NON-Neurogenic

Chronic Urinary RetentionAUA White Paper

Great Lakes SUNA Inside Urology

March 16, 2018

Michelle J. Lajiness FNP-BC

Nurse Practitioner DMC Urology

Incidence

Really unknown

Lack consensus on definition

Unknown

Difficult to differentiate non neurogenic

from neurogenic

AUA White Paper

Based on expert opinion

Lacks evidenced base trials

Lacks consensus

No standardized criteria

Goals of White Paper

Characterize patients with CUR into clinically definable index patient populations in adult men and women(>18 years old)

Propose diagnostic and treatment alogorithms for these index populations

Identify future areas of research for CUR

CUR Definition

There is no one definition

Use of the term varies in the literature

Research tends to use atonic detrusor

Urodynamic study

No contraction during study

Recently linked with primary muscle

activity and underactive bladder

ICS definition

A contraction of reduced strength and/or

duration, resulting in prolonged

bladder emptying and/or failure to

achieve complete bladder emptying

within a normal time span

AUA Definition (clinical)

Non Neurogenic CUR is empirically

defined herein as an elevated PVR

>300 mL that has persisted for at least

six months documented on two or

more separate occasions.

Controversy

PVR as definition

PVR consensus >100- >500 mL

Cut off value based on total volume

voided vs. volume left

Sign not uniform diagnosis

Conditions Commonly

associated with CUR

Outlet obstruction

Poor bladder contractility

Outlet obstruction

Long-term use of medications

Antihistamines

Alpha adrenergic agonists

antipsychotics

Urethral or bladder neck constricture

High grade pelvic floor prolapse

Urethral diverticula in women

Outlet Obstruction

Prior anti-incontinence procedure

Prior vaginal vault prolapse procedure

Primary bladder neck obstruction in

men and women

Dysfunctional voiding

Poor bladder contractility

Long standing outlet obstruction

Long term use of medication

Anticholinergic/Antispasmotic

Tricyclic anti depressants

Beta adrenergic agonist

Calcium channel blockers

Non steroidal anti inflammatory

Opioids

Benzodiazepines

antipsychotics

Poor Bladder Contractility

Diabetes

Constipation

Frailty

idiopathic

Categories of CUR

High –risk

Subset of individuals with CUR who

are at potentially elevated risk for

organ system harm or failure from

CUR

Symptomatic CUR

Subset of individuals who are

bothered by symptoms

High risk CUR Radiology findings

Hydronephrosis

Hydroureter

Lab findings Stage III chronic kidney disease

• GFR 30-50 mL/min

Recurrent symptomatic, culture proven UTI

Culture proven systemic urosepsis

Signs and symptoms Urinary Incontinence associated with skin

breakdown

UI associated with decub

Symptomatic CUR

Having subjectively moderate to severe

urinary symptoms impacting QOL on a

validated urinary questionnaire

History of requiring catheterization for

treatment of a symptomatic episode of

inability to void within the last 6 months

Excluding acute onset or urinary retention

caused by oncologic, traumatic, or any

neurologic event.

Treatment Algorithm

Treatment Summary

Taken from Stoffel et al (2016) Non-Neurogenic Chronic Urinary Retention:

Consensus Definition, Management Strategies, and future Opportunities

Treatment

If patient is asymptomatic and there is

no hydro---

DO NOT CATH PATIENT

Index Patient

The first medically-identified Pt in a

family or other group, with a particular

condition which triggers a line of

investigation

Medication

Outlet obstruction caused by prostate

Alpha blockers

5-alpha- reductase inhibitors

Primary bladder obstruction male and

female

Alpha blockers

Improve bladder contractility

Cholinergic agonist

• Bethanechol

Catheterization

CIC performed frequently enough to

effectively target reduction of risk and

symptoms should be tailored for the

individual treatment plan

If long term catheterization is needed

consider SP tube

Surgical Treatments

Dictated by etiology

In men obstruction secondary to

prostate several surgeries available

Chronic BOO in women secondary to

prior mid urethral sling placement

simple sling incision

Prolapse- several options

Surgical Treatment

CUR due to decreased bladder

contractility consider sacral

neuromodulation

Outcome measures

Symptom improvement , as measured by

quality questionnaires

Risk reduction, as defined by resolution of

hydronephrosis, renal failure, recurrent UTI,

urosepsis, and secondary complications

from overflow incontinence

Successful trial of voiding without

catheterization

Stability of symptoms and risk over time

WHAT’S NEXT

Define it

Determine causes

Research on interventions

Multi-institutional cohort studies

Identify molecular markers

Investigation for pharmacological and

neurological interventions.

UAB Symposium

Index Patient Examples

50 year old male

c/o urinary frequency, hesitancy, slow

stream and nocturia

Index Patient 1 work-up

AUA SI >15

50 g prostate on DRE

UA normal

PVR- 350 cc

Risk Category

Low/Risk Symptomatic

Index Patient 1 Treatments

Timed voiding

Fluid management

PVR 6 months later 450 cc

Renal Ultrasound and renal panel

negative

Treatment Index Patient 1

Offer CIC and/or

Alpha blockers and/or

5-alpha- reductase inhibitors

Formal evaluation for outlet

obstruction with a UDS

Goal improve QOL monitor with

validated questionnaires

Index Patient 2

77 year old male

HX of CHF

Four culture positve UTI’s over the

past 3 months

Long history of bothersome, irritative

LUTS

Index Patient 2 work-up

60 g prostate

2 separate PVR’s over 6 months

>500ml

UA positive for leukocyte esterase,

nitrites, and crystals

Renal US shows mild to moderate

hydronephrosis and a 3 cm bladder

stone

Risk Category

High/Risk Symptomatic

Index Patient 2 Treatment

Immediate catheterization to address

UTI and hydro

Consider evaluation for a bladder

outlet procedure and/or lithotripsy

Long term CIC or SP Tube

Index Patient 3

75 yo female

No symptoms

No prior urologic history

Presents to EC after a fall for hip pain

CT shows distended bladder no hydro

PE shows mild vaginal vault prolapse

PVRS consistently >400 mL

Risk Category

Low Risk/Asymptomatic

Index Patient 4

80 yo male

Distant history or TURP and

chronically elevated PVR

No bothersome symptoms

RUS shows bilat

hydroureteronephrosis and a PVR

1,800 mL

Risk Category

High Risk/Asymptomatic

Index Patient 4 treatment

PVR consistent with longstanding

bladder decompensation

Short term indwelling foley

CIC if able after

Conclusion

Need clinical research studies

Only treat those high risk categories

Treatment should be based on

Assessment of symptoms

Reduction of risk

Ability to void without catheterization

Stability of symptoms/risk over time