ABSTRACT
Introduction:
There are no reliable clinical markers to predict the size of the obstructing prostate and the success of trial without catheter (TWOC) in men with benign prostate enlargement (BPE) and acute retention of urine (AUR). TWOC fails in men with large prostates. Patients with a large prostate have a shorter extraurethral catheter length (EUCL). This prospective study was conducted to assess whether EUCL could be a surrogate clinical marker for prostatic enlargement and the success of TWOC.
Methods:
Alpha-blocker naïve men with AUR due to BPE underwent clinical, laboratory, and ultrasound assessment, and EUCL measurement. They were started on alpha-blockers before being subjected to TWOC. Patients with a successful TWOC were followed on medical management till October 2024 and were classified as pass. Patients who had retention (immediately or during follow-up) were classified as failures. Relationship of EUCL with prostate dimensions was evaluated. Regression analysis was performed to determine the clinical factors predicting the success of TWOC.
Results:
Amongst the 76 patients that were recruited, 43 failed the TWOC and 33 were voiding well with a median AUR-free time of 1059 days and a follow-up period of 2106 days. Patients in the failed group had larger prostates. EUCL had a significant negative correlation with the dimensions of the prostate. EUCL ≤170 mm had a significantly higher odds of failed TWOC (Odds ratio 7.92 [95% confidence interval 2.09–29.96], Z = 3.047, P = 0.002).
Conclusions:
Shorter EUCL can be an important clinical marker of the prostate size and a predictor of failed TWOC. In resource-poor settings, EUCL can be used to plan referral to urology services or TWOC.
INTRODUCTION
Acute urinary retention (AUR) is one of the most distressing and painful complications of benign prostatic enlargement (BPE). Although AUR was previously considered as one of the indications for surgical intervention, with the advent of alpha-blockers, the trial without catheter (TWOC) with medical treatment is currently considered the first-line option.[1] Various factors that predict successful TWOC include the patient’s age, prostate volume (PV), intravesical prostate protrusion (IPP), bladder wall thickness (BWT), and prostate-specific antigen (PSA).[2,3,4,5,6,7] Preretention international prostate symptom score (IPSS) and postvoid residual (PVR) urine volume are important predictors of progression of BPE.[8] PV is usually assessed clinically by digital rectal examination (DRE) or by ultrasonography. Although fairly reliable, DRE usually underestimates the prostate size,[9] whereas the ultrasound may not be easily available in resource-poor settings. There is a need for a clinical marker that could help the primary care physician to make an informed decision in patients presenting with AUR due to BPE, about giving TWOC or referral to urology services.
It is a common and logical observation that, in patients with large prostatic adenomas, the visible length of the catheter outside the urethra is short, which in turn, may act as a clinical predictor of the outcome of TWOC and the need for an intervention. We hypothesised that extraurethral catheter length (EUCL) may be an indicator of prostate size, and a reduced EUCL might predict a higher chance of failure of TWOC and the need for urological surgery [Figure 1].
Figure 1.
Hypothesis: As prostate enlarges, extra-urethral catheter length decreases
In this prospective cohort study, we aimed to quantify and verify whether EUCL could be correlated with prostate size and the success of TWOC and hence, could serve as a potential clinical marker for decision-making. If so, based on the EUCL, patients who are likely to fail TWOC may be counseled accordingly. In resource-poor settings or situations where the waiting time for ultrasound examination is long, a shorter EUCL could be a clinical criterion for the primary care physician to refer the patient to a urology department; otherwise, the patient would be offered a TWOC with an alpha blocker in the primary care setting and referred only when the TWOC fails.
METHODS
Recruitment
This prospective cohort study was conducted at the “Tirthankar Super Speciality Hospital,” which is a urology clinic located at Akola, a district in Maharashtra, India, catering to the rural population of around nine million in nearby places.[10] Between 2018 and 2024, adult men with AUR due to BPE in whom a urethral catheter was inserted and who consented to voluntary participation were included in this study. AUR was defined as a sudden onset inability to pass urine despite having a full bladder. Patients with AUR due to constipation or drug-induced AUR or with shorter follow-up were excluded from the study. For drug-induced AUR, the patients were asked if they were taking antihistaminic, cough syrups, oral bronchodilators, cold medicines, any opioids, or alcohol ingestion. Patients with prostate cancer, urethral stricture, bladder stones, chronic urine retention, or neurogenic bladder were also excluded from the study. Recruitment was stopped in March 2020 due to COVID-19-related restrictions, but follow-up of the patients was continued till the end of October 2024. During the COVID-19 period, the follow-up was mainly telephonic, and after the end of COVID-19 restrictions, patients were encouraged to come for the outpatient visit as needed. At each outpatient visit, symptom assessment, DRE, and other investigations were performed as per the clinical need. As BPE is a slowly progressive disorder, patients who completed a follow-up period of at least 1 year were included in the final analysis. Patients who were already on alpha-blockers at the time of initial AUR were offered surgical intervention and were excluded from the analysis. EUCL was measured by the same trained study staff. To maintain uniformity of the measurements, all the patients received a catheter from a single manufacturer (Rusch, India) of sizes 12, 14, or 16 Fr. Catheters of other sizes and from other manufacturers were excluded from the study. The catheter balloon was inflated to 10 ml in all the patients.
