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Flashcard 7059444469004

Question
Integration by substitution is essentially
Answer
[default - edit me]

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Flashcard 7059445779724

Question
[default - edit me]
Answer
he reverse of the chain rule for differentiation

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ally the reverse of the chain rule for differentiation
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rearrange the integrand as a function of something times the derivative of that same something,
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In men, AUR is most often secondary to benign prostatic hyperplasia (BPH); AUR is rare in women [2,3].
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hrough: Jan 2022. | This topic last updated: Sep 29, 2021. INTRODUCTION — Acute urinary retention (AUR) is the inability to voluntarily pass urine. It is the most common urologic emergency [1]. <span>In men, AUR is most often secondary to benign prostatic hyperplasia (BPH); AUR is rare in women [2,3]. This topic will review issues related to evaluation and management of AUR. The diagnosis and treatment of BPH and chronic urinary retention in women are discussed separately. ●(See "Cli




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The most common mechanisms are outflow obstruction, neurologic impairment, or an inefficient detrusor muscle [9,10]. Other causes include medications, infection, and trauma
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1:13. PATHOGENESIS AND ETIOLOGIES — A variety of pathophysiologic mechanisms may be responsible for the development of acute urinary retention (AUR). Several mechanisms may occur concurrently. <span>The most common mechanisms are outflow obstruction, neurologic impairment, or an inefficient detrusor muscle [9,10]. Other causes include medications, infection, and trauma. ●Outflow obstruction – Obstruction is the most common cause of AUR [11]. The flow of urine can be impeded by mechanical factors (physical narrowing of the urethral channel) and/or dyna




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In males, the most common cause of obstruction is benign prostatic hyperplasia (BPH) [2-5,11]. Other causes of outflow obstruction in men include constipation, prostate or bladder cancer, urethral stricture, urolithiasis, phimosis, or paraphimosis [4,13].
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11]. The flow of urine can be impeded by mechanical factors (physical narrowing of the urethral channel) and/or dynamic factors (increased muscle tone within and around the urethra) [9,12,13]. •<span>In males, the most common cause of obstruction is benign prostatic hyperplasia (BPH) [2-5,11]. Other causes of outflow obstruction in men include constipation, prostate or bladder cancer, urethral stricture, urolithiasis, phimosis, or paraphimosis [4,13]. (See "Lower urinary tract symptoms in males" and "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia" and "Strictures of the adult male urethra".) •In fem




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In females, obstruction is generally secondary to anatomic distortion, including pelvic organ prolapse (eg, cystocele or rectocele), pelvic masses, or, less commonly, urethral diverticulum [7,14-23].
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imosis [4,13]. (See "Lower urinary tract symptoms in males" and "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia" and "Strictures of the adult male urethra".) •<span>In females, obstruction is generally secondary to anatomic distortion, including pelvic organ prolapse (eg, cystocele or rectocele), pelvic masses, or, less commonly, urethral diverticulum [7,14-23]. (See "Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management", section on 'Urinary symptoms' and "Urethral diverticulum in women".) ●Neurolo




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AUR can occur with spinal cord injuries from trauma, infarct or demyelination, epidural abscess and epidural metastasis, Guillain-Barré syndrome, diabetic neuropathy, and stroke [13]
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supply to the detrusor muscle [4]. Incomplete relaxation of the urinary sphincter mechanism (dyssynergia) can also result in elevations in both voiding pressures and post-void residual volumes. <span>AUR can occur with spinal cord injuries from trauma, infarct or demyelination, epidural abscess and epidural metastasis, Guillain-Barré syndrome, diabetic neuropathy, and stroke [13]. AUR is typically accompanied by back pain and/or other neurologic deficits. Patients with neurologic impairment may develop acute-on-chronic urinary retention. (See individual topic re




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AUR may occur in patients with an inefficient detrusor muscle when a precipitating event results in an acute distended bladder (eg, with a fluid challenge, during general or epidural analgesia without an indwelling catheter) [9,13,24-26]. This most often occurs in patients with obstructive urinary symptoms at baseline.
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or other neurologic deficits. Patients with neurologic impairment may develop acute-on-chronic urinary retention. (See individual topic reviews on each disorder.) ●Inefficient detrusor muscle – <span>AUR may occur in patients with an inefficient detrusor muscle when a precipitating event results in an acute distended bladder (eg, with a fluid challenge, during general or epidural analgesia without an indwelling catheter) [9,13,24-26]. This most often occurs in patients with obstructive urinary symptoms at baseline. ●Medications – Multiple medications (table 1) are implicated as a cause of urinary retention; most common among these are the anticholinergic and sympathomimetic drugs [27]. Medications




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Multiple medications (table 1) are implicated as a cause of urinary retention; most common among these are the anticholinergic and sympathomimetic drugs [27].
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id challenge, during general or epidural analgesia without an indwelling catheter) [9,13,24-26]. This most often occurs in patients with obstructive urinary symptoms at baseline. ●Medications – <span>Multiple medications (table 1) are implicated as a cause of urinary retention; most common among these are the anticholinergic and sympathomimetic drugs [27]. Medications lead to AUR through a variety of mechanisms. Patients taking opioids and anticholinergic medications are at higher risk for AUR due to decreased bladder sensation [1,28]. An




