DETERMINATION OF THE EFFECT OF ALFUZOSIN IN PATIENTS WITH ACUTE URINARY RETENTION SECONDARY TO BENIGN PROSTATIC ENLARGEMENT.
Background: Lower urinary tract symptoms are the most common reason for elderly males presenting to the hospital. Acute urinary retention previously considered as an absolute indication for surgery is now being challenged by alpha blockers.
Methodology: This descriptive study was done at Aga Khan Hospital and Shalamar Hospital over a three year period. Using convenience sampling 270 patients were registered and out of them 172 patients were selected on basis of inclusion and exclusion criteria. The selected patients were catheterized and were put on Alpha Blockers.
Results: Showed that 102 (59.5%) were able to void after catheter was removed while 70 (40.5%) had to be catheterized again and planned for surgery.
Conclusion: Our study has shown that acute urinary retention is no longer an indication for immediate surgery and a trial without catheter with alpha blockers should be attempted.
Keywords: BPH AUR ALFUZOSIN TURP.
Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) are very common among aging men.1 Risk factors for acute urinary retention include old age increased prostate volume postvoid residual volume severe Lower urinary tract symptoms and reduced peak urinary flow rate.2 From a large cohort of 2115 community dwelling men aged 40 79 years in Minnesota (USA) it was estimated that a 60 year old man had a 23% probability of experiencing an episode of acute urinary retention if he survived another 20 years.3
The management of retention of urine is by passing a catheter to drain the bladder and relieve the symptoms of obstruction the subsequent and definite management thereafter is not standardized. Acute urinary retention is one of the end points of complications of Lower urinary tract symptoms secondary to benign prostatic hyperplasia or may even be the initial presentation. This was previously considered an absolute indication for the patient to undergo Trans urethral resection of prostate (TURP). Alpha Blockers have become the mainstay of the medical treatment of Lower urinary tract symptoms suggestive of benign prostatic obstruction (BPO). Their beneficial effects are a result of smooth muscle relaxation in the prostate capsule and the bladder neck and the preprostatic urethra.
MATERIALS AND METHODS
This Descriptive study was conducted in the Urology departments of the Aga Khan University Hospital Karachi and Shalamar medical and dental college Hospital Lahore. The duration of the study was 3 years. Total number of 270 patients were registered using convenient sampling. Out of 270 patients 172 patients were selected by using following inclusion and exclusion criterias. The inclusion criteria was male patients older than 50 years who came to the hospital with painful acute urinary tract and male patients with post catheterization volume of 400 1000.
Those patients who had Neurogenic bladder proven or suspected Carcinoma of the prostate suspected or proven urinary tract infection including prostatitis confirmed or suspected urethral stricture history of prostatic or urethral surgery pelvic surgery and painful anal conditions and patients already on alpha blockers were excluded.
Those patients who fulfilled the inclusion criteria and exclusion criteria were enrolled for the study. History of constipation urinary tract infection functional class previous medication and comorbids were recorded. Baseline ultrasound performed from Radiology department. All the patients were catheterized and started on ablockers and called in the clinic minimum 36 hours after starting ablockers for a trial without catheter.
A total of 270 patients were selected and out of them 98 patients were excluded giving a total study population of 172 patients. The mean age was 65.1 with SD 9.5 years as shown in table 1. The mean residual volume was 713.3 ml with SD 149.7 ml as in table 2. Majority (56.1%) patients in our study were functional class I 47% were functional class II and only one patient was functional class III. Trial without catheter was successful in 59.5% of patients while 40.5% failed trial without catheter as shown in table 3. When group statistics were applied using recatheterization as the main outcome with the Ttest dividing the sample into two groups that is successful and unsuccessful:
No significant difference was noted in functional class of two groups.
No significant difference was noted in the age distribution of the 2 groups.
No significant difference was noted in the residual volume of the 2 groups.
No significant difference was noted in the interval between onset of retention and catheterization of the 2 groups.
Significant difference was noted in the duration of Lower urinary tract symptoms of the 2 groups meaning that the patients who had lower urinary tract symptoms for a longer duration had more successful trial without Catheter as below in table 4.
Table 1: Age of the patients in years n = 172.
Table 2: Residual volume (ml) duration between retention and catheterization (hours) and duration of Lower Urinary Tract Symptoms (weeks).
###Residual###I nterval###Duration of Lower
###Volume at###Retention and###Urinary Tract
###Catheterization###Catheterization###Symptoms in Weeks
Table 3: Need for recatheterization following Trial without Catheter.
Table 4: Duration of Lower Urinary Tract Symptoms prior to acute urinary retention.
