Prevention and management of postoperative urinary retention after urogynecologic surgery

Elizabeth J Geller, Elizabeth J Geller

Abstract

Postoperative urinary retention (POUR) is a frequent consequence of gynecologic surgery, especially with surgical correction of urinary incontinence and pelvic organ prolapse. Estimates of retention rates after pelvic surgery range from 2.5%-43%. While there is no standard definition for POUR, it is characterized by impaired bladder emptying, with an elevation in the volume of retained urine. The key to management of POUR is early identification. All patients undergoing pelvic surgery, especially for the correction of incontinence or prolapse, should have an assessment of voiding function prior to discharge. There are several ways to assess voiding function - the gold standard is by measuring a postvoid residual. Management of POUR is fairly straightforward. The goal is to decompress the bladder to avoid long-term damage to bladder integrity and function. The decision regarding when to discontinue catheter-assisted bladder drainage in the postoperative period can be assessed in an ongoing fashion by measurement of postvoid residual. The rate of prolonged POUR beyond 4 weeks is low, and therefore most retention can be expected to resolve spontaneously within 4-6 weeks. When POUR does not resolve spontaneously, more active management may be required. Techniques include urethral dilation, sling stretching, sling incision, partial sling resection, and urethrolysis. While some risk of POUR is inevitable, there are risk factors that are modifiable. Patients that are at higher risk - either due to the procedures being performed or their clinical risk factors - should be counseled regarding the risks and management options for POUR prior to their surgery. Although POUR is a serious condition that can have serious consequences if left untreated, it is easily diagnosed and typically self-resolves. Clinician awareness of the condition and vigilance in its diagnosis are the key factors to successful care for patients undergoing surgical repair.

Keywords: incontinence; postoperative; prolapse; urinary retention.

Figures

Figure 1
Figure 1
Assessment of urethral angle, utilizing sterile cotton swab at the urethrovesical junction. Notes: (A) Normal urethral position. (B) Hypermobile urethral angle, with bladder demonstrating prolapse. (C) Overcorrected urethral angle, with bladder elevated beyond a normal position; postsurgical change from incontinence or prolapse repair.

