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CLINICAL REVIEW: Mark Emberton and Ken Anson Fortnightly review: Acute urinary retention in men: an age old problem BMJ 1999; 318: 921-925 [Full text]

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Acute urinary retention in men: a more complex issue

Jeremy J Elkabir   (15 April 1999)

Acute urinary retention in men: a more complex issue 15 April 1999
Jeremy J Elkabir Send response to journal: Re: Acute urinary retention in men: a more complex issue	EDITOR-We wish to congratulate Messrs. Emberton and Anson on a timely and informative review concerning acute urinary retention (AUR).1 Part of the review focuses on the use of finasteride to reduce the risk of AUR (the PLESS trial).2 We respectfully disagree with the authors that the continuous administration of finasteride for four years is 'probably warranted' in men with large prostates, moderate to severe symptoms and poor urinary flow rates. Firstly the cost implications are enormous and necessitate comment. In order to prevent one event (AUR or prostatectomy) 15 patients would have to be treated for four years. This would cost £19,4753 to prevent a 'single infrequent non life-threatening event'. Secondly the reduction in mean symptom scores using long-term finasteride was small (mean reduction 3.3 points) and not comparable to the results obtained following prostatectomy, where mean symptom scores were reduced by 19.4 points.4 Furthermore it has not been suggested what should happen at the end of the four years. Is the medication to be stopped, with the probability of prostatic regrowth, or does the patient have to remain on finasteride for life? The answers are not known. We therefore conclude that long-term finasteride is not an efficient or cost-effective method of preventing AUR and prostatectomy should remain first line therapy in the patient group described. The review also describes patients with drained bladder volumes of >1L and low detrusor pressures who have a worse outcome (failure of catheter removal or failure of prostatectomy). Most urologists would describe this group as having 'chronic urinary retention', even though there is no agreed criteria which constitute this definition. It is clear that there is an urgent need to set uniform standards so that data may be properly evaluated and therefore different treatments can be compared. Jeremy J Elkabir, Higher Surgical Trainee in Urology Anup Patel, Consultant Urologist Justin A Vale, Consultant Urologist Ross O'N Witherow, Consultant Urologist St. Mary's Hospital, Imperial College of Science Technology and Medicine, London W2 1NY 1 Emberton M, Anson K. Acute urinary retention in men: and age old problem. BMJ 1999;318:921-5. 2 McConnell JD, Bruskewitz R, Walsh P, Andriole G, Lieber M, Holtgrewe HL et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with beingn prostatic hyperplasia. N Eng J Med 1998;338:557-63. 3 Proscar: Basic NHS cost. Monthly index of medical specialities (mimms) 1999;4:231. 4 Emberton M, Neal DE, Black N, Fordham M, Harrison M, McBrien MP et al. The effect of prostatectomy on symptom severity and quality of life. Br J Urol 1996;77:233-47.