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Difficulty: MediumUrologic Surgery

A 72-year-old man is brought to the emergency department by his daughter due to increasing confusion and lethargy over the past 24 hours. The daughter reports that the patient has not urinated since yesterday morning. For the past several years, he has had progressive difficulty initiating urination, a weak stream, and nocturia. His temperature is 37.1°C (98.8°F), blood pressure is 168/92 mm Hg, pulse is 96/min, and respirations are 16/min. Physical examination reveals a dull, suprapubic mass extending to the umbilicus that is mildly tender to palpation. Digital rectal examination demonstrates a symmetrically enlarged, smooth prostate without nodules. Laboratory studies show a blood urea nitrogen of 78 mg/dL and serum creatinine of 5.2 mg/dL. A renal ultrasound demonstrates bilateral hydronephrosis and a markedly distended urinary bladder. Which of the following is the most appropriate initial step in the management of this patient?

  1. A
    Intravenous fluid resuscitation and furosemide
  2. B
    Bilateral percutaneous nephrostomy tube placement
  3. Placement of an indwelling urethral catheterAnswer
  4. D
    Transurethral resection of the prostate
  5. E
    Empiric administration of intravenous broad-spectrum antibiotics

Answer

Placement of an indwelling urethral catheter
The most appropriate initial step in management is the placement of an indwelling urethral catheter. This patient presents with acute urinary retention (AUR) secondary to underlying benign prostatic hyperplasia (BPH), which has led to postrenal acute kidney injury (AKI) evidenced by markedly elevated creatinine and bilateral hydronephrosis. The immediate clinical priority in postrenal AKI is rapid mechanical relief of the obstruction. Because the obstruction is located at the bladder neck/prostatic urethra (infravesical), a urethral catheter will effectively drain the distended bladder, rapidly relieve the bilateral ureteral back-pressure, and facilitate the recovery of renal function. Once renal function has stabilized and the patient is optimized, definitive surgical options can be explored.

Step-by-Step Solution

1
Identify the primary clinical problem
The patient has acute urinary retention (anuria, palpable suprapubic mass, distended bladder on ultrasound) complicated by postrenal acute kidney injury (elevated BUN and creatinine, bilateral hydronephrosis).
Recognizing the obstructive nature of the acute kidney injury directs immediate therapy toward mechanical decompression rather than medical management.
2
Determine the anatomic level of obstruction
The ultrasound shows a distended bladder along with bilateral hydronephrosis, indicating the obstruction is distal to the bladder (infravesical), highly likely due to benign prostatic hyperplasia given the patient's age and history.
The precise anatomic level of obstruction determines the most appropriate and least invasive method of urinary drainage.
3
Select the most appropriate initial intervention
Placement of an indwelling urethral (Foley) catheter is indicated.
Urethral catheterization is the most direct, least invasive method to bypass prostatic obstruction, decompress the bladder, and rapidly resolve the postrenal acute kidney injury.

Key Concept

Acute urinary retention complicated by postrenal acute kidney injury due to benign prostatic hyperplasia requires immediate bladder decompression with an indwelling urethral catheter before considering definitive surgical procedures.
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Topics

Urologic Surgery

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