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Infections may lead to AUR in the setting of inflammation that causes obstruction. For example, an acutely inflamed prostate gland from acute prostatitis can cause AUR, particularly in men who already have BPH [11,29]. Similarly, a urinary tract infection can cause urethritis and urethral edema resulting in AUR [1,29].
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linergic medications also reduce detrusor contractility [28]. Nasal decongestants that contain sympathomimetic agents increase smooth muscle tone in the region of the bladder neck. ●Infection – <span>Infections may lead to AUR in the setting of inflammation that causes obstruction. For example, an acutely inflamed prostate gland from acute prostatitis can cause AUR, particularly in men who already have BPH [11,29]. Similarly, a urinary tract infection can cause urethritis and urethral edema resulting in AUR [1,29]. (See "Acute bacterial prostatitis", section on 'Clinical manifestations'.) Genital herpes may cause AUR both from local inflammation as well as sacral nerve involvement. (See "Epidemiol




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Genital herpes may cause AUR both from local inflammation as well as sacral nerve involvement.
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ave BPH [11,29]. Similarly, a urinary tract infection can cause urethritis and urethral edema resulting in AUR [1,29]. (See "Acute bacterial prostatitis", section on 'Clinical manifestations'.) <span>Genital herpes may cause AUR both from local inflammation as well as sacral nerve involvement. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Primary'.) Other infections that have been associated with AUR include




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Other infections that have been associated with AUR include varicella zoster and vulvovaginitis [1,11,29].
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R both from local inflammation as well as sacral nerve involvement. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Primary'.) <span>Other infections that have been associated with AUR include varicella zoster and vulvovaginitis [1,11,29]. ●Trauma – Patients with trauma to the pelvis, urethra, or penis may develop AUR from mechanical disruption [11]. (See "Blunt genitourinary trauma: Initial evaluation and management".) ●




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AUR may also occur postoperatively or in the postpartum period.
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●Trauma – Patients with trauma to the pelvis, urethra, or penis may develop AUR from mechanical disruption [11]. (See "Blunt genitourinary trauma: Initial evaluation and management".) ●Other – <span>AUR may also occur postoperatively or in the postpartum period. (See "Overview of post-anesthetic care for adult patients", section on 'Inability to void'.) CLINICAL PRESENTATION — Acute urinary retention (AUR) generally presents as an inability to




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Acute urinary retention (AUR) generally presents as an inability to pass urine, usually associated with lower abdominal and/or suprapubic discomfort [13]. Affected patients are often restless and may appear in considerable distress. In older adult patients, particularly those with dementia or other forms of cognitive impairment, AUR may present as an acute change of mental status [30].
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".) ●Other – AUR may also occur postoperatively or in the postpartum period. (See "Overview of post-anesthetic care for adult patients", section on 'Inability to void'.) CLINICAL PRESENTATION — <span>Acute urinary retention (AUR) generally presents as an inability to pass urine, usually associated with lower abdominal and/or suprapubic discomfort [13]. Affected patients are often restless and may appear in considerable distress. In older adult patients, particularly those with dementia or other forms of cognitive impairment, AUR may present as an acute change of mental status [30]. These manifestations may be less pronounced when AUR is superimposed upon chronic urinary retention. Chronic urinary retention is often painless [31]. Acute-on-chronic urinary retention




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These manifestations may be less pronounced when AUR is superimposed upon chronic urinary retention. Chronic urinary retention is often painless [31]. Acute-on-chronic urinary retention may present with overflow incontinence. The patients may complain of incontinence rather than the inability to pass urine.
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may appear in considerable distress. In older adult patients, particularly those with dementia or other forms of cognitive impairment, AUR may present as an acute change of mental status [30]. <span>These manifestations may be less pronounced when AUR is superimposed upon chronic urinary retention. Chronic urinary retention is often painless [31]. Acute-on-chronic urinary retention may present with overflow incontinence. The patients may complain of incontinence rather than the inability to pass urine. Patients with AUR are likely to present initially to an emergency department or the office of a primary care clinician. Hospitalized patients may develop AUR, often related to medicatio




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The patient history should focus on previous history of retention or lower urinary tract symptoms (table 2), prostate disease (hyperplasia or cancer), pelvic or prostate surgery, radiation, or pelvic trauma. The patient should also be asked about the presence of hematuria, dysuria, fever, low back pain, neurologic symptoms, or rash. Finally, a complete list of medications (including over-the-counter medications (table 1)) should be obtained
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ial evaluation of patients with symptoms suggestive of acute urinary retention (AUR) should begin with a history and physical examination to determine the likelihood of the disorder. ●History – <span>The patient history should focus on previous history of retention or lower urinary tract symptoms (table 2), prostate disease (hyperplasia or cancer), pelvic or prostate surgery, radiation, or pelvic trauma. The patient should also be asked about the presence of hematuria, dysuria, fever, low back pain, neurologic symptoms, or rash. Finally, a complete list of medications (including over-the-counter medications (table 1)) should be obtained. Younger patient age, a history of cancer or intravenous drug abuse, and the presence of back pain or neurologic symptoms suggest the possibility of spinal cord injury or compression. H




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Younger patient age, a history of cancer or intravenous drug abuse, and the presence of back pain or neurologic symptoms suggest the possibility of spinal cord injury or compression.
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resence of hematuria, dysuria, fever, low back pain, neurologic symptoms, or rash. Finally, a complete list of medications (including over-the-counter medications (table 1)) should be obtained. <span>Younger patient age, a history of cancer or intravenous drug abuse, and the presence of back pain or neurologic symptoms suggest the possibility of spinal cord injury or compression. However, patients with spinal pathology generally do not present primarily with AUR. These patients will most often have other signs and symptoms of spinal cord pathology, with AUR bein




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The initial physical examination should include lower abdominal palpation. The urinary bladder may be palpable, either on abdominal or rectal examination. Deep suprapubic palpation will provoke discomfort.
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tures and diagnosis of neoplastic epidural spinal cord compression", section on 'Clinical features' and "Spinal epidural abscess", section on 'Clinical manifestations'.) ●Physical examination – <span>The initial physical examination should include lower abdominal palpation. The urinary bladder may be palpable, either on abdominal or rectal examination. Deep suprapubic palpation will provoke discomfort. DIAGNOSIS — The diagnosis of acute urinary retention (AUR) is made by demonstrating retained urine by either bladder ultrasound or catheterization, in the appropriate clinical setting.




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In patients whose history and physical examination strongly suggest a diagnosis of AUR, or those in acute distress, it is reasonable to proceed directly to catheterization, which is both diagnostic and therapeutic, rather than waiting to obtain a bladder ultrasound. Alternatively, a bladder scanner can be used if immediately available.
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ood first choice for patients who are not in extreme distress, because it is noninvasive, it is more comfortable for the patient, and bladder decompression can be avoided if results are normal. <span>In patients whose history and physical examination strongly suggest a diagnosis of AUR, or those in acute distress, it is reasonable to proceed directly to catheterization, which is both diagnostic and therapeutic, rather than waiting to obtain a bladder ultrasound. Alternatively, a bladder scanner can be used if immediately available. (See 'Options for bladder decompression' below.) A bladder volume on ultrasound ≥300 cc suggests urinary retention warranting decompression. However, the bladder ultrasound may be inacc




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A bladder volume on ultrasound ≥300 cc suggests urinary retention warranting decompression. However, the bladder ultrasound may be inaccurate due to body habitus, tissue edema, or prior surgery and scarring. If the patient is in discomfort and unable to void, a urethral catheter should be placed regardless of the estimated volume on bladder ultrasound.
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stic and therapeutic, rather than waiting to obtain a bladder ultrasound. Alternatively, a bladder scanner can be used if immediately available. (See 'Options for bladder decompression' below.) <span>A bladder volume on ultrasound ≥300 cc suggests urinary retention warranting decompression. However, the bladder ultrasound may be inaccurate due to body habitus, tissue edema, or prior surgery and scarring. If the patient is in discomfort and unable to void, a urethral catheter should be placed regardless of the estimated volume on bladder ultrasound. Upon placement of a urethral catheter, the initial amount of urine drained should be noted. Patients with volumes <200 cc likely do not have acute urinary retention. These patients s




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Upon placement of a urethral catheter, the initial amount of urine drained should be noted. Patients with volumes <200 cc likely do not have acute urinary retention. These patients should undergo further evaluation by a urologist in an outpatient setting.
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, tissue edema, or prior surgery and scarring. If the patient is in discomfort and unable to void, a urethral catheter should be placed regardless of the estimated volume on bladder ultrasound. <span>Upon placement of a urethral catheter, the initial amount of urine drained should be noted. Patients with volumes <200 cc likely do not have acute urinary retention. These patients should undergo further evaluation by a urologist in an outpatient setting. The decision of whether to leave the catheter in is discussed below. (See 'Acute management' below.) POST-DIAGNOSTIC EVALUATION — In patients with acute urinary retention (AUR), the pos




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In patients with AUR of unknown etiology, further physical examination should include the following:

• Rectal examination – A rectal examination should be done in both all patients to evaluate for masses, fecal impaction, perineal sensation, and rectal sphincter tone. A normal prostate examination does not preclude benign prostatic hyperplasia (BPH) as a cause of obstruction.

• Pelvic examination – Women with urinary retention should have a pelvic examination.

• Neurologic evaluation – The neurologic examination should include assessment of strength, sensation, reflexes, and muscle tone.

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Acute management' below.) POST-DIAGNOSTIC EVALUATION — In patients with acute urinary retention (AUR), the post-diagnostic evaluation focuses on determining an etiology. ●Physical examination – <span>In patients with AUR of unknown etiology, further physical examination should include the following: •Rectal examination – A rectal examination should be done in both all patients to evaluate for masses, fecal impaction, perineal sensation, and rectal sphincter tone. A normal prostate examination does not preclude benign prostatic hyperplasia (BPH) as a cause of obstruction. •Pelvic examination – Women with urinary retention should have a pelvic examination. •Neurologic evaluation – The neurologic examination should include assessment of strength, sensation, reflexes, and muscle tone. ●Laboratory studies – A urine sample should be obtained and sent for urinalysis and urine culture. The need for other laboratory testing should be determined based upon findings from th




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A urine sample should be obtained and sent for urinalysis and urine culture.

The need for other laboratory testing should be determined based upon findings from the patient's history and physical examination. Most patients who present to the emergency department with concern for urinary retention have serum chemistries and creatinine checked. These should be checked in any patient whose history suggests acute-on-chronic urinary retention to evaluate for renal failure.

Other labs that may be helpful include a complete blood count (CBC) for suspected infection. We do not check a prostate-specific antigen (PSA) as it is expected to be elevated during an episode of AUR.

