Post-operative urinary retention: Review of literature

Table 1 Various risk factors for urinary retention in the postoperative period

Definitive	Equivocal	Unrelated
Age[1,3,5,9,10]; Pre-existing neurologic abnormality (stroke, cerebral palsy, multiple sclerosis, diabetic and alcohol neuropathy, poliomyelitis)[1,9]; Bladder volume on entry to PACU[3]; Surgical procedure (anorectal, colorectal, urogynaecolgical)[5,7,11,12]; Intraoperative aggressive fluid administration[1,3,5,6,11,13]; Postoperative pain and need for postoperative analgesia[5,7,9,11,14]; Postoperative opioid use[1,5,11]	Gender[1,3,7,9,15]; Preoperative urinary tract pathology[5,7,9,16,17]; Anaesthetic technique (general anaesthesia vs neuraxial anaesthesia)[1,2,6,9,10,12,17]; Duration of surgery[1,3,5-7,18]	American Society of Anaesthesiologists physical status[18]; Presence of pelvic drain[18]; Pelvic infection[18]

PACU: Post anaesthesia care unit.

Table 2 Diagnostic modalities for postoperative urinary retention

Method of diagnosis	Ref.	Objective	Sample population	Results
Clinical examination
Palpable bladder distension	Bailey et al[25] (1976)	To study effect of fluid restriction on incidence of POUR	500 patients undergoing anorectal surgeries	Significant reduction in POUR with fluid restriction
Palpable bladder or patient discomfort	Petros et al[11] (1991)	To determine incidence of and factors influencing POUR after herniorrhaphy	295 patients who had undergone herniorrhaphy	Factors affecting POUR included age, fluid restriction, type of anaesthesia
Palpable/distended bladder or patient discomfort	Petros et al[13] (1990)	To determine factors affecting POUR after surgery for benign anorectal diseases	111 patients who had undergone surgery for benign anorectal diseases under spinal anaesthesia	Using long-acting local anaesthetic (bupivacaine) and use of > 1000 mL fluid increased risk of POUR
	Waterhouse et al[26] (1987)	To identify patients at risk of POUR	103 patients undergoing total hip replacement	At-risk patients included those with inability to pass urine into bottle while lying supine, with history of voiding difficulty, and with urinary peak flow rate suggestive of obstruction
Clinical assessment by patient or nurses	Pavlin et al[12] (1999)	To compare patient outcome after ambulatory surgery with or without USG monitoring of bladder volume	334 patients undergoing outpatient surgeries	USG monitoring was beneficial in patients at high-risk for POUR
Manual palpation and percussion of bladder	Greig et al[27] (1995)	To compare bladder volume by manual and USG examination	90 patients undergoing laparoscopic surgery	Manual assessment of bladder failed to detect urinary retention especially in obese patients
Painful urinary retention or manual palpation of bladder	Stallard et al[28] (1998)	To measure incidence of POUR	280 patients undergoing general surgical operations	Incidence of POUR was 6% and was attributed to decreased awareness of bladder sensation
Failure to void till 8 h postoperatively and distended bladder/patient discomfort	Cataldo et al[29] (1991)	To study role of prazosin for prevention of POUR after anorectal surgeries	51 patients undergoing elective anorectal procedures	Prophylactic use of prazosin did not decrease incidence of POUR
Failure to void postoperatively	Pawlowski et al[30] (2000)	To compare the time for discharge after use of two doses of mepivacaine in ambulatory SAB	60 patients undergoing ambulatory surgery for anterior cruciate ligament tear under spinal anaesthesia	None of the patient in either group had difficulty in voiding
Distended bladder	Esmaoglu et al[31] (2004)	To compare time for hospital discharge for knee arthroscopies under unilateral vs bilateral SAB	70 patients undergoing elective outpatient knee arthroscopy	Urinary retention was present in bilateral SAB group with longer time to discharge
Distended/palpable bladder and failure to void postoperatively	Evron et al[32] (1985)	To assess urinary retention after epidural methadone and morphine	120 females scheduled for caesarean section under epidural anaesthesia	Lower incidence of urinary complications with use of epidural methadone