References

    1. Buchko BL, Robinson LE. An evidence-based approach to decrease early postoperative urinary retention following urogynecologic surgery. Urol Nurs. 2012;32(5):260–264.
    1. Dörflinger A, Monga A. Voiding dysfunction. Curr Opin Obstet Gynecol. 2001;13(5):507–512.
    1. Partoll LM. Efficacy of tension-free vaginal tape with other pelvic reconstructive surgery. Am J Obstet Gynecol. 2002;186(6):1292–1295. discussion 1295–1298.
    1. MacLean AB, Cardozo L. Incontinence in Women. London, UK: Royal College of Obstetricians and Gynaecologitsts Press; 2002.
    1. Foster RT, Borawski KM, South MM, Weidner AC, Webster GD, Amundsen CL. A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery. Am J Obstet Gynecol. 2007;197(6):627.e1–627.e4.
    1. Geller EJ, Hankins KJ, Parnell BA, Robinson BL, Dunivan GC. Diagnostic accuracy of retrograde and spontaneous voiding trials for postoperative voiding dysfunction: a randomized controlled trial. Obstet Gynecol. 2011;118(3):637–642.
    1. Natale F, La Penna C, Saltari M, Piccione E, Cervigni M. Voiding dysfunction after anti-incontinence surgery. Minerva Ginecol. 2009;61(2):167–172.
    1. Siddighi S, Karram MM. Surgical and nonsurgical approaches to treat voiding dysfunction following antiincontinence surgery. Curr Opin Obstet Gynecol. 2007;19(5):490–495.
    1. Stothers L, Goldenberg SL, Leone EF. Complications of periurethral collagen injection for stress urinary incontinence. J Urol. 1998;159(3):806–807.
    1. Hakvoort RA, Dijkgraaf MG, Burger MP, Emanuel MH, Roovers JP. Predicting short-term urinary retention after vaginal prolapse surgery. Neurourol Urodyn. 2009;28(3):225–228.
    1. Mahfouz W, Al Afraa T, Campeau L, Corcos J. Normal urodynamic parameters in women: part II – invasive urodynamics. Int Urogynecol J. 2012;23(3):269–277.
    1. Toyonaga T, Matsushima M, Sogawa N, et al. Postoperative urinary retention after surgery for benign anorectal disease: potential risk factors and strategy for prevention. Int J Colorectal Dis. 2006;21(7):676–682.
    1. Bracken JN, Huffaker RK, Yandell PM, et al. A randomized comparison of bupivacaine versus saline during placement of tension-free vaginal tape. Female Pelvic Med Reconstr Surg. 2012;18(2):93–96.
    1. Kim J, Lee DS, Jang SM, Shim MC, Jee DL. The effect of pudendal block on voiding after hemorrhoidectomy. Dis Colon Rectum. 2005;48(3):518–523.
    1. Volpi E, Ferrero A, Sismondi P. Laparoscopic identification of pelvic nerves in patients with deep infiltrating endometriosis. Surg Endosc. 2004;18(7):1109–1112.
    1. Dietz HP, Haylen BT, Vancaillie TG. Female pelvic organ prolapse and voiding function. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(5):284–288.
    1. Hong B, Park S, Kim HS, Choo MS. Factors predictive of urinary retention after a tension-free vaginal tape procedure for female stress urinary incontinence. J Urol. 2003;170(3):852–856.
    1. Romanzi LJ, Chaikin DC, Blaivas JG. The effect of genital prolapse on voiding. J Urol. 1999;161(2):581–586.
    1. Sokol AI, Jelovsek JE, Walters MD, Paraiso MF, Barber MD. Incidence and predictors of prolonged urinary retention after TVT with and without concurrent prolapse surgery. Am J Obstet Gynecol. 2005;192(5):1537–1543.
    1. Kobak WH, Walters MD, Piedmonte MR. Determinants of voiding after three types of incontinence surgery: a multivariable analysis. Obstet Gynecol. 2001;97(1):86–91.
    1. Keita H, Diouf E, Tubach F, et al. Predictive factors of early postoperative urinary retention in the postanesthesia care unit. Anesth Analg. 2005;101(2):592–596. table of contents.
    1. Joelsson-Alm E, Ulfvarson J, Nyman CR, Divander MB, Svensén C. Preoperative ultrasound monitoring can reduce postoperative bladder distension: a randomized study. Scand J Urol Nephrol. 2012;46(2):84–90.
    1. Choi S, Mahon P, Awad IT. Neuraxial anesthesia and bladder dysfunction in the perioperative period: a systematic review. Can J Anaesth. 2012;59(7):681–703.
    1. Mahan KT, Wang J. Spinal morphine anesthesia and urinary retention. J Am Podiatr Med Assoc. 1993;83(11):607–614.
    1. Kamphuis ET, Kuipers PW, van Venrooij GE, Kalkman CJ. The effects of spinal anesthesia with lidocaine and sufentanil on lower urinary tract functions. Anesth Analg. 2008;107(6):2073–2078.
    1. Bhatia NN, Bergman A. Urodynamic predictability of voiding following incontinence surgery. Obstet Gynecol. 1984;63(1):85–91.
