, but not when hydronephrosis and renal impairment are present.

Reference: NICE CG97: Lower urinary tract symptoms in men: management, recommendations 1.7.3 to 1.7.8 (Last updated June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations NICE CG97: Lower urinary tract symptoms in men: management, recommendation 1.7.7 (Last updated June 2015) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations