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First ALiEM journal article: Trial of void for acute urinary retention

Posted Mar 19 2013 12:00am

Post author: 
Massoud Kazzi, MD
EM Resident, SUNY Downstate Medical Center

Blog peer reviewer for  ALiEM journal pilot project :
Javier Benítez, MD

Trial of Void in the Emergency Department (ED) A patient may present to the ED after foley catheter placement for acute urinary retention (AUR) a few days ago and now requests catheter removal. Ideally this should be performed in the urologist’s office. However, occasionally patients cannot or do not follow up with the urologist in a timely manner and return to the ED expecting urethral catheter removal. A careful history and physical should be performed along with a consulting urologist. If the eventual decision is to remove the urethral catheter in the ED, what is important to know about a Trial of Void (TOV)?
What is a Trial of Void? A Trial of Void, also referred to as Trial Without Catheter, involves removal of the urethral catheter and an assessment of the patient’s ability to spontaneously urinate. If successful, the patient may avoid or delay surgical intervention and possibly be managed medically.

Traditional technique:
  1. Remove the catheter, and encourage oral fluid intake.
  2. Measure the post-void residual (PVR) by re-catheterization or, more humanely, ultrasounding of the bladder. Also quantify the amount of urine spontaneously voided. [1,2] 
If the amount of urine voided is > 150 mL or the PVR is < 100 mL, there is a low recurrence of AUR and the TOV is considered successful. [3] PVR volumes up to 300 mL can be acceptable in patients who have chronic urinary retention. [4]

Alternative technique: The infusion method Because we don't often have several hours in the ED for the bladder to refill after oral fluid intake, one might consider accelerating this process.

Infuse 300–500 mL of saline in the bladder prior to catheter removal. When compared to the standard method of oral fluid intake, it reduces time to discharge by almost 80 minutes as compared to the standard method. [5]

How long after initial catheter placement can removal and Trial of Void take place? No definitive guidelines exist. However, a survey of 6,074 patients with AUR by Fitzpatrick et al. [8] found that in patients whose catheter was removed at ≤ 3 days vs. ≥ 4 days, there was a lower frequency of
  • Urinary tract infection: 3.4% vs 7.2%
  • Catheter obstruction: 0.8% vs 3.1%
  • Urosepsis: 0.6% vs 1.2%
Traditional teaching and previous studies demonstrated that prolonging catheterization improves success of TOV attempt. [4] More recent studies have found either no improvement, or that TOV at ≤ 3 days was more successful than TOV done later. [6] Regardless of when the catheter was removed, of utmost importance is the prior use of α-1 blockers, which several studies show improve the likelihood of successful TOV. [7, 8]


Suprapubic view-Urinary Retention_Bladder Volume

Bottom Line
  1. Consider a TOV as early as Day 3 if the patient has been taking α-1 blockers appropriately. 
  2. When performing a TOV, consider the infusion method to speed up the time to decision and patient discharge.
References
  1. O’Connell B, et al. The Development and Trial of Best Practice Protocol for Management of Urinary Retention in Elderly Patients in Acute and Sub-Acute Settings, Deakins University. ISBN:   1741560624
  2. Fuse H, et al. Measurement of residual urine volume using a portable ultrasound instrument. Int Urol Nephrol 1996;28(5):633-7. PMID 9061421  
  3. Choong S, Emberton M. Acute Urinary Retention. BJU Int 2000;85:186-201. DOI 10.1046/j.1464-410x.2000.00409.x
  4. Kalejaiye O, et al. Management of Acute and Chronic Retention in Men. European Urology Supplements 2009 Apr;8(6):523-529 DOI 10.1016/j.eursup.2009.02.002
  5. Boccola MA, et al. The infusion method trial of void vs. standard catheter removal in the outpatient setting: a prospective randomized trial. BJU Int 2011 Apr;107 Suppl 3:43-46. PMID 21492377
  6. Desgrandchamps F, et al. The management of acute urinary retention in France: A cross-sectional survey of 2618 men with benign prostatic hyperplasia. BJU Int. 2006 Apr;97(4):727-33. PMID 16536763
  7. Zeif H-J, et al. Alpha Blocker treatment for men to increase chances to have urinary catheter successfully removed. Cochrane Database Syst Rev 2009; (4):CD006744. PMID 19821385
  8. Fitzpatrick JM, et al. Management of acute urinary retention: a worldwide survey of 6074 men with benign prostatic hypertrophy. BJU Int 2012;109:88-95. PMID 22117624
Source:  Image 1   Image 2   Image 3
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