A patient may present to the ED after foley catheter placement for acute urinary retentiveness (AUR) a few days ago and now requests catheter removal. Ideally this should be performed in the urologist'south office. However, occasionally patients cannot or do non follow up with the urologist in a timely manner and return to the ED expecting urethral catheter removal. A conscientious history and physical should be performed forth with a consulting urologist. If the eventual decision is to remove the urethral catheter in the ED, what is of import to know about a Trial of Void (TOV)?

Massoud Kazzi, Doc
EM Resident, SUNY Downstate Medical Center

 Blog peer reviewerfor ALiEM journal pilot projection:
Javier Benítez, Md

What is a Trial of Void?

A Trial of Void, also referred to as Trial Without Catheter, involves removal of the urethral catheter and an assessment of the patient'due south ability to spontaneously urinate. If successful, the patient may avert or delay surgical intervention and possibly be managed medically.

Traditional technique

  1. Remove the catheter, and encourage oral fluid intake.
  2. Measure the post-void remainder (PVR) past re-catheterization or, more than humanely, ultrasounding of the bladder. Also quantify the corporeality of urine spontaneously voided. 1,ii

If the amount of urine voided is > 150 mL or the PVR is < 100 mL, there is a low recurrence of AUR and the TOV is considered successful. 3 PVR volumes up to 300 mL tin can be acceptable in patients who have chronic urinary retention. iv

Culling technique: The infusion method

Because we don't ofttimes have several hours in the ED for the float to refill after oral fluid intake, 1 might consider accelerating this process.

Infuse 300–500 mL of saline in the bladder prior to catheter removal. When compared to the standard method of oral fluid intake, information technology reduces time to discharge by almost fourscore minutes as compared to the standard method. 5

How long afterward initial catheter placement can removal and Trial of Void have place?

No definitive guidelines exist. However, a survey of 6,074 patients with AUR by Fitzpatrick et al. vi found that in patients whose catheter was removed at ≤ 3 days vs. ≥ 4 days, in that location was a lower frequency of:

  • Urinary tract infection: 3.4% vs 7.two%
  • Catheter obstruction: 0.8% vs 3.1%
  • Urosepsis: 0.vi% vs i.two%

Traditional teaching and previous studies demonstrated that prolonging catheterization improves success of TOV attempt. 4 More contempo studies have found either no improvement, or that TOV at ≤ 3 days was more successful than TOV done after. 7 Regardless of when the catheter was removed, of utmost importance is the prior use of α-1 blockers, which several studies evidence improve the likelihood of successful TOV. half dozen,eight

Bottom Line

  1. Consider a TOV as early as Mean solar day iii if the patient has been taking α-ane blockers accordingly.
  2. When performing a TOV, consider the infusion method to speed upwards the time to decision and patient discharge.
Fuse H, Yokoyama T, Muraishi Y, Katayama T. Measurement of residual urine volume using a portable ultrasound musical instrument. Int Urol Nephrol. 1996;28(v):633-637. [PubMed]
O'Connell B, Ostaszkiewicz J, Ski C. Evolution and Trial of All-time Practice Protocol for Management of Urinary Retention in Elderly Patients in Acute and Sub-Acute Settings. Geelong, Vic.: Deakin University; 2006.
Kalejaiye O, Speakman MJ. Management of Astute and Chronic Retention in Men. European Urology Supplements. 2009;8(6):523-529. doi: 10.1016/j.eursup.2009.02.002
Boccola K, Sharma A, Taylor C, Wong L, Travis D, Chan S. The infusion method trial of void vs standard catheter removal in the outpatient setting: a prospective randomized trial. BJU Int. 2011;107 Suppl 3:43-46. [PubMed]
Fitzpatrick J, Desgrandchamps F, Adjali K, et al. Management of acute urinary retention: a worldwide survey of 6074 men with beneficial prostatic hyperplasia. BJU Int. 2012;109(one):88-95. [PubMed]
Desgrandchamps F, De L, Doublet J, RetenFrance S. The direction of astute urinary retention in France: a cross-exclusive survey in 2618 men with beneficial prostatic hyperplasia. BJU Int. 2006;97(4):727-733. [PubMed]
Zeif H, Subramonian K. Alpha blockers prior to removal of a catheter for acute urinary retention in adult men. Cochrane Database Syst Rev. 2009;(four):CD006744. [PubMed]
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