Failure to void spontaneously within 8 h of removal of urinary catheter	Paulsen et al[33] (2001)	To compare postoperative recovery after bowel resection with thoracic epidural vs patient-controlled analgesia	49 patients undergoing elective bowel resection	Patients with thoracic epidural had lower pain scores but higher incidence of POUR and other complications
Urinary retention graded as: 0 = none; 1 = mild hesitancy; 2 = straight catheter required; and 3 = Foley catheter required	Baron et al[34] (1996)	To evaluate effect of addition of epinephrine on postoperative requirement of epidural fentanyl	38 patients undergoing elective posterolateral thoracotomy	Addition of epidural epinephrine decreased fentanyl requirement with no significant change in POUR incidence
Delayed spontaneous micturition	Lanz et al[35] (1982)	To study effect of epidural morphine on postoperative analgesia	174 patients receiving lumbar epidural anaesthesia orthopaedic procedures	Better postoperative analgesia but higher incidence of POUR with epidural morphine
Failure to void till 12 h postoperatively	Dobbs et al[36] (1997)	To compare postoperative outcomes in continuous bladder drainage vs in-out catheterization during total abdominal hysterectomy	100 females scheduled for total abdominal hysterectomy for non-malignant cause	Significantly higher incidence of POUR after in-out bladder catheterization
Failure to void postoperatively along with patient discomfort/palpable bladder	Kumar et al[37] (2006)	To evaluate the occurrence of POUR after total knee arthroplasty and role of indwelling bladder catheterization	142 patients undergoing total knee arthroplasty	19.7% patients had POUR. Authors recommended use of indwelling catheter for management of POUR
Bladder catheterization
Requirement of bladder catheterization	Lau et al[10] (2004)	To ascertain optimal management of POUR (in-out catheterization vs indwelling catheter)	1448 patients undergoing elective inpatient general surgery	In-out catheterization recommended for POUR over indwelling catheter
Need for catheterization within 24 h postoperatively	Toyonaga et al[7] (2006)	Incidence and risk factors for POUR after surgery for benign anorectal diseases	2011 patients who underwent surgery for benign anorectal diseases under SAB	Incidence of POUR was 16.7%. Perioperative pain and excessive fluid administration were found to be risk factors
Need for urinary qcatheter (indweliing and/or temporary) within 24 h after surgery	Zaheer et al[14] (1998)	Incidence and risk factors for POUR after surgery for benign anorectal diseases	1026 patients who underwent surgery for benign anorectal diseases	Incidence of POUR was more after haemorrhoidectomy than other anorectal procedures.
Requirement of catheterization (with resulting urinary volume > 400 mL)	Faas et al[38] (2002)	Effect of SAB vs epidural anaesthesia on pain, urinary retention and ambulation in patients scheduled for inguinal herniorrhaphy	144 patients scheduled for elective inguinal herniorrhaphy	SAB resulted in more incidence of POUR and delayed ambulation
Need for catheterization (with residual volume > 500 mL)	Olofsson et al[39] (1996)	To compare post-partum urinary retention after epidural labour analgesia with bupivacaine and adrenaline vs bupivacaine and sufentanil	1000 antenatal females scheduled for epidural labour analgesia	Epidural anaesthesia led to higher risk for post-partum urinary retention
Need for catheterization	Lingaraj et al[40] (2007)	Incidence and risk factors for POUR after total knee arthroplasty	125 patients who underwent total knee arthroplasty	Incidence of POUR was 8%; predisposing factors being male gender and epidural anaesthesia
Need for catheterization	O’Riordan et al[41] (2000)	Risk factors for POUR after lower limb joint replacements	116 patients undergoing lower limb replacements	Increasing age, male gender, and use of patient-controlled analgesia (PCA) were risk factors
Need for catheterization	Jellish et al[42] (1996)	To compare perioperative outcomes after SAB vs GA for lumbar disc and laminectomy procedures	122 patients undergoing lumbar laminectomy or disc surgery	Incidence of POUR was similar in both groups
Need for catheterization	Fernandes MCBC et al[43] (2007)	To determine incidence of POUR in patients using postoperative opioid analgesics (PCA or epidural)	1316 patients undergoing elective surgery and using opioids for postoperative analgesia	Incidence of POUR was 22% ; with higher incidence in patients using continuous epidural analgesia
Need for catheterization	Matthews et al[44] (1989)	To compare efficacy of epidural vs paravertebral bupivacaine infusion for post-thoracotomy analgesia	20 patients scheduled for thoracotomy and pulmonary resection	Analgesia was comparable in both groups. Incidence of urinary retention was lower in paravertebral group
Need for catheterization	Peiper et al[45] (1994)	To compare perioperative outcomes after LA vs GA for inguinal hernia repair	607 patients operated for inguinal hernia repair	Patients in LA group had lower intensity of pain and had fewer complications e.g. POUR
Need for catheterization within 48 h postoperatively	Fletcher et al[46] (1997)	To study postoperative analgesia with iv paracetamol and ketoprofen after lumbar disc surgery	64 adults undergoing surgery for lumbar disc herniation	Postoperative analgesia was better in patients receiving both paracetamol and ketoprofen; with no difference in incidence of POUR
Ultrasonographic assessment
Inability to void with residual volume ≥ 600 mL	Pavlin et al[12] (1999)	To evaluate the effect of ultrasonographic monitoring of bladder volume postoperatively after ambulatory surgery	334 patients scheduled for outpatient surgeries	USG assessment helped in evaluating the need for catheterization in patients at high risk for POUR
Inability to void with bladder volume ≥ 600 mL	Daurat et al[4] (2015)	To determine the reliability of diagnosis of POUR by a simplified USG measurement of largest transverse bladder diameter	100 patients undergoing orthopaedic surgery	Measurement of largest transverse bladder diameter using USG facilitated in diagnosing POUR
Inability to void with bladder volume > 600 mL	Lamonerie et al[6] (2004)	To determine the prevalence and risk factors for POUR using USG	177 patients undergoing a variety of surgical procedures	44% patients had bladder distension as measured by USG. Risk factors for POUR were increasing age, SAB, and surgical duration > 2 h
Inability to void with bladder volume > estimated bladder capacity [(30 mL/age in years) + 30 mL]	Rosseland et al[47] (2005)	To assess reliability of postoperative USG monitoring of bladder volume in children	48 children of 0-15 years who had undergone surgical procedure under GA	Reliability of USG monitoring was good in children above 3 years age
Inability to void with bladder volume ≥ 500 mL	Joelsson-Alm et al[48] (2012)	To evaluate the efficacy of preoperative USG monitoring in decreasing POUR	281 patients scheduled foremergencyorthopaedic surgery	Preoperative scanning of bladder helped in decreasing incidence of POUR
Inability to void with residual volume ≥ 600 mL	Ozturk et al[49] (2016)	To evaluate efficacy of preoperative and postoperative bladder scanning to decrease incidence of POUR	80 patients receiving SAB for arthroscopic knee surgery	Postoperative USG monitoring can reduce incidence of POUR
Inability to void with residual volume > 500 mL	Rosseland et al[50] (2002)	To compare bladder volume measured by USG with that measured after catheterization	36 patients undergoing surgical procedure under SAB	Good correlation was found between volume estimated by USG and that measured after catheterization
Inability to void within 30 min with bladder volume > 600 mL	Keita et al[3] (2005)	To determine risk factors for POUR	313 patients scheduled for elective surgery	Risk factors for POUR included intraoperative fluids > 750 mL, increasing age and bladder volume > 270 mL in PACU
Inability to void with bladder volume ≥ 500 mL	Gupta et al[51] (2003)	To compare outcome with two doses of bupivacaine (along with fentanyl) for SAB for inguinal herniorrhaphy	40 patients scheduled for outpatient inguinal herniorrhaphy	Bupivacaine 7.5 mg provide better analgesia than 6mg but led to more urinary retention and longer hospital stay

GA: General anaesthesia; LA: Local anaesthesia; POUR: Postoperative urinary retention; SAB: Subarachnoid block.