    1. Dawson T, Lawton V, Adams E, Richmond D. Factors predictive of post-TVT voiding dysfunction. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(11):1297–1302.
    1. Lemack GE, Krauss S, Litman H, et al. Urinary Incontinence Treatment Network Normal preoperative urodynamic testing does not predict voiding dysfunction after Burch colposuspension versus pubovaginal sling. J Urol. 2008;180(5):2076–2080.
    1. Nager CW, Brubaker L, Litman HJ, et al. Urinary Incontinence Treatment Network A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012;366(21):1987–1997.
    1. Alnaif B, Drutz HP. The accuracy of portable abdominal ultrasound equipment in measuring postvoid residual volume. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10(4):215–218.
    1. Al-Shaikh G, Larochelle A, Campbell CE, Schachter J, Baker K, Pascali D. Accuracy of bladder scanning in the assessment of postvoid residual volume. J Obstet Gynaecol Can. 2009;31(6):526–532.
    1. Hakvoort RA, Thijs SD, Bouwmeester FW, et al. Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for incomplete voiding after vaginal prolapse surgery: a multicentre randomised trial. BJOG. 2011;118(9):1055–1060.
    1. Zmora O, Madbouly K, Tulchinsky H, Hussein A, Khaikin M. Urinary bladder catheter drainage following pelvic surgery – is it necessary for that long? Dis Colon Rectum. 2010;53(3):321–326.
    1. Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data. Arch Surg. 2008;143(6):551–557.
    1. Centers for Medicare and Medicaid Services, The Joint Commission . Specifications Manual for National Hospital Inpatient Quality Measures, v4.3b. Oak Brook, IL: Joint Commission Resources; 2014.
    1. Cundiff G, Bent AE. Suprapubic catheterization complicated by bowel perforation. Int Urogynecol J. 1995;6:110–113.
    1. Sethia KK, Selkon JB, Berry AR, Turner CM, Kettlewell MG, Gough MH. Prospective randomized controlled trial of urethral versus suprapubic catheterization. Br J Surg. 1987;74(7):624–625.
    1. Healy EF, Walsh CA, Cotter AM, Walsh SR. Suprapubic compared with transurethral bladder catheterization for gynecologic surgery: a systematic review and meta-analysis. Obstet Gynecol. 2012;120(3):678–687.
    1. Dixon L, Dolan LM, Brown K, Hilton P. RCT of urethral versus suprapubic catheterization. Br J Nurs. 2010;19(18):S7–S13.
    1. Jannelli ML, Wu JM, Plunkett LW, Williams KS, Visco AG. A randomized controlled trial of clean intermittent self-catheterization versus suprapubic catheterization after urogynecologic surgery. Am J Obstet Gynecol. 2007;197(1):72.e1–72.e4.
    1. Molden S, Bracken J, Nguyen A, et al. A retrospective multicenter study on outcomes after midurethral polypropylene sling revision for voiding dysfunction. Female Pelvic Med Reconstr Surg. 2010;16(6):340–344.
    1. South MM, Wu JM, Webster GD, Weidner AC, Roelands JJ, Amundsen CL. Early vs late midline sling lysis results in greater improvement in lower urinary tract symptoms. Am J Obstet Gynecol. 2009;200(5):564.e1–564.e5.
    1. Segal J, Steele A, Vassallo B, et al. Various surgical approaches to treat voiding dysfunction following anti-incontinence surgery. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(4):372–377.
    1. Rardin CR, Rosenblatt PL, Kohli N, Miklos JR, Heit M, Lucente VR. Release of tension-free vaginal tape for the treatment of refractory postoperative voiding dysfunction. Obstet Gynecol. 2002;100(5 Pt 1):898–902.
    1. Stanton SL, Cardozo LD, Kerr-Wilson R. Treatment of delayed onset of spontaneous voiding after surgery for incontinence. Urology. 1979;13(5):494–496.
    1. Hershberger JM, Milad MP. A randomized clinical trial of lorazepam for the reduction of postoperative urinary retention. Obstet Gynecol. 2003;102(2):311–316.
    1. Li N, He HB, Wang CW. Clinical observation of urinary retention after hemorrhoid and fistula operation treated with suspen-ding moxibustion. Zhongguo Zhen Jiu. 2010;30(7):571–573. Chinese.
    1. Yi WM, Pan AZ, Li JJ, Luo DF, Huang QH. Clinical observation on the acupuncture treatment in patients with urinary retention after radical hysterectomy. Chin J Integr Med. 2011;17(11):860–863.
    1. Buchko BL, Robinson LE, Bell TD. Translating an evidence-based algorithm to decrease early postoperative urinary retention after urogynecologic surgery. Urol Nurs. 2013;33(1):24–28.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner