Benign Prostatic Hyperplasia Pathway

Acute urine retention: A medical emergency where a person is abruptly unable to pass urine, experiencing a full bladder with significant discomfort or pain, often caused by a blockage in the urinary tract, such as benign prostatic hyperplasia (BPH). 

High pressure chronic urine retention: An inability to empty the bladder completely over a prolonged period, resulting in significantly elevated pressure within the bladder, which can lead to complications such as hydronephrosis and renal impairment, and possibly nocturnal enuresis. 

Low pressure chronic urine retention: A condition where a person is unable to completely empty their bladder over a long period of time, but without Acute Kidney Injury (AKI) or hydronephrosis. 

Benign Prostate Enlargement (BPE): A descriptive terminology for a non-cancerous enlargement of the prostate that may or may not result in bothersome Lower Urinary Tract Symptoms (LUTS). 

Bladder outflow obstruction: A condition in which there is a blockage or resistance to the normal flow of urine from the bladder. This obstruction can occur at any point along the urinary tract, typically at the level of the urethra or the bladder neck.  

NHS England Decision tool:

https://www.england.nhs.uk/wp-content/uploads/2023/11/Decision-support-tool-making-a-decision-about-enlarged-prostate.pdf

Getting It Right First Time (GIRFT):

https://gettingitrightfirsttime.co.uk/wp-content/uploads/2023/09/Urology-Pathway_Bladder-outlet-obstruction-FINAL-V1-August-2023.pdf

AEEP – Anatomical Endoscopic Enucleation of the Prostate

AKI – Acute Kidney Injury

BNI – Bladder Neck Incision

BPH – Benign Prostatic Hyperplasia

DRE – Digital Rectal Examination

FV – Frequency Volume

GLL – Green Light Laser

LTC – Long-Term Catheter

LUTS – Lower Urinary Tract Symptoms

IPSS – Inferior Petrosal Sinus Sampling

ISC – Intermittent Self-Catheterisation

iTIND – Temporary Inserted Nitinol Device

NVH – Non-Visible Haematuria

PAE – Prostatic Artery Embolisation

PSA – Prostate-Specific Antigen

PVR – Post-Void Residual

RASP – Robotic Assisted Simple Prostatectomy

Rezum – Minimally invasive treatment using sterile water vapour to shrink enlarged prostate tissue

TURP – Transurethral Resection of the Prostate

TWOC – Trial Without Catheter   

U&Es – Urea and Electrolytes

***Example – for adaptation in NHS Boards***

Trial without catheter (TWOC)

Patient information leaflet

This leaflet provides information for patients with a urinary catheter who are expecting their catheters to be removed, either in the urology clinic or in the community.  It aims to answer the most common questions and manage patient expectations regarding the TWOC.

Note: This leaflet is tailored to NHS Highland due to its unique geography and long distances some patients may need to travel to their nearest hospital.

What is TWOC?

It is the procedure of removing a urinary catheter. Catheters can be either urethral (catheters in the urine pipe) or suprapubic (catheter through the abdomen). Catheter removal must take place in a safe environment allowing the patient to manage outcomes of catheter removal. Following removal, it must be confirmed that a patient is able to pass urine spontaneously. 

Where can TWOC happen?

TWOC can be booked either in a hospital setting, for example, the Highland Urology Centre in Raigmore Hospital, the outpatient department in the rural General Hospitals, or in the community carried out by community nurses, either in GP practices or by home visit.

How to prepare for TWOC?

Before your appointment, make sure to drink plenty of non-alcoholic fluids. If there are any symptoms of urinary infection or bleeding, please inform the nurse before your appointment.

What does the TWOC involve?

When you attend the appointment the nurse will explain the process, verbally consent you to remove the catheter and explain the TWOC process fully.

The catheter stays in place by inflating a balloon, filled with water, inside the bladder. During the TWOC the nurse will deflate the balloon using an empty syringe and gently withdraw the catheter out of the urine pipe.

If the TWOC is arranged in a hospital setting, you will be asked to drink plenty of fluids and to pass urine twice. After each void your bladder will be scanned to make sure you are emptying your bladder satisfactorily.

If the TWOC is arranged in the community setting, the nurse will advise you to drink plenty of fluids and empty your bladder in the toilet. You will receive a follow-up phone call in the next few hours to check that you are emptying your bladder satisfactorily.  If you are unable to pass urine the community nurse will advise you about the next step. 

If you do not pass urine within 4 hours after the removal of the catheter; you are passing only small amounts of urine; you have abdominal pain; or have not yet received a phone call from your community nursing team, you should contact them as soon as possible.

How would the TWOC be deemed successful?

Either by confirmation of satisfactory bladder emptying on bladder scanner (hospital setting) or subjectively by receiving patient feedback on voiding (in community setting).

What to look out for after a successful TWOC?

You should drink plenty of fluids and empty your bladder regularly. You should also get in touch with your nurse, GP or out of hours service if you have any signs of infection or urine retention, for example;

• Difficulty or inability to pass urine
• Lower abdominal or back pain
• Blood in the urine
• High temperature
• Cloudy or smelly urine

How to contact urology department?

Tel:

Email:

For more information regarding TWOC please visit the British Association of Urological Surgeons (BAUS) website: www.baus.org.uk

Or simply scan the QR code provided to take you to the website;

[Clinician name and job role]

August 2025

***Example – for adaptation in NHS Boards***

Self removal of catheter: standard operating procedure

Version 2. C. Gunner, NHS Highland, June 2024.

***Example – for adaptation in NHS Boards***

Self Removal of Catheter (sROC) Patient Information

You have been identified as a suitable patient for self removal of catheter.

Only remove your catheter on the date advised by your surgeon, as indicated above. Early removal of catheter may result in health complications.

You should remove your catheter first thing in the morning, before or by 8am at the latest. This allows time for reinsertion of a catheter within working hours if you are not able to pass urine after the catheter has been removed.

When you are ready to remove your catheter, only on or after the date advised, please follow these steps:

1. Make sure you have recently moved your bowels. If you are constipated you may struggle to pass urine once your catheter has been removed. Drink plenty of water (around a glass per hour) on the day you remove your catheter.

2.  Empty the catheter bag into the toilet and then either stand in the shower or on a towel. Using a pair of scissors, cut the coloured part of the catheter off, as shown below, and let go of the catheter.

3. The fluid from the balloon that holds the catheter in the bladder will slowly trickle out of the cut tubing and the catheter will fall out by itself.

4.  Put the catheter, tubing and drainage bag in your normal general waste bin.

If the catheter does not fall out, carry on with normal activities and it should fall out within the next few hours.

If you are unable to pass urine in the next 4 hours, if the catheter does not fall out within 4 hours or if you are passing only small amounts of urine and experience lower abdominal pain, please urgently contact your Community Nursing Team using the phone number at the top of this leaflet. You may need to have a catheter reinserted.

A video of the steps outlined above is available at tinyurl.com/catheterremoval or scan this QR code:

If you are happy to provide feedback on your experience we would be grateful if you could fill in an online questionnaire in order for us to improve our service. Please type this link into an internet browser to complete an anonymous questionnaire or scan the QR code below:

tinyurl.com/selfroc

V2. Department of Urology, Raigmore Hospital, NHS Highland. June 2024.

Click the image to open the pathway;