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Concept: Urinary retention

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BACKGROUND: Diabetic patients have a higher risk of bladder cancer and benign prostatic hyperplasia (BPH). Theoretically, BPH patients may have an increased risk of bladder cancer because residual urine in the bladder surely increases the contact time between urinary excreted carcinogens and the urothelium. However, whether BPH increases bladder cancer risk in patients with type 2 diabetes has not been studied. METHODS: The reimbursement databases of all Taiwanese diabetic patients under oral anti-diabetic agents or insulin from 1996 to 2009 were retrieved from the National Health Insurance. An entry date was set at 1 January 2006 and a total of 547584 men with type 2 diabetes were followed up for bladder cancer incidence until the end of 2009. Incidences of bladder cancer for BPH by status and by duration were calculated and adjusted hazard ratios (95 % confidence intervals) were estimated by Cox regression. The effects of diabetes duration and medications used for diabetic control in relation with bladder cancer risk were also evaluated by Cox regression in BPH men. RESULTS: The incidences were 258.77 and 69.34 per 100,000 person-years for patients with and without BPH, respectively, adjusted hazard ratio 1.794 (1.572, 2.047). For BPH patients, those who underwent surgical procedures for BPH had a higher incidence than those who did not (355.45 vs. 250.09 per 100,000 person-years), respective adjusted hazard ratios: 2.459 (1.946, 3.109) and 1.709 (1.492, 1.958). The significantly higher risk could be demonstrated for BPH of any duration: respective adjusted hazard ratios 1.750 (1.430, 1.605), 1.844 (1.543, 2.203), 2.011 (1.680, 2.406) and 1.605 (1.341, 1.921) for BPH <1, 1--3, 3--5 and >=5 years versus patients without BPH. Sensitivity analyses for patients aged >=60 years and after excluding BPH patients with surgical procedures or without surgical procedures, respectively, yielded similar results. In BPH men, diabetes duration was not significantly related with bladder cancer; but metformin was consistently associated with a significantly lower risk, with adjusted hazard ratio of 0.719 (0.590, 0.875) for all ages and 0.742 (0.604, 0.912) for age >=60 years. CONCLUSIONS: BPH is a significant risk factor for bladder cancer in men with type 2 diabetes. Metformin may protect against bladder cancer in BPH men.

Concepts: Diabetes mellitus type 2, Urine, Obesity, Urology, Urinary bladder, Benign prostatic hyperplasia, Prostate, Urinary retention

164

To analyse the severity profiles and progression criteria in patients diagnosed of benign prostatic hyperplasia (BPH) in urology clinics in Spain.

Concepts: Prostate cancer, Urology, Urinary incontinence, Urination, Benign prostatic hyperplasia, Prostate, Urinary retention, Hyperplasia

28

What’s known on the subject? and What does the study add? Chronic urinary retention (CUR) is a poorly defined entity, as the key element of definition, significant postvoid residual urine volume (PVR), has not a worldwide and moreover evidenced-based definition. There is no agreement on which is the threshold value to define a significant PVR and different society produced guidelines with different thresholds ranging from 300 mL to 1000 mL. Diagnosis is difficult, and management has not been defined yet. There is a lack of studies on the best management of these patients, as this group of patients has always been considered at high risk of failure. Only one study compares conservative with the surgical management but it is not a randomised controlled trail. This review offers a systematic appraisal of the most recent publications on CUR. It indicates the absence of a real worldwide agreed definition, as the two keys element of it are not satisfactorily defined yet: significant PVR, is suffering from a lack of evidenced-based definition, and percussable or palpable bladder is a very nebulous concept as it is not a criteria of certainty as different individual variables affect it. This has an important effect on management which is not structured. Most of the trials involving benign prostatic hyperplasia treatments (either medical or surgical) tend to exclude this group of patients, which is a clinically important group, comprising up to a quarter of men undergoing TURP in the UK. Urinary retention describes a bladder that does not empty completely or does not empty at all. Historically, urinary retention has been classified as either acute or chronic the latter is generally classified as high pressure or low pressure according to the bladder filling pressure on urodynamic. A MEDLINE® search for articles written in English and published before January 2010 was done using a list of terms related to urinary retention: ‘urinary retention’, ‘chronic urinary retention’ and ‘PVR’. Chronic urinary retention (CUR) is defined by the International Continence Society as ‘a non-painful bladder, which remains palpable or percussable after the patient has passed urine’. Abrams was the first to choose a residual urine volume >300 mL to define CUR as he considered it the minimum volume at which the bladder becomes palpable suprapubically. The UK National Institute for Health and Clinical Excellence lower urinary tract symptoms (LUTS) guidelines define CUR as a postvoid residual urine volume (PVR) of >1000 mL. No studies have specifically addressed the problem of quantifying the minimum amount of urine present in the bladder to define CUR. Nor did we find any publications objectively assessing at what amount of urine a bladder can be palpable. The ability to feel a bladder may rely on variables (i.e. medical skills and patient habitus). There is a marked variability of PVR, so the test should be repeated to improve precision. As defining CUR is difficult, structured management is challenging. Nearly all prospective trials exclude men with CUR from analysis, possibly anticipating a poor outcome and a high risk of complications. However, men with CUR are a clinically important group, comprising up to 25% of men undergoing transurethral resection of the prostate. Definition of CUR is imprecise and arbitrary. Most studies seem to describe the condition as either a PVR of >300 mL in men who are voiding, or >1000 mL in men who are unable to void. This confusion leads to an inability to design and interpret studies; indeed most prospective trials simply exclude these patients. There is a clear need for internationally accepted definitions of retention to allow both treatment and reporting of outcomes in men with LUTS, and for such definitions to be used by all investigators in future trials.