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etention should have a pelvic examination. •Neurologic evaluation – The neurologic examination should include assessment of strength, sensation, reflexes, and muscle tone. ●Laboratory studies – <span>A urine sample should be obtained and sent for urinalysis and urine culture. The need for other laboratory testing should be determined based upon findings from the patient's history and physical examination. Most patients who present to the emergency department with concern for urinary retention have serum chemistries and creatinine checked. These should be checked in any patient whose history suggests acute-on-chronic urinary retention to evaluate for renal failure. Other labs that may be helpful include a complete blood count (CBC) for suspected infection. We do not check a prostate-specific antigen (PSA) as it is expected to be elevated during an episode of AUR. ACUTE MANAGEMENT — The initial management of acute urinary retention (AUR) is prompt bladder decompression by catheterization, with urinalysis and culture. Options for bladder decompres




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A 14 to 18 gauge French catheter should be inserted as first-line in most patients with AUR [11]. Indications for choosing a smaller or larger catheter are discussed below.
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indications to urethral catheterization' below), particularly in patients for whom AUR is expected to resolve (eg, patients with urinary tract infections or AUR secondary to medication effect). <span>A 14 to 18 gauge French catheter should be inserted as first-line in most patients with AUR [11]. Indications for choosing a smaller or larger catheter are discussed below. (See 'Difficulties with urethral catheterization' below.) For patients with an initial urine volume of less than 200 cc, immediate catheter removal and subsequent observation for recurr




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For patients with an initial urine volume of less than 200 cc, immediate catheter removal and subsequent observation for recurrence is usually appropriate. These patients should be evaluated for other causes of abdominal and/or suprapubic discomfort.
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ld be inserted as first-line in most patients with AUR [11]. Indications for choosing a smaller or larger catheter are discussed below. (See 'Difficulties with urethral catheterization' below.) <span>For patients with an initial urine volume of less than 200 cc, immediate catheter removal and subsequent observation for recurrence is usually appropriate. These patients should be evaluated for other causes of abdominal and/or suprapubic discomfort. (See "Evaluation of the adult with abdominal pain" and "Evaluation of acute pelvic pain in nonpregnant adult women".) For patients with greater than 200 cc of urine, the volume drained




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For patients with greater than 200 cc of urine, the volume drained in the first 10 to 15 minutes should be noted and recorded as it is useful for subsequent management regarding duration of catheter use. If this volume exceeds 400 cc, the catheter is typically left in place. For volumes less than 400 cc, the decision to leave the catheter in place is guided by the clinical scenario.

For patients with greater than 200 cc and less than 400 cc, the decision on catheterization may take into account multiple factors. Patient comorbidities, mental status, ability to return to the hospital, and numerous other factors may influence this decision to leave an indwelling catheter.

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ld be evaluated for other causes of abdominal and/or suprapubic discomfort. (See "Evaluation of the adult with abdominal pain" and "Evaluation of acute pelvic pain in nonpregnant adult women".) <span>For patients with greater than 200 cc of urine, the volume drained in the first 10 to 15 minutes should be noted and recorded as it is useful for subsequent management regarding duration of catheter use. If this volume exceeds 400 cc, the catheter is typically left in place. For volumes less than 400 cc, the decision to leave the catheter in place is guided by the clinical scenario. For patients with greater than 200 cc and less than 400 cc, the decision on catheterization may take into account multiple factors. Patient comorbidities, mental status, ability to return to the hospital, and numerous other factors may influence this decision to leave an indwelling catheter. In patients with back pain or neurologic symptoms, the presence of spinal cord compression should be considered. Younger age, history of malignancy, or intravenous drug abuse can be ass




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In patients with AUR, we generally leave the catheter in place for three to five days, after which the patient is given a voiding trial. Examples of earlier catheter removal include postoperative patients who are initially unable to void but recover this ability within a few hours.
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ith back pain or neurologic symptoms, the presence of spinal cord compression should be considered. Younger age, history of malignancy, or intravenous drug abuse can be associated risk factors. <span>In patients with AUR, we generally leave the catheter in place for three to five days, after which the patient is given a voiding trial. Examples of earlier catheter removal include postoperative patients who are initially unable to void but recover this ability within a few hours. Contraindications to urethral catheterization — Urethral catheterization is contraindicated in patients who have had recent urologic surgery (eg, radical prostatectomy or urethral recon




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Urethral catheterization is contraindicated in patients who have had recent urologic surgery (eg, radical prostatectomy or urethral reconstruction), and these patients should have suprapubic catheterization. (See 'Suprapubic catheter' below.)

Although there is a theoretical risk to placement of a urethral catheter in the setting of acute bacterial prostatitis, these patients may have an attempt at gentle urethral catheterization by an experienced clinician.