Recatheterized###N###Mean (weeks)###Std. Deviation###Std. Error Mean###p value
Acute urinary retention is a significant public health issue as all patients with acute urinary retention will need medical health attention the standard management is for the patient to be catheterized and either admitted to the hospital which increases the cost. Alternately the patient is put on discharged care with its attendant problems. Acute urinary retention in certain setups is considered an absolute indication for prostatic surgery4 the others being recurrent urinary tract infections secondary bladder stones deterioration of renal functions decompensation of the bladder i.e. diverticulum formation failure to respond or tolerate medical therapy and bleeding from the prostate. So if this protocol is followed it would put a significant load on the health system.
Alpha blockers have been effectively used in the treatment of acute urinary retention with different but significant numbers of success.59 There is dearth of local data to guide the management of acute urinary retention. Hence the aim of our study was to prospectively determine the effect of ALFUZOSIN in patients with acute urinary retention secondary to benign prostatic obstruction.
In table 1 the mean age of patients in our sample was 65.1 years with a minimum age of 50 and a maximum of 86 years. Histological changes of Benign Prostatic Hyperplasia start by the age of 40 years as shown by previous studies.1011 In a study12 the average age was 70.6 and they had noted that most of their patients were retired. In another study it was stated that retention was rare in men less than 60 years.
In table 2 we have presented the significance of the residual volume at catheterization. This is a very important variable as it is important in excluding patients who might have a neurogenic bladder. These patients commonly have a large capacity indicating atonicity of the bladder wall. Hence in our inclusion criteria we specified that only patients who have a painful retention and a residual volume of 400 1000 ml will be included similarly patients who have a very small capacity bladder also might have an increased chance of having an irritable bladder hence the lower limit was set to 400 ml. In a previous study13 patients who had a catheterization residual volume of more than 1000 ml were at a high risk of failure of trial without catheter. However in our study we noticed that the residual volume at catheterization 713.3 ml with SD 149.7 ml as we had already excluded the patients who had a residual volume of more than 1000 ml.
The other variable discussed in the table 3 is the interval between onset of retention and catheterization. If the patient stays in retention for a long time and the bladder is distended the detrussor muscle would become over distended and the inherent strength of the detrussor might take about two weeks to return. The mean interval between retention and catheterization was 7.1 hours with SD 2.1 hours with a minimum of 4 hours and a maximum of 16 hours.
Another variable discussed in table 4 is the duration of lower urinary tract symptoms. This shows the chronicity of the disease with possible effects on the bladder and the lower urinary tract. The mean duration of the symptoms was 88.3 weeks with a standard deviation of 57 weeks with a minimum of 4 weeks and a maximum of 208 weeks.
In table 3 we considered the main outcome of our study that is the need for recatheterization. The patients who were catheterized were those who again developed urinary retention and thus failed trial without catheter. In our study we found that 59.5% of the patients had a successful trial without catheter meaning that ALFUZOSIN was effective in these patients while 40.5% of our patients failed a trial without catheter. If as in the past when acute urinary retention was considered an absolute indication of trans urethral resection of prostate. all of our patients would have undergone prostatic surgery but with a trial without catheter and ALFUZOSIN 59.5% of our patients were saved of avoided the prostatic surgery which in our centre is trans urethral resection of prostate. Other international studies found trial without catheter to be successful in 80%14 55%15 50%16 63%.17
From table 4 correlated the main out come that is need for recatheterization that is failed trial without catheter with patient and disease related factors.
In table 4 we considered the duration of lower urinary tract symptoms as an independent variable for successful trial without catheter. The duration of symptoms might lead to some changes in the bladder and the lower urinary tract itself causing an affect on the trial without catheter. Interestingly we found that the patients who had a successful trial without catheter had duration of Lower Urinary Tract Symptoms. For a mean of 149 63 weeks. Those who failed a trial without catheter had duration of symptoms of mean 69.5 weeks 42. weeks. (p value 0.012) which is statistically significant.
Our study has shown that acute urinary retention is no longer an absolute indication for trans urethral resection of prostate and that more than half of the patients would be able to return to their normal voiding practices in a short term follow up if started on ALFUZOSIN and will be saved from the possible complications and morbidities of surgery with a catheter in place. Further research is required into why our population developed early acute urinary retention compared to the international literature and the true factors affecting this early problem need to be identified and if these factors are preventable it would be of use to the community.
Our study concluded that 59.5% patients with acute urinary retention receiving ALFUZOSIN had a Successful trial without catheter. In our study acute urinary retention affected younger men compared to the literature. We found that duration of lower urinary tract symptoms was significantly inversely proportional to the success of trial without catheter. Over all this study has added to the evidence that acute urinary retention is not an absolute indication for immediate trans urethral resection of prostate.
Conflict of Interest
The authors declare no financial or non financial conflict of interests.
We are extremely thankful to Dr. Abdul Razzaq and Dr. Anila Jamshaid for taking care of the patients.
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|Date:||Dec 31, 2014|
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