Concepts: Urine, Urology, Urinary bladder, Urinary system, Ureter, Urinary retention, Prostatic stent

28

We present a unique case of a large urinary bladder stone protruding through the external urethral meatus in a 77-year-old woman, which was causing acute urinary retention, complicated by bilateral hydronephrosis, and was removed under topical anesthesia in the emergency department. Epidemiology, etiology, clinical presentation and management of urinary bladder stones are briefly discussed.

Concepts: Kidney, Urine, Urology, Urinary bladder, Urinary system, Urethra, Urinary retention, Urinary meatus

28

Objective: The primary objective of this study was to evaluate the length of 5-alpha reductase inhibitor (5ARI) therapy on the likelihood of acute urinary retention (AUR) and prostate surgery in patients diagnosed with benign prostatic hyperplasia (BPH). Additionally, this study attempted to quantify the relationship between length of 5ARI therapy and monthly BPH-related medical costs. Study design: This study used MarketScan® claims data from January 1, 2003, to December 31, 2008. Male Medicare patients ≥ 65 years and Medicaid patients ≥ 50 years who received a diagnosis of BPH and at least one claim for a 5ARI during the study period were included. Cox proportional hazards models were used to evaluate the effect of length of therapy on AUR and surgery, whereas generalized linear models were used to assess the effect on costs. Results: In 28,903 patients, every additional 30 days of 5ARI therapy reduced the likelihood of AUR and prostate surgery by 14 and 11%, respectively, while each 30-day increment of 5ARI therapy reduced BPH-related costs by 15%. Conclusion: For patients remaining on 5ARI therapy, significant clinical and economic benefits may be realized, including reductions in AUR and prostate surgery rates and reduced medical costs for these clinical events.

Concepts: Prostate cancer, Urology, Benign prostatic hyperplasia, Prostate, Urinary retention, Dihydrotestosterone, 5-alpha-reductase inhibitor, Dutasteride

28

Objective:To evaluate the clinical and urodynamic impact of intravesical electrostimulation (IVES) on incomplete spinal cord injury (SCI) patients suffering from chronic neurogenic non-obstructive urinary retention (N-NOR).Methods:One-hundred and two patients underwent at least 28 consecutive daily IVES sessions because objective evidence of detrusor acontractility instead of hypocontractility was detected. Diary entries written at various stages by each patient were compared (7 days before the IVES cycle, 15-21 days into the cycle and 7 days before its end). Responders were patients with a mean 50% reduction in both the number of daily catheterizations and post-void residual urine. Responders underwent further urodynamics at the end of the IVES cycle; patients experiencing first sensation of bladder filling, and the mean volume of first sensation of bladder filling per ml, Qmax ml s(-1), among others, were evaluated. Nineteen individuals who repeated another IVES round were included in this study.Results:Thirty-eight subjects (37.2%) responded to IVES and of those, 83.3% recovered the first sensation of bladder filling after the IVES round. Nineteen responders repeated IVES within 1 year, owing to loss of efficacy. They obtained similar voiding symptoms improvement and urodynamic results as after the first IVES cycle. A timespan of <2 years from SCI to IVES, and the presence of first sensation of bladder filling at baseline represented significant predictive parameters for IVES success (P<0.05) using χ(2)-test.Conclusions:IVES represents a possible therapeutic option for incomplete SCI patients with N-NOR.Spinal Cord advance online publication, 13 November 2012; doi:10.1038/sc.2012.120.

Concepts: Urine, Urology, Urinary incontinence, Urinary bladder, Urinary system, Ureter, Urinary retention

25

Urinary retention is a common complication following hospital care, which can result in overdistension of the bladder and, at worst, chronic bladder damage and persistent micturition difficulties.

Concepts: Urine, Hospital, Urology, Urinary incontinence, Urinary bladder, Urinary system, Urethra, Urinary retention

5

and Objectives: We evaluated associations between histological prostate inflammation and development and progression of BPH/LUTS in men randomized to placebo in the REDUCE study over a 4-year period.

Concepts: Medical terms, Prostate cancer, Urology, Urinary bladder, Benign prostatic hyperplasia, Prostate, Urinary retention, Prostatic stent

4

A 68 year old lady presented to urology department suffering from acute urinary retention. The U/S revealed hydronephrosis in left kidney and a mass at the left side of the small pelvis which pushed forward the uterus and the bladder. The CT scan confirmed a mixed (solid and cystic) mass, with diameter of 12 cm with interpretation of the left ovary. The patient underwent laparotomy and the mass was excised after a difficult dissection due to severe adhesion with the bowel. The well-capsulated mass was a retained surgical sponge. The patient had undergone cesarean procedure 29 years ago.

Concepts: Kidney, Urology, Urinary incontinence, Urinary bladder, Urinary system, Ureter, Pelvis, Urinary retention

3

To evaluate the effects of electroacupuncture (EA) on the International Prostate Symptom Score (IPSS), postvoid residual urine (PVR), and maximum urinary flow rate (Qmax), and explore the difference between EA at acupoints and non-acupoints in patients with moderate to severe benign prostate hyperplasia (BPH).

Concepts: Prostate cancer, Urology, Benign prostatic hyperplasia, Prostate, Urinary retention, Finasteride, International Prostate Symptom Score, Prostatic stent