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Examples of earlier catheter removal include postoperative patients who are initially unable to void but recover this ability within a few hours. Contraindications to urethral catheterization — <span>Urethral catheterization is contraindicated in patients who have had recent urologic surgery (eg, radical prostatectomy or urethral reconstruction), and these patients should have suprapubic catheterization. (See 'Suprapubic catheter' below.) Although there is a theoretical risk to placement of a urethral catheter in the setting of acute bacterial prostatitis, these patients may have an attempt at gentle urethral catheterization by an experienced clinician. (See "Acute bacterial prostatitis", section on 'Nonantimicrobial therapy'.) Difficulties with urethral catheterization — Some patients may have an obstruction that does not readily allo




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Some patients may have an obstruction that does not readily allow passage of the catheter. A partially obstructing urethral or prostatic scar may be present if the patient has had a prior transurethral procedure (eg, transurethral resection of the prostate), or pelvic trauma or radiation [10]. In this case, the obstruction may be bypassed by downsizing the catheter to a 10 or 12 gauge French indwelling catheter. In the absence of prior instrumentation or injury, the more common cause of obstruction would be an enlarged prostate. In this case, a larger catheter (20 or 22 gauge) with a firm coude tip may be needed and may require urologic consultation.
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attempt at gentle urethral catheterization by an experienced clinician. (See "Acute bacterial prostatitis", section on 'Nonantimicrobial therapy'.) Difficulties with urethral catheterization — <span>Some patients may have an obstruction that does not readily allow passage of the catheter. A partially obstructing urethral or prostatic scar may be present if the patient has had a prior transurethral procedure (eg, transurethral resection of the prostate), or pelvic trauma or radiation [10]. In this case, the obstruction may be bypassed by downsizing the catheter to a 10 or 12 gauge French indwelling catheter. In the absence of prior instrumentation or injury, the more common cause of obstruction would be an enlarged prostate. In this case, a larger catheter (20 or 22 gauge) with a firm coude tip may be needed and may require urologic consultation. (See "Placement and management of urinary bladder catheters in adults", section on 'Transurethral catheter placement'.) If attempts to pass a catheter are not successful, urgent urology




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Placement of a suprapubic (SP) catheter is sometimes necessary in patients who have contraindications to or fail urethral catheterization (eg, those with recent urologic surgery, acute prostatitis, urethral stricture disease, severe benign prostatic hyperplasia [BPH], or other anatomic abnormalities).
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omplications of urethral catheters are discussed separately. (See "Complications of urinary bladder catheters and preventive strategies", section on 'Urethral catheters'.) Suprapubic catheter — <span>Placement of a suprapubic (SP) catheter is sometimes necessary in patients who have contraindications to or fail urethral catheterization (eg, those with recent urologic surgery, acute prostatitis, urethral stricture disease, severe benign prostatic hyperplasia [BPH], or other anatomic abnormalities). SP catheters are usually placed by a urologist. Suprapubic tubes can be placed in either the operating room, the emergency department, or occasionally an outpatient clinic. However, pat




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In cases when no urologist or appropriately trained clinician is available and the patient is in distress, bladder distention can be temporarily relieved with suprapubic aspiration via a needle. However, this treatment can make subsequent SP placement more difficult or even dangerous due to bladder decompression. If an appropriately trained medical professional will be available in the near future, needle decompression should be deferred.
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nt, or occasionally an outpatient clinic. However, patient factors (age, health, medications, body mass index, prior surgical history, etc) may preclude placement outside of the operating room. <span>In cases when no urologist or appropriately trained clinician is available and the patient is in distress, bladder distention can be temporarily relieved with suprapubic aspiration via a needle. However, this treatment can make subsequent SP placement more difficult or even dangerous due to bladder decompression. If an appropriately trained medical professional will be available in the near future, needle decompression should be deferred. (See "Placement and management of urinary bladder catheters in adults", section on 'Suprapubic catheter placement'.) SP catheters have some benefits over indwelling urethral catheters.




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We recommend complete drainage of the bladder in patients with AUR. At one time, rapid complete bladder decompression was thought to increase the rate of potential complications (transient hematuria, hypotension, and postobstructive diuresis). However, partial drainage and clamping does not reduce these complications and may increase risk for urinary tract infection [31,34-36]
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cement, including bowel perforation and wound infection. (See "Complications of urinary bladder catheters and preventive strategies", section on 'Suprapubic catheters'.) Rate of decompression — <span>We recommend complete drainage of the bladder in patients with AUR. At one time, rapid complete bladder decompression was thought to increase the rate of potential complications (transient hematuria, hypotension, and postobstructive diuresis). However, partial drainage and clamping does not reduce these complications and may increase risk for urinary tract infection [31,34-36]. Complications of decompression — Complications associated with bladder decompression include [1]: ●Hematuria – Hematuria occurs in 2 to 16 percent of patients but is rarely clinically




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Hematuria occurs in 2 to 16 percent of patients but is rarely clinically significant [31]. For example, one trial found that hematuria occurred in approximately 11 percent of patients with AUR; hematuria resolved with irrigation for almost all patients [37].
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these complications and may increase risk for urinary tract infection [31,34-36]. Complications of decompression — Complications associated with bladder decompression include [1]: ●Hematuria – <span>Hematuria occurs in 2 to 16 percent of patients but is rarely clinically significant [31]. For example, one trial found that hematuria occurred in approximately 11 percent of patients with AUR; hematuria resolved with irrigation for almost all patients [37]. ●Transient hypotension – After initial bladder decompression, patients may experience a transient hypotension [31]. However, blood pressure usually normalizes without intervention and d




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After initial bladder decompression, patients may experience a transient hypotension [31]. However, blood pressure usually normalizes without intervention and does not progress to clinically significant hypotension.
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For example, one trial found that hematuria occurred in approximately 11 percent of patients with AUR; hematuria resolved with irrigation for almost all patients [37]. ●Transient hypotension – <span>After initial bladder decompression, patients may experience a transient hypotension [31]. However, blood pressure usually normalizes without intervention and does not progress to clinically significant hypotension. ●Postobstructive diuresis – Relief of urinary tract obstruction can lead to a postobstructive diuresis, which is defined as a diuresis that persists after decompression of the bladder.