Ethical statement
This study was approved by the Institutional Ethics Committee of the Government Medical College Akola vide GMCA/EC/227/2018. Informed consent was obtained from all the participants before enrolment.
Research questions
The research questions were as follows:
Is there a relationship between the EUCL and prostate dimensions?
Can the EUCL predict the success of TWOC?
Research hypothesis
A short EUCL is a clinical marker of an enlarged prostate and a predictor of failure of TWOC.
Evaluation
Detailed history and clinical evaluation, such as age, weight, body mass index (BMI), IPSS, duration of symptoms, DRE, and relevant laboratory investigations, were performed. The EUCL was measured from the external urethral meatus (EUM) to the end of the catheter. Measurement was done up to the end of the catheter and not up to the “Y,” as it is the most precise point in the measurement. Similarly, the EUM was taken as the precise point. All the measurements were performed with the patient in the supine position, and the catheter was placed straight on the right thigh without any tension. A single trained study staff member (PMM) made all the measurements using the same measuring tape throughout the study [Figure 2].
Figure 2.
Measurement of extraurethral catheter length
Transabdominal ultrasound (TAUS) was used to measure the BWT, with the bladder filled at approximately 150 ml with the catheter clamped, and for the assessment of the upper tracts. The transrectal ultrasound (TRUS) measured other parameters, such as transverse prostate width (TPW), axial prostate length (APL), maximum sagittal prostate length (SPL), intravesical protrusion of the prostate on TRUS (IPP-TR), prostatic urethral angle (PUA), circumference of the prostate (PCIR), area of prostate (PAR), and transitional zone volume (TZV). The PV was calculated using the formula PV = TPW × APL × SPL × pi/6. The presumed circle area ratio (PCAR) and the transition zone index (TZI) were also calculated.[11,12] All the measurements were conducted by a single observer (SK) using Philips HD 11XE and Affiniti 70 G ultrasonography equipment.
Follow-up
All patients were started on alpha-blockers. Combination treatment of alpha-blockers and 5-alpha reductase inhibitors was not offered. The alpha-blockers used were either tamsulosin 0.4 mg, silodosin 8 mg, or alfuzosin 10 mg once a day (as per the choice of the urologist). After 5 or more days, they were subjected to a TWOC. Patients who failed the TWOC were offered surgical treatment for BPE. Patients with a successful TWOC were followed with the medical management till October 2024.
The outcomes were classified as pass or fail depending on the results of the TWOC. Patients who passed a minimum of 100 ml of urine and had a nonpalpable bladder after 8 h of TWOC were classified as having a “successful TWOC” and were included in the pass group. Whenever in doubt, the success of TWOC was confirmed by examining the PVR urine by a bedside ultrasound. Patients with a successful TWOC were continued on alpha-blocker medications and were followed. Patients who developed AUR during the follow-up period were catheterized and were offered surgery (shifted to the fail group). Only patients who were passing urine well throughout the follow-up period were categorized into the pass group. The choice of alpha-blocker was a decision of the treating urologist [Figure 3].
Figure 3.
Study flow. AUR: Acute urinary retention, EUCL: Extra urethral catheter length, TAUS: Transabdominal ultrasound, TRUS: Transrectal ultrasound, TWOC: Trial without catheter
Duration of follow-up
The patients who voided well after the TWOC were followed up for >1 year till the end of October 2024. Data collection was stopped in October 2024. If they developed urinary retention during the follow-up, they were classified as fail. Patients who were lost to follow-up before October 2024, if they were voiding well at the time of the last follow-up, were censored and classified as pass. Similarly, the patients who died due to an unrelated cause, if they were voiding satisfactorily, were also censored and were classified as pass.
