Immediate Management

The immediate management of any patient presenting with failure to empty their bladder, history and examination aside, is directed to draining the bladder. This is discussed in detail in Chap. 19, "Surgical Techniques and Percutaneous Procedures". In most cases, the passage of a Foley urethral catheter (under aseptic conditions) is sufficient to bypass the obstruction and establish drainage of the bladder. Typically, the catheter stays in place for at least 24 - 48 h while long-term management is decided and instigated. In some cases, however, it is not possible to pass a Foley catheter due to the nature of the obstruction. This can be overcome in some patients by using alternative catheters, such as those with a Coudé tip, which are often able to navigate the obstruction as described in Chap. 19, "Surgical Techniques and Percutaneous Procedures". If no urethral access is available, then the next option is to proceed to suprapubic cystosto-my. In some patients, specifically those with prior lower abdominal surgery, this may need to be carried out under ultrasound guidance. Finally, if this is not possible, then there is no option other than open surgical cystostomy, but this should be regarded as a last resort.

If catheterization is successful, and there are no features suggestive of high risk of recurrent UR, and the patient has normal renal function, i.e., a diagnosis of "typical" uncomplicated UR secondary to BPE (which should make up approximately 70% patients with AUR), then typically we would proceed to institute pharmacological therapy to aid chances of a successful trial without catheter (TWOC).

However, in patients not meeting the above criteria, further investigations are required. In cases where renal function is disturbed, it is appropriate to perform ultrasonographic examination of the upper tracts to both diagnose obstructive uropathy and exclude any coexisting renal abnormality. In patients with true high-pressure CUR, there maybe a degree of hydronephrosis, but this should resolve promptly (within 48 h) of catheterization. These patients will typically need definitive bladder drainage, usually via long-term ure-thral or suprapubic drainage, with surgical intervention as deemed appropriate by TURP. If definitive bladder drainage is not ensured, then the high-pressure CUR will almost invariably recur.

Cases of CUR with no hydronephrosis or renal impairment are termed low-pressure CUR and are usually associated with a low-pressure low-flow voiding pattern. These patients fare badlywith TURP, and are best managed with clean intermittent self-catheterization (CISC), as the detrusor muscle tends not to recover from its chronically distensible hypercompliant state. CISC is an alternative long-term method of bladder drainage in those patients with BOO who are unfit for surgery, but some patients encounter difficulties with large obstructing prostate glands actually passing the catheters into the bladder. Also, the technique needs to be closely observed prior to discharge to the community, as some patients find it much harder than others.

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