Tuesday, March 19, 2013

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


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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7 comments:

  1. Jerry Hoffman made a great point on EMA a few months ago: ask the patient! If the foley was for simple urinary retention, they know EXACTLY what failing a TOV means. They know what it's like to go home with a foley, and they know what it was like to have AUR, so they can decide if it's worth it. Plus, they had AUR so now they know the signs even better. Pretty much the ideal case for patient involvement in decision making.

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    1. Excellent point. We often DO forget about the patient. I bet their predictive accuracy is just as good as the PVR measurement.

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    2. Thanks for posting Seth. Your point is really well taken, the patient is already familiar with all of the potential outcomes in case of removal. I also agree that we don't involve the patient enough in all of these decisions, nor put ourselves in their place often enough. I'm certainly dreading my future days of BPH and will be happy to get the foley catheter out as soon as possible!!

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  2. Had never thought of the infusion method. Great idea. Urology follow up difficult, to say the least, at my shop. Pt input is key to this if it is going to work. We can aid the process by prescribing alpha-1 blockers and ultrasound. I have found this to be one of the few quick-hit things we can do in the ED that provides the highest patient satisfaction, if done correctly. Great article.

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    1. I love the infusion method ideas as well. Hadn't thought of it, although we sometimes do instill fluids to distend the bladder through a foley for CT cystograms. Totally makes sense!

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    2. I thought it was a very cool idea as well. It was also interesting to learn practice patterns around the world. Some countries such a France are more aggressive about taking the foley out sooner, with seemingly no difference in TOV failure. It is something we can do to help our patients feel much more comfortable and can accomplish within a reasonable time period in the ED

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  3. A great tip from Dr. Samuel J. Sillitti who posted on the ALiEM Facebook page:
    " As an OB/Gyn who does quite a bit of urogyn, I started using the fill method a little over a year ago. I find the bladder scanner can be off and this is important enough to get an accurate measurement. Thus, I used to always straight cath. I now retrograde fill using the foley before removal until the patient has the urge to void. I then have them void immediately and can get an accurate PVR simply by measuring the output. A bladder scan can then be used to verify. Simple and quick!!!"

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