Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

1. What is the etiology of acute and chronic urinary retention in adults?
2. How do we define urinary retention (base case) including those with known neurologic problems? (aka What is considered abnormal PVR?)
3. What is the natural history and consequences of urinary retention?
4. Who is at risk for urinary retention and who should get screened?
5. What should the diagnostic workup for identification of urinary retention include?
6. What are the effective treatment/management options for urinary retention?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• Suprapubic catherization vs. urethral catherization
• Catheterization vs. catheterization plus pharmacologic agent
• Catheterization vs. surgery

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Adult men and women

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

• Elderly
• Disabled with neurologic disorders such as spinal cord injury

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Improvement in symptoms or cure
• Improvement in quality of life

Describe any health-related risks, side effects, or harms that you are concerned about.

• Risk of infection
• Risk of renal failure, upper urinary tract deterioration, and urosepsis
• Risk of hematuria, hypotension, and postobstructive diuresis from rapid decompression
• Risk of UTI, sepsis, trauma, stones, urethral strictures or erosions, prostatitis and potential development of squamous cell carcinoma from use of chronic indwelling catheters
• Risk of radiation exposure from diagnostic imaging (CT)
• Risk of intraoperative complications, bleeding, postoperative complications, and hospital mortality from prostatic surgery

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cancer
• Cardiovascular disease, including stroke and hypertension
• Dementia, including Alzheimer's disease
• Diabetes mellitus
• Functional limitations and disability
• Infectious diseases, including HIV/AIDS

AHRQ Priority Populations

• Women
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicare

Importance

Describe why this topic is important.

Urinary retention is a condition that affects more men than women and particularly the elderly, men over 60. [Emberton] Two large cohort studies of U.S. men from 40 to 83 years of age show the overall incidence of urinary retention to be 4.3 to 6.8 per 1000 men per year. [Meigs 1999] Another study shows that in men ages 70 to 79 they have a one in 10 chance of developing urinary retention within the next five years, and the risk for men in their 80s is almost one in three. [Jacobsen1997][Mebust 1989] In women the incidence of urinary retention is not well documented. [Selius 2008] Urinary retention is common among those with neurologic conditions.

BPH, as a cause of urinary retention, is the 4th most expensive urologic condition for Medicare (UDA 2007). It has been estimated that In the U.S. there are approximately 2 million office visits and more than 250,000 surgical procedures performed for patients with BPH. [Jacobsen 1997] In 25 to 30% of patients undergoing transurethral resection of the prostate has been the reason for surgery. [Mebust 1989].

Costs associated with acute urinary retention include medications, catheters, office visits, surgeries, hospital stays, and after care. These costs will grow as the US population ages and the elderly become, as expected a larger percentage of the total population. In addition, based on past performance, life expectancy may be expected to continue to increase.

Urinary retention has been defined as the inability to voluntarily urinate. [Curtis, 2001] It is a urological emergency characterized by a sudden and painful inability to pass urine. [Fitzpatrick 2006]. There are many causes of urinary retention. The retention can be classified as obstructive, infectious and inflammatory, pharmacologic, neurologic, or other. [Selius 2008]??The most common obstructive cause among men is benign prostatic hyperplasia. Advanced Prostate Cancer in men which has invaded the urethra or bladder neck is another obstructive caus

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

If the topic nomination is accepted the AUA may produce a clinical practice guideline on urinary retention in 2013 or 2014 from an AHRQ evidence report. At a minimum AUA will post the review on its guidelines web site. AUA is an experienced partner of AHRQ in making use of their evidence reports in this manner.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

There is substantial variability in the ways that urinary retention is screened, evaluated and treated. With the availability of non invasive bladder scanners and ultrasound technology, many clinicians have included screening for retention among their patients. The value of this is uncertain but classic silent prostatism is a well established phenomenon. Moreover, the reliability of single measurement has been questioned and the post void residual that is considered to be clinically significant is highly debated.

With treatment, some clinicians first use an approach of catherization, others combine that with a pharmacological agent, and yet others rapidly opt for surgery. Within these options there is great variation in duration of catheterization, in pharmaceuticals prescribed, the length of the hospital stay, and the type of follow-up care needed.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

To assist clinicians and patients in their decision-making the AUA may develop a clinical practice guideline based on the evidence report AHRQ would create from its systematic review of the medical literature on urinary retention. Having worked with AHRQ topic nominations before It is experienced in developing guidelines from AHRQ evidence reports. Use of the report will significantly reduce by several months the time normally required to develop a guideline.

If AUA is not able to use the review to develop a guideline, it will post the review on the guidelines’ page of the AUA web site.

• If developed, the guideline will be officially published on the guidelines’ page of the AUA website http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm Here it can be accessed by clinicians, primary care physicians, and the public in general. Publicity will be distributed to the national and medical press, including Twitter and Facebook, to alert these audiences to the guideline’s existence. On this site a webinar developed by the guideline’s panel chair will be located for viewing by web site visitors, as will a patient guide on urinary retention.

A plenary session about this guideline will be presented to clinicians attending the AUA annual meeting held after its publication. The guideline will be incorporated into the AUA Office of Education’s Urology Core Curriculum, the most comprehensive reference guide available detailing the knowledge necessary to deliver quality urological care.

Several other derivative publications will be produced from this guideline and disseminated. Targeted toward the national and international community of clinicians, a 4000-word summary of the guideline will be written by the panel chair and appear approximately four to six months after guideline publication in the peer reviewed Journal of Urology. This journal is the most widely read and highly cited journal in the field. All articles are indexed by MEDL

Describe the timeframe in which an answer to your question is needed.

The AUA is flexible. If it is possible to develop a guideline from the evidence report development would begin the year in which the evidence report is issued. If, because of competing priorities to revise existing AUA guidelines, a guideline cannot begin, the evidence report will be posted on the web site immediately

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Vulnerable populations include the frail, the elderly and disabled patients with neurologic disorders such as spinal cord injury.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

To assist clinicians and patients in their decision-making the AUA may develop a clinical practice guideline based on the evidence report AHRQ would create from its systematic review of the medical literature on urinary retention. Having worked with AHRQ topic nominations before It is experienced in developing guidelines from AHRQ evidence reports. Use of the report will significantly reduce by several months the time normally required to develop a guideline.

If AUA is not able to use the review to develop a guideline, it will post the review on the guidelines’ page of the AUA web site.

• If developed, the guideline will be officially published on the guidelines’ page of the AUA website http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm Here it can be accessed by clinicians, primary care physicians, and the public in general. Publicity will be distributed to the national and medical press, including Twitter and Facebook, to alert these audiences to the guideline’s existence. On this site a webinar developed by the guideline’s panel chair will be located for viewing by web site visitors, as will a patient guide on urinary retention.

A plenary session about this guideline will be presented to clinicians attending the AUA annual meeting held after its publication. The guideline will be incorporated into the AUA Office of Education’s Urology Core Curriculum, the most comprehensive reference guide available detailing the knowledge necessary to deliver quality urological care.

Several other derivative publications will be produced from this guideline and disseminated. Targeted toward the national and international community of clinicians, a 4000-word summary of the guideline will be written by the panel chair and appear approximately four to six months after guideline publication in the peer reviewed Journal of Urology. This journal is the most widely read and highly cited journal in the field. All articles are indexed by MEDL

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

Familiarity with the program in general.