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Relief of urinary tract obstruction can lead to a postobstructive diuresis, which is defined as a diuresis that persists after decompression of the bladder. A postobstructive diuresis is primarily a problem with chronic, not acute, urinary retention and usually represents an appropriate attempt to excrete excess fluid retained during the period of obstruction [38].
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experience a transient hypotension [31]. However, blood pressure usually normalizes without intervention and does not progress to clinically significant hypotension. ●Postobstructive diuresis – <span>Relief of urinary tract obstruction can lead to a postobstructive diuresis, which is defined as a diuresis that persists after decompression of the bladder. A postobstructive diuresis is primarily a problem with chronic, not acute, urinary retention and usually represents an appropriate attempt to excrete excess fluid retained during the period of obstruction [38]. Any patient with urinary retention can develop postobstructive diuresis. Many patients can manage the increase in urine output by increasing oral fluid intake. In patients who are unabl




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The majority of patients can be safely managed as an outpatient once the bladder is decompressed [39]. Hospitalization is indicated for patients who have urosepsis, have obstruction related to malignancy, or acute myelopathy [11]. Patients with associated acute renal failure also require hospitalization [1].
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— When possible, medications that may be contributing to AUR (table 1) should be stopped. Patients with infectious etiologies should be treated appropriately. Indications for hospitalization — <span>The majority of patients can be safely managed as an outpatient once the bladder is decompressed [39]. Hospitalization is indicated for patients who have urosepsis, have obstruction related to malignancy, or acute myelopathy [11]. Patients with associated acute renal failure also require hospitalization [1]. Prior to discharge, patients should be instructed in managing the catheter, emptying their catheter bag, and monitoring their urine output. Prophylactic antibiotics are not indicated fo




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The duration of catheterization depends on the underlying etiology for AUR. Patients with an underlying etiology that is being treated and expected to resolve (eg, urinary tract infection) should attempt a voiding trial as soon as possible that condition has been treated to avoid catheter complications.
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der catheters in adults", section on 'Catheter care' and "Placement and management of urinary bladder catheters in adults", section on 'Prophylactic antibiotics'.) Duration of catheterization — <span>The duration of catheterization depends on the underlying etiology for AUR. Patients with an underlying etiology that is being treated and expected to resolve (eg, urinary tract infection) should attempt a voiding trial as soon as possible that condition has been treated to avoid catheter complications. (See "Complications of urinary bladder catheters and preventive strategies", section on 'General complications' and "Complications of urinary bladder catheters and preventive strategies




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In other patients who have underlying etiologies not likely to resolve (eg, spinal cord injury) and/or who have acute-on-chronic urinary retention, catheterization may become chronic. Those patients may benefit from either long-term clean intermittent catheterization (CIC) or SP placement.
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' and "Placement and management of urinary bladder catheters in adults", section on 'Catheter removal' and "Postoperative urinary retention in females", section on 'Spontaneous voiding trial'.) <span>In other patients who have underlying etiologies not likely to resolve (eg, spinal cord injury) and/or who have acute-on-chronic urinary retention, catheterization may become chronic. Those patients may benefit from either long-term clean intermittent catheterization (CIC) or SP placement. (See "Placement and management of urinary bladder catheters in adults", section on 'Clean intermittent catheterization' and 'Suprapubic catheter' above.) The duration of catheterization




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Clean intermittent catheterization — CIC has fewer complications compared with indwelling urethral and SP catheterization. In patients with AUR, compared with indwelling catheters, CIC is associated with an increased rate of spontaneous voiding and reduction in urinary tract infections [40].
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ermittent catheterization' and 'Suprapubic catheter' above.) The duration of catheterization in men with benign prostatic hyperplasia is discussed below. (See 'Trial without a catheter' below.) <span>Clean intermittent catheterization — CIC has fewer complications compared with indwelling urethral and SP catheterization. In patients with AUR, compared with indwelling catheters, CIC is associated with an increased rate of spontaneous voiding and reduction in urinary tract infections [40]. CIC may be a reasonable option in hospitalized patients where nursing care is available and AUR is expected to resolve in a short period of time. CIC is also a reasonable option for out




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CIC may be a reasonable option in hospitalized patients where nursing care is available and AUR is expected to resolve in a short period of time. CIC is also a reasonable option for outpatients who are comfortable with managing the catheter and patients with acute-on-chronic urinary retention who are expected to require long-term catheterization (eg, prior spinal cord injury).
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and SP catheterization. In patients with AUR, compared with indwelling catheters, CIC is associated with an increased rate of spontaneous voiding and reduction in urinary tract infections [40]. <span>CIC may be a reasonable option in hospitalized patients where nursing care is available and AUR is expected to resolve in a short period of time. CIC is also a reasonable option for outpatients who are comfortable with managing the catheter and patients with acute-on-chronic urinary retention who are expected to require long-term catheterization (eg, prior spinal cord injury). (See "Placement and management of urinary bladder catheters in adults", section on 'Intermittent' and "Placement and management of urinary bladder catheters in adults", section on 'Clea




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If the etiology for AUR is not found on initial evaluation, patients should be referred to a urologist to evaluate for less common anatomic etiologies (eg, urethral stricture or urethral diverticulum) and/or for possible bladder function testing. Urodynamic studies should be performed by a urologist with experience in functional bladder disorders.
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ginal defects (eg, rectocele) leading to incontinence should be evaluated by a gynecologist. (See "Clinical manifestations, diagnosis, and nonsurgical management of posterior vaginal defects".) <span>If the etiology for AUR is not found on initial evaluation, patients should be referred to a urologist to evaluate for less common anatomic etiologies (eg, urethral stricture or urethral diverticulum) and/or for possible bladder function testing. Urodynamic studies should be performed by a urologist with experience in functional bladder disorders. (See "Strictures of the adult male urethra" and "Urethral diverticulum in women".) Benign prostatic hyperplasia — BPH is the most common cause of AUR [2-5,11]. Men who have not been dia




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Medical management — In men with BPH or presumed BPH, we recommend initiating an alpha-1-adrenergic antagonist (eg, alfuzosin 10 mg) at the time of initial catheterization. We also suggest ongoing treatment with an alpha-1-adrenergic blocker and a 5-alpha reductase inhibitor to delay the recurrence of AUR.
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ed before effective medical management was available found that one-half of men experienced a recurrence of AUR within one week, and two-thirds experienced a recurrence within one year [25,41]. <span>Medical management — In men with BPH or presumed BPH, we recommend initiating an alpha-1-adrenergic antagonist (eg, alfuzosin 10 mg) at the time of initial catheterization. We also suggest ongoing treatment with an alpha-1-adrenergic blocker and a 5-alpha reductase inhibitor to delay the recurrence of AUR. Alpha-1-adrenergic antagonists function to relieve the mechanical obstruction associated with BPH by relaxation of the smooth muscle at the bladder neck and the prostatic capsule [42].




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Alpha-1-adrenergic antagonists function to relieve the mechanical obstruction associated with BPH by relaxation of the smooth muscle at the bladder neck and the prostatic capsule [42]. A 2014 systematic review of nine randomized trials evaluating alpha-1-adrengeric antagonists prior to the removal of urethral catheters for AUR found moderate evidence that alpha-1-adrenergic antagonists increase success rates of trials without a catheter (relative risk [RR] 1.55, 95% CI 1.36-1.76) with low incidence of adverse effects [43].
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, alfuzosin 10 mg) at the time of initial catheterization. We also suggest ongoing treatment with an alpha-1-adrenergic blocker and a 5-alpha reductase inhibitor to delay the recurrence of AUR. <span>Alpha-1-adrenergic antagonists function to relieve the mechanical obstruction associated with BPH by relaxation of the smooth muscle at the bladder neck and the prostatic capsule [42]. A 2014 systematic review of nine randomized trials evaluating alpha-1-adrengeric antagonists prior to the removal of urethral catheters for AUR found moderate evidence that alpha-1-adrenergic antagonists increase success rates of trials without a catheter (relative risk [RR] 1.55, 95% CI 1.36-1.76) with low incidence of adverse effects [43]. Several different types of alpha-1-adrenergic antagonists are available with similar mechanisms and differing side effect profiles (table 3) [44]. Alfuzosin and tamsulosin have been eva




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5-alpha reductase inhibitors (eg, finasteride and dutasteride) decrease the incidence of AUR in men with BPH but do not reduce the early recurrence of AUR [49-51]. Patients need to be treated for more than one year to prevent AUR and reduce the need for surgery.
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patients who received alfuzosin as maintenance therapy (17 versus 24 percent). Risk reduction for surgery with alfuzosin was 61, 52, and 29 percent at one, three, and six months, respectively. <span>5-alpha reductase inhibitors (eg, finasteride and dutasteride) decrease the incidence of AUR in men with BPH but do not reduce the early recurrence of AUR [49-51]. Patients need to be treated for more than one year to prevent AUR and reduce the need for surgery. Trial without a catheter — Initial bladder decompression and initiation of medical therapy should be followed by a TWOC. We suggest that patients have two trials prior to considering su




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Initial bladder decompression and initiation of medical therapy should be followed by a TWOC. We suggest that patients have two trials prior to considering surgical therapy. We generally have patients attempt a TWOC one to two weeks after the catheter is placed. While a second TWOC for patients who fail the initial trial has a lower rate of success than the initial TWOC, for patients who fail the initial TWOC, we suggest a second trial of TWOC after an additional two weeks with the catheter.
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men with BPH but do not reduce the early recurrence of AUR [49-51]. Patients need to be treated for more than one year to prevent AUR and reduce the need for surgery. Trial without a catheter — <span>Initial bladder decompression and initiation of medical therapy should be followed by a TWOC. We suggest that patients have two trials prior to considering surgical therapy. We generally have patients attempt a TWOC one to two weeks after the catheter is placed. While a second TWOC for patients who fail the initial trial has a lower rate of success than the initial TWOC, for patients who fail the initial TWOC, we suggest a second trial of TWOC after an additional two weeks with the catheter. In our office, a voiding trial starts with catheter removal early in the morning, either at home or in the office. Patients are encouraged to hydrate aggressively and to return to the o




