Different treatment options are available for patients with chronic urinary retention (CUR). The aim of this study was to explore the different treatments patients received from the urologist and the related complications.

For this retrospective study male patients were included who started treatment in 2014 for non-neurogenic CUR with a post-void residual (PVR) >150 ml. Patients were excluded because of urinary retention for a period shorter than four months, CUR with neurogenic origin, or the absence of clinical data. The follow-up began at the date of first treatment and ended on 1 September 2020. 
We analyzed all hospital contacts from the electronic patient records during the follow up period. These included different treatment steps, the related complications and the consequences thereof, such as additional diagnostics and additional treatments. Curative-intended options were de-obstructive prostate surgery, mostly transurethral resection of the prostate (TURP) or laser TURP, or sacral neuromodulation (SNM). Palliative options were clean intermittent catheterization (CIC), a urethral catheter (UC), a suprapubic catheter (SPC), and watchful waiting (WW).

One hundred seventy-seven patients were included with a median age of 77 years (range 44-94) and a median follow-up of 68 months (range 1-319) during which they had a median of 8 hospital contacts (range 1-51). Four patients were excluded because of treatment with a percutaneous nephrostomy catheter due to another cause than CUR. 

Curative treatments
A part of patients was treated with a curative intent (n=50). Forty-nine patients (28%) had de-obstructive surgery of the prostate. Thirty-three percent of these patients could stop catheterization, compared to 6% of the patients in the group treated with catheterization . Patients treated with de-obstructive prostate surgery, were significantly more likely to end in the WW-group (OR 4.179). One patient received SNM in another hospital. Other baseline characteristics did not affect the final treatment outcome.
With regard to complications, the patient with SNM did not have any recorded complications. In the 30-days after prostate surgery, 36 complications were recorded. The most common were UTI’s (n=17) and haematuria (n=11). Other complications included frequency, urgency or urge incontinence (n=7) and a bladder perforation (n=1). 

Palliative treatments
The first and last treatment steps are displayed in Figure 1. Patients had a median of three (range 1-18) treatment steps until final treatment was attained. Most patients had a urethral catheter as first treatment (74%) and a form of catheterization as last treatment (87%). 

Complications
The incidence rate of the complications for catheterization and WW are presented in Table 1. An incidence rate of for example 1373 UTIs per 1000 patient-years can be explained as an average of 1.4 UTIs per patient per year. Catheterization (SPC, UC and CIC) gives a significantly higher chance of an UTI (incidence rate ratio (IRR) of 3.679, 95% CI: 2.920-4.686, p<0.001) and haematuria (IRR of 5.35, 95% CI: 2.292-15.12, p<0.001) compared to WW. However, patients in the WW-group have a much higher chance of post renal problems compared to catheterization (IRR of 25.36, 95% CI: 8.726-103.7, p<0.001). However, most post-renal problems (89%) were already present at the start of the first treatment. 
When comparing different forms of catheterization, CIC has a significantly lower incidence rate for all complications compared to UC and SPC (p<0.01), except for haematuria. SPC has a significantly lower incidence rate for all complications compared to UC (p<0.05), except for catheter pain.

Most male CUR-patients were treated with a form of catheterization, and these patients experience significant burden i.e. more UTIs, macroscopic haematuria, catheter problems and pain compared to the WW-group. Nevertheless, patients in the WW-group had a significantly higher chance of post-renal problems, mostly before onset of catheterisation.
In some patients, the burden of catheterization may be avoided by treating the underlying cause of urinary retention, such as bladder outlet obstruction (BOO) and/or detrusor underactivity (DU) (1). For a long time TURP has been the cornerstone of surgical treatment of BOO due to benign prostate hyperplasia (2), and some studies suggest that patients with DU might improve after TURP compared to doing nothing (3). In our study, 33% of the patients who had de-obstructive prostate surgery could stop catheterization.

This retrospective study demonstrates that men with CUR are most often treated with catheterization. This brings significant burden, such as UTIs, hematuria, catheter related problems, and pain. CIC is the most favourable form of catheterization. A selected group of men with CUR might benefit from de-obstructive prostate surgery.

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