Statistical methods
Descriptive and analytical statistics were performed using https://www.real-statistics.com/, a package on Microsoft Excel. Correlation statistics were performed Pearson’s correlation coefficient (r) analysis. Normative data were compared by t-test, and nonnormative data were compared by the Mann–Whitney test. The impact of clinical factors on the outcome of TWOC was evaluated with logistic regression analysis. The input parameters chosen for the regression were the age, height, weight, BMI, DRE, duration of symptoms, IPSS score, and EUCL because these parameters can be easily measured by a general practitioner (GP) or a primary care physician without any laboratory evaluation. For the same reason, data from ultrasound dimensions were not included in the regression analysis. Optimal cutoff value of EUCL was calculated using Youden’s statistics, and EUCL was evaluated as a predictor marker for TWOC success using a 2 × 2 table.
The authors confirm the availability of, and access to, all the original data reported in this study upon reasonable request, in compliance with ethical guidelines.
RESULTS
Recruitment and follow-up
A total of 143 patients were evaluated for eligibility. Sixty-seven patients were excluded for the following reasons: already on alpha-blockers (24), chronic retention (1), suspected or proven cancer prostate (11), urethral stricture (1), unwillingness to undergo ultrasound or incomplete ultrasound examination (17), associated vesical calculus (7), withdrawal of consent for the study (3), lost to follow-up before completing 1 year (2), and one patient who was too frail for TWOC and elected to be on long-term catheter. Finally, 76 patients who were recruited and completed at least 1 year of follow-up were analyzed [Figure 4].
Figure 4.
Disposition of study participants. TWOC: Trial without catheter, FU: Follow up
Demographic characteristics
There were 33 patients in the pass group and 43 in the fail group. The groups were comparable with regard to age, weight, height, BMI, and IPSS score. The patients in the fail group were symptomatic for a longer duration and had a shorter EUCL [Table 1].
Table 1.
Demographic characteristics
| Parameter | Pass group (n=33) | Fail group (n=43) | P |
|---|---|---|---|
| Age (year) | 67.64±8.82 | 68.42±8.40 | 0.69 |
| Weight (kg) | 57.74±11.82 | 60.91±10.32 | 0.22 |
| Height (cm) | 161.27±6.39 | 162.56±6.78 | 0.40 |
| BMI (kg/m2) | 22.17±4.04 | 22.99±3.35 | 0.35 |
| Duration of symptoms (months)* | 5.75±10.93 | 11.40±18.51 | 0.04 |
| IPSS score* | 17.00±10.54 | 14.51±8.39 | 0.21 |
| EUCL (mm) | 188.85±18.87 | 175.95±23.70 | 0.01 |
*Duration of symptoms and IPSS score data not normally distributed. Nonparametric test was applied. For other parameters t-test was used. BMI=Body mass index, IPSS=International Prostate Symptom Score, EUCL=Extraurethral catheter length
Duration of follow-up and catheter-free survival
These patients were followed up from 1 to 2106 days from the date of TWOC. Median follow-up was 593 days. Of these 76 alpha-blocker naïve patients, 20 patients had retention on the same day, seven failed within 1 week, two during the 1st year, and the remaining 14 patients failed at various points of follow-up after 1 year. The remaining 33 patients were voiding urine satisfactorily till the end of the study. Median retention-free survival was 1059 days [Figure 5].
Figure 5.
Catheter-free survival curve (Kaplan–Meier method) X axis is time in days and Y axis is probability of catheter-free survival over time
The catheter-free survival curve showed that after an initial sharp drop, only 20% of the patients were lost over the next 5 years, suggesting a slow progression of the disease condition and a good impact of nonsurgical treatment (alpha-blockers).
Ultrasound measurements and relationship with extraurethral catheter length
Of the ultrasound parameters, the measurements of pass versus fail group; APL, maximum SPL, intravesical protrusion of the prostate on TRUS (IPP-TR), TZV, TZI and PV were significantly smaller in the pass group compared to the fail group. Whereas BWT, TPW, PUA, and PCAR were not statistically different amongst the groups [Table 2].
Table 2.
Ultrasound parameters
| Parameter | Pass group (n=33) | Fail group (n=43) | P |
|---|---|---|---|
| BWT (mm) | 6.99±1.01 | 7.16±1.08 | 0.47 |
| TPW (cm) | 4.88±0.59 | 5.15±0.57 | 0.05 |
| APL (cm) | 3.30±1.12 | 3.94±0.82 | 0.007 |
| Maximum SPL (cm) | 4.77±1.04 | 5.34±0.97 | 0.01 |
| PV (cc)* | 43.07±25.73 | 59.10±24.96 | 0.001 |
| IPP-TR (cm)* | 5.76±4.98 | 8.63±5.69 | 0.02 |
| PUA (°) | 33.06±11.04 | 30.24±8.87 | 0.23 |
| PCIR | 14.60±2.57 | 16.23±2.16 | 0.004 |
| PAR | 13.96±5.48 | 17.25±4.99 | 0.008 |
| PCAR | 0.78±0.06 | 0.80±0.05 | 0.16 |
| TZV* (cc) | 24.67±17.78 | 37.34±19.43 | 0.003 |
| TZI | 0.55±0.11 | 0.62±0.11 | 0.01 |
*PV, IPP-TR, TZV were not normally distributed. BWT=Bladder wall thickness, TPW=Transverse prostate width, APL=Axial prostate length, SPL=Sagittal prostate length, PV=Prostate volume, PUA=Prostatic urethral angle, PCAR=Presumed circle area ratio, TZV=Transitional zone volume, TZI=Transition zone index, IPP-TR=Intravesical protrusion of the prostate on TRUS, PCIR=Circumference of the prostate, PAR=Area of prostate
Relationship of extra-urethral catheter length and prostate measurements
EUCL showed a negative relationship with TPW (r = −0.55, P < .00001), APL (r = −0.47, P = 0.000018), SPL (r = −0.47, P = 0.000018), PV (r = −0.59, P < 0.00001) [Figure 6], IPP-TR (r = −0.34, P = 0.0023), TZV (r = −0.65, P < 0.00001), and TZI (r = −0.48, P = 0.000014). As these parameters increased, the EUCL decreased. EUCL did not have a significant relationship with BWT (r = −0.10, P = 0.36), PUA (r = 0.07, P = 0.52), or PCAR (r = −0.15, P = 0.18).
Figure 6.
Relationship of extraurethral catheter length and prostate volume
Clinical factors impacting trial without catheter
The clinical parameters affecting the outcomes, viz, age, weight, height, BMI, DRE, duration of symptoms, IPSS score, and EUCL, were analysed with logistic regression analysis. EUCL was the only factor affecting the outcomes of TWOC. The P values for various factors were: age (0.70), weight (0.60), height (0.65), BMI (0.56), DRE (0.10), duration of symptoms (0.30), IPSS (0.22), and EUCL (0.03). The coefficient (−0.032) denotes that as EUCL decreases, the chances of failed TWOC increased (odds ratio = 0.97 [0.94–0.99]). The optimal cutoff value for predicting the success of the TWOC was 170 mm as per the Youden’s statistics. An EUCL longer than 170 mm would indicate the success of TWOC, and an EUCL shorter than 170 mm would indicate TWOC failure [Supplementary Table 1].
Supplementary Table 1.
Regression table
| Coeff | SE | Wald | P | Exp(B) | Lower | Upper | |
|---|---|---|---|---|---|---|---|
| Intercept | 25.66 | 41.35 | 0.38 | 0.53 | 1.39E+11 | ||
| Age | 0.01 | 0.03 | 0.15 | 0.70 | 1.01 | 0.95 | 1.08 |
| Weight | 0.18 | 0.34 | 0.27 | 0.60 | 1.19 | 0.62 | 2.30 |
| Height | −0.11 | 0.25 | 0.20 | 0.65 | 0.89 | 0.55 | 1.46 |
| BMI | −0.51 | 0.88 | 0.33 | 0.57 | 0.60 | 0.11 | 3.40 |
| DRE | −0.55 | 0.34 | 2.64 | 0.10 | 0.58 | 0.30 | 1.12 |
| Duration | 0.02 | 0.02 | 1.06 | 0.30 | 1.03 | 0.98 | 1.07 |
| IPSS | −0.04 | 0.03 | 1.49 | 0.22 | 0.96 | 0.91 | 1.02 |
| EUCL | −0.03 | 0.01 | 4.51 | 0.03 | 0.97 | 0.94 | 1.00 |
BMI=Body mass index, IPSS=International Prostate Symptom Score, DRE=Digital rectal examination, SE=Standard error, EUCL=Extra-urethral catheter length
Evaluation of extraurethral catheter length as a predictor marker of trial without catheter success
As per the cutoff value from Youden’s statistics, EUCL equal to or smaller than 170 mm was considered as a predictor of failed TWOC, and EUCL longer than 170 mm as a predictor of successful TWOC [Table 3].
Table 3.
Association of extraurethral catheter length with trial without catheter failure
| Observed TWOC fail (disease present) | Observed TWOC pass (disease absent) | Total | |
|---|---|---|---|
| Test positive (EUCL ≤170 mm) Predicting EUCL fail | 19 | 3 | 22 |
| Test negative (EUCL >170 mm) Predicting EUCL pass | 24 | 30 | 54 |
| Total | 43 | 33 | 76 |
OR 7.92 (95% CI 2.09–29.96), Z statistic 3.047, P=0.002. EUCL=Extraurethral catheter length, TWOC=Trial without catheter, CI=Confidence interval, OR=Odds ratio
This ratio shows significantly higher odds of failure of TWOC when the EUCL is ≤170 mm. When the EUCL ≤170mm, there are very high chances (almost 80%) of failure of TWOC and of developing recurrent retention of urine.
DISCUSSION
In the present study, a shorter EUCL was found to be an important clinical predictive marker of the failure of TWOC. EUCL had a negative correlation with most of the prostate dimensions on ultrasonography. The TWOC is a standard protocol for managing AUR in patients with BPE. The reported success rate of TWOC in the literature varies from 28% to 79% [Table 4]. The various factors reported in the literature for predicting the success of TWOC are age, severity of Lower urinary tract symptom (LUTS), spontaneous vs precipitated AUR, prostate size, BWT, retention volume, PSA, and alpha-blocker use.
Table 4.
Factors predicting trial without catheter success or failure
| Reference/Reference number | n | TWOC success | Percentage of TWOC success | Factors predicting TWOC failure |
|---|---|---|---|---|
| Taube and Gajraj, 1989[5] | 60 | 17 | 28.33 | PVR >900 |
| Lim et al., 1993[6] | 79 | 46 | 58.22785 | High PVR (>800 mL), PSA |
| Kumar et al., 2000[13] | 40 | 22 | 55 | Prostate size on DRE |
| McNeill et al., 2004[7] | 81 | 34 | Prostate size on DRE | |
| Li et al., 2009[14] | 143 | Day 0: 50.3 Day 3: 76.9 Day 6: 79.0 Cumulative | Retention volume | |
| Daly et al., 2009[15] | 72 | 27 first and 20 second TWOC | 65 cumulative | PSA, prostate size on DRE, retention volume |
| Fitzpatrick et al., 2012[1] | 6074 | 61 | Age, prostate size on DRE, severity of LUTS, retention volume, spontaneous AUR | |
| Bhomi and Bhattachan, 2011[16] | 64 | 28 | 43.75 | IPP, IPSS, prostate size and retention volume |
| Park et al., 2012[17] | 299 | 161 | 53.84 | Age, prostate size, PSA, retention volume |
| Mahadik et al., 2013[2] | 77 | 30 | 38.96 | Age, prostate size on DRE and ultrasound |
| Bansal and Arora, 2017[4] | 2188 | 737 | 33.68 | Age, baseline AUA score, IPP, PV, and retention volume |
| Das et al., 2018[18] | 90 | 51 | 56.7 | IPP, retention volume, duration of LUTS |
| Jha et al., 2020[3] | 90 | 58 | 64.44 | Age, IPSS, RUV, IPP and BWT |
LUTS=Lower urinary tract symptoms, IPSS=International Prostate Symptom Score, BWT=Bladder wall thickness, RUV=Residual urine volume, PV=Prostate volume, DRE=Digital rectal examination, PSA=Prostate-specific antigen, TWOC=Trial without catheter, PVR=Postvoid residual
The present study underlines the importance of EUCL as a clinical parameter in the treatment planning of patients with BPE with AUR. As the dimensions of the prostate increase, the EUCL decreases. EUCL can be used as a surrogate marker for various prostatic dimensions. Most of the available literature mentions the importance of prostate size as an important predictor of the success of TWOC and the possible need for BPE-related surgery. Multiple studies have demonstrated that the prostate size, as determined by DRE by the treating urologist, was a predictor of success of TWOC.[1,2,7,13,15] DRE is a commonly used clinical parameter for assessing the size of the prostate. TAUS and TRUS provide objective assessments of the prostate size. Ultrasound measurements of the prostate weight/size and various ultrasound parameters have been reported as factors predicting the success of TWOC:[2,4,16,17] Jha et al.[3] and Das et al.[18] reported that among the ultrasound parameters, only IPP, and not PV, was a significant predictor of a successful TWOC. The present study has shown that EUCL is an easily assessable surrogate marker for all these prostate parameters; hence, EUCL can be used as a clinical marker for predicting the success of TWOC.