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In our office, a voiding trial starts with catheter removal early in the morning, either at home or in the office. Patients are encouraged to hydrate aggressively and to return to the office in the early afternoon for a postvoid residual (PVR). A PVR over 400 cc is generally considered a failure, under 200 cc would be a success, and PVRs between 200 to 400 cc result in a risk benefit discussion of options. If the patient is unable to void or if they are voiding with high PVRs, they are offered instruction in clean intermittent catheterization. If they are unable or unwilling to do this, a catheter is placed.
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l the initial trial has a lower rate of success than the initial TWOC, for patients who fail the initial TWOC, we suggest a second trial of TWOC after an additional two weeks with the catheter. <span>In our office, a voiding trial starts with catheter removal early in the morning, either at home or in the office. Patients are encouraged to hydrate aggressively and to return to the office in the early afternoon for a postvoid residual (PVR). A PVR over 400 cc is generally considered a failure, under 200 cc would be a success, and PVRs between 200 to 400 cc result in a risk benefit discussion of options. If the patient is unable to void or if they are voiding with high PVRs, they are offered instruction in clean intermittent catheterization. If they are unable or unwilling to do this, a catheter is placed. Reported success rates for initial TWOC in men with prostate disease with AUR have ranged from 20 to 40 percent [45]. Factors that favor a successful TWOC include age less than 65 years




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Reported success rates for initial TWOC in men with prostate disease with AUR have ranged from 20 to 40 percent [45]. Factors that favor a successful TWOC include age less than 65 years, detrusor pressure greater than 35 cm H2O, a drained volume of less than one liter at catheterization, and the identification of a precipitating event [41,45].
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nt is unable to void or if they are voiding with high PVRs, they are offered instruction in clean intermittent catheterization. If they are unable or unwilling to do this, a catheter is placed. <span>Reported success rates for initial TWOC in men with prostate disease with AUR have ranged from 20 to 40 percent [45]. Factors that favor a successful TWOC include age less than 65 years, detrusor pressure greater than 35 cm H2O, a drained volume of less than one liter at catheterization, and the identification of a precipitating event [41,45]. The optimal duration of catheter management in men with BPH prior to a trial of voiding has been evaluated, with contradictory findings. Randomized trials found an increase in the likel




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The optimal duration of catheter management in men with BPH prior to a trial of voiding has been evaluated, with contradictory findings. Randomized trials found an increase in the likelihood of spontaneous voiding when catheters were removed at seven days rather than immediately or after two days [52,53]. However, an observational study in 2600 men with AUR found that men who were catheterized for three days or less had greater success with spontaneous voiding compared with men catheterized for more than three days [54]. Two limitations of this observational study include the potential for greater underlying comorbidity in the men who were catheterized longer; and that 80 percent were treated with an alpha-1-adrenergic antagonist.
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OC include age less than 65 years, detrusor pressure greater than 35 cm H2O, a drained volume of less than one liter at catheterization, and the identification of a precipitating event [41,45]. <span>The optimal duration of catheter management in men with BPH prior to a trial of voiding has been evaluated, with contradictory findings. Randomized trials found an increase in the likelihood of spontaneous voiding when catheters were removed at seven days rather than immediately or after two days [52,53]. However, an observational study in 2600 men with AUR found that men who were catheterized for three days or less had greater success with spontaneous voiding compared with men catheterized for more than three days [54]. Two limitations of this observational study include the potential for greater underlying comorbidity in the men who were catheterized longer; and that 80 percent were treated with an alpha-1-adrenergic antagonist. Surgical therapy — Men who fail a second TWOC may require surgical therapy. Surgical therapy remains the definitive treatment of AUR. Among symptomatic patients with BPH, transurethral




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Men who fail a second TWOC may require surgical therapy. Surgical therapy remains the definitive treatment of AUR. Among symptomatic patients with BPH, transurethral resection of the prostate (TURP) reduces the risk of developing AUR by 85 to 90 percent [55].
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tudy include the potential for greater underlying comorbidity in the men who were catheterized longer; and that 80 percent were treated with an alpha-1-adrenergic antagonist. Surgical therapy — <span>Men who fail a second TWOC may require surgical therapy. Surgical therapy remains the definitive treatment of AUR. Among symptomatic patients with BPH, transurethral resection of the prostate (TURP) reduces the risk of developing AUR by 85 to 90 percent [55]. (See "Surgical treatment of benign prostatic hyperplasia (BPH)".) We evaluate all patients being considered for surgical intervention following an episode of AUR with urodynamic studies




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We evaluate all patients being considered for surgical intervention following an episode of AUR with urodynamic studies, to determine whether retention is directly related to outlet obstruction, with concomitant elevation in bladder pressures, or to an inefficient bladder muscle. Patients with bladder impairment are unlikely to benefit from a surgical procedure aimed to reducing outlet resistance.
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patients with BPH, transurethral resection of the prostate (TURP) reduces the risk of developing AUR by 85 to 90 percent [55]. (See "Surgical treatment of benign prostatic hyperplasia (BPH)".) <span>We evaluate all patients being considered for surgical intervention following an episode of AUR with urodynamic studies, to determine whether retention is directly related to outlet obstruction, with concomitant elevation in bladder pressures, or to an inefficient bladder muscle. Patients with bladder impairment are unlikely to benefit from a surgical procedure aimed to reducing outlet resistance. With respect to the timing of surgery, the general recommendation is to wait 30 days or more following an episode of AUR [39]. Patients who undergo surgery immediately following an epis