The duration of LUTS before AUR has been evaluated in the literature. Das et al.[18] in their study demonstrated that LUTS of less than two and a half months duration can predict the success of TWOC with a sensitivity of 87.2%. Mahadik et al.[2] also reported the effect of duration of LUTS on the success of TWOC. Thirty percent of the patients with LUTS of >3 months duration, and 56% of the patients with LUTS of <3 months duration had a successful TWOC (risk ratio, 1.867; 95% confidence interval, 0.6807–5.119; P = 0.0822). The present study also had a similar observation. The patients in the fail group were symptomatic for a significantly longer duration than the pass group (11.40 months vs. 5.75 months, P = 0.04). However, on logistic regression analysis, the duration of the LUTS was not found to be a significant factor impacting the success of TWOC. As compared to the reported literature, the overall duration of the LUTS was longer in the present study population because the author’s urology clinic caters to a large rural population with scarce medical facilities. As reported by many studies,[1,2,3,4,17] age plays a major role in predicting the success of TWOC. In all these studies, older patients were at an increased risk of failed TWOC. In the present study, age was not found to be a significant predictor of the success of TWOC.
In the present study, only a single attempt of TWOC was offered to the patients. It can be argued that a second TWOC should be offered to all the patients regardless of alpha-blocker use. However, recurrent retention is possible in most such patients.[7] This study was conducted at a urology clinic situated in a rural district of Maharashtra, India, in a tier-three city. The centre caters to the rural population in a 32000 km2 area[10] where very few expert urology services are available. The main mode of transport is road transport by public buses, which are not available in the late hours. Travel times by road can range from 2 to 5 h. To avoid the morbidity of AUR, especially in resource-poor settings where patients must travel long distances to reach the urology service, patients who had retention of urine while on alpha-blockers were offered BPE surgery without offering a second TWOC.
This study attempted to find a value of EUCL wherein successful TWOC could be offered to patients with BPE and AUR in the primary healthcare setting. It can be argued that TWOC should not be offered in the primary healthcare setting if the patient develops recurrent retention or any other complication. In this cohort, 56 of the 76 alpha-blocker naïve patients, in whom the TWOC was offered, voided well on the day of TWOC. The number of successful TWOCs is significant. Moreover, given a choice, a patient prefers basic treatment in their local surroundings.[19] In this study, patients received different alpha-blockers (tamsulosin, alfuzosin, or silodosin) and all these patients were grouped together. As far as the success of TWOC is concerned, none of the alpha-blockers have proven to be superior over the others in all the previous studies.[20,21,22]
Based on our findings, we propose that patients with BPE with AUR should be catheterized and started on alpha-blockers. Patients with EUCL shorter than 170 mm should be referred to urology services promptly. The patients with EUCL longer than 170 mm may be offered TWOC in the primary healthcare settings and referred to urology services electively as and when the need arises. Although this recommendation is of utility to a GP, surgeon, physician, or a urologist catering to patients with BPE with AUR, it may be especially useful in resource-poor settings. This is the first study to introduce EUCL as a clinical marker. EUCL as a clinical marker would need evaluation in different study populations and ethnic groups. If EUCL is proved to be an important marker in different study populations, it may be worthwhile to consider manufacturing urethral catheters with centimetre markings like the markings on endotracheal tubes. This would avoid the hassle of measuring EUCL with a measuring tape and may be more comfortable for the patients.
Strengths
The present study showed a significant negative relationship between the EUCL and various dimensions of the prostate. The EUCL can be used as a simple, non-invasive, cost-free, and reproducible clinical tool for determining the success of TWOC and the need for urology referral in resource-poor settings.
Limitations
This is a single-center study where patients received only one attempt at TWOC. The choice of the alpha-blocker was also not standardized. This study did not measure the impact of stretched or flaccid penile length on the EUCL. Exact measurement of the residual volume was not performed. This study was limited to a cohort of Indian patients living in the study area. EUCL measurements may differ between ethnic groups and countries. EUCL as a clinical marker would need evaluation in different study populations and ethnic groups.
CONCLUSIONS
A shorter EUCL was found to be associated with higher prostatic volume and was an important predictor for failure of TWOC. As the prostate size increased, the EUCL decreased. EUCL may be used as a simple noninvasive surrogate marker of the prostate size in primary healthcare, especially in resource-poor settings, to plan a voiding trial or to consider referral to an expert urology service.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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