DR TAHEREH FOROOGHIFAR FELLOWSHIP OF PELVIC FLOOR DISORDERS Postoperative urinary retention

Postoperative urinary retention (POUR) refers to impaired voiding after a procedure despite a full bladder that results in an elevated postvoid residual.

It is defined by the International Continence Society and the International Urogynecological Association as an “abnormally slow and/or incomplete micturition.

Incidence General surgical population (men and women) 4 to 13 percent Cesarean delivery done with epidural anesthesia 23 to 28 percent. Pelvic surgery range 2 to 43 percent

RISK FACTORSR ● Age over 50 years (doubles the risk of POUR) ● History of preexisting urinary retention ● Concurrent neurologic disease ● Administration >750 mL of intravenous fluid ● Duration of surgery >2 hours ● Intraoperative anticholinergic(atropine) ● Use of regional anesthesia ● History of prior pelvic surgery ● Incontinence surgery and radical pelvic surgery

Women with these risk factors for voiding dysfunction are counseled about the increased risk of POUR and may be taught clean intermittent catheterization prior to surgery.

Some risk factors can be lessened An indwelling bladder catheter: epidural anesthesia patient-controlled anesthesia vaginal pack Constipation can worsen voiding dysfunction: counseling about maintaining a bowel regimen

CLINICAL PRESENTATION Slow urine stream straining to void feeling of incomplete bladder emptying have suprapubic pressure or pain the others poor need to immediately re-void sensitivity, position-dependent micturition. Specifity for elevated PVR

CAUSES OF POUR Bladder (detrusor) dysfunction Urethral obstruction Failure of pelvic floor relaxation

Abnormal bladder function Preexisting voiding dysfunction Anesthetic agents Nerve injury secondary to surgery Cystotomy Bladder overdistention injury Postoperative agents used for analgesia

Preexisting voiding dysfunction Aggravate with: Effects of anesthesia Surgical intervention Tissue edema, Medications Counseling prior to surgery: increased risk of POUR clean intermittent catheterization

Bupivacaine : seven to eight hours of neural blockade. Epidural,spinal and combined spinal/epidural Anesthetic agents

Nerve injury secondary to surgery The main nerves at risk are: parasympathetic and sympathetic nerves in the pelvic and hypogastric plexus

Nerve injury after surjery The incidence of POUR: hysterectomy for benign disease < radical hysterectomy. total hysterectomy = supracervical hysterectomy open approach =laparoscopic approaches.

Cystotomy hysterectomy 0.9 to 2.9 percent. retropubic sling 2 to 5 percent. unable to void void only small volumes lack voiding sensation suprapubic pain elevated postvoid residual (PVR) abdominal fullness

Cystotomy The differentiation cystotomy from urinary retention: Irrigating the bladder with 75 mL to 100 mL of sterile saline through a bladder catheter Attempting to withdraw the same amount of fluid cystography or cystoscopy

Bladder overdistention injury The bladder is filled to volumes greater than 400 to 600 ml or greater than 120 percent of capacity. Ischemia and reperfusion damage to the bladder wall

Urethral obstruction Mechanical Failure of pelvic floor relaxation

Mechanical Self-limited obstruction Sling obstruction Urethral foreign body Pelvic organ prolapse Urethral injury Constipation

Mechanical (urethral) Sling obstruction compressing the midurethra (midurethral slings) or the bladder neck (fascial slings and retropubic suspensions) Treatment: Surgical lysis of sling We do not perform urethral dilation following synthetic sling placement (increase the risk of urethral mesh erosion ).

Sling obstruction transobturator midurethral slings retropubic midurethral slings Burch urethropexy fascial slings tot< tvt< burch< fascial sling

Mechanical Urethral foreign body: Possible etiologies of urethral sling erosion include : excessive sling tension postoperative transurethral dilation Cystoscopy and urethroscopy : direct visualization of the eroded sling or suture

Urethral injury Over time, foreign material in the urethra : obstructs urine flow stone formation recurrent urinary tract infection elevated PVR Requires surgical reconstruction of the urethra and removal of the causative agent.

Failure of pelvic floor relaxation Failure to relax the striated muscles of the urethra and pelvic floor during normal voiding: dysfunctional voiding can worsen after pelvic surgery. These women typically use abdominal straining(Valsalva maneuver) to overcome the urethral outlet resistance.

Diagnosis U/A, U/C POST VOIDING RESIDUAL VOLUME VOIDING TRIAL CYSTOSCOPY URODYNAMIC STUDY

PVR PVR of 50 mL to 100 mL is normal PVR greater than 200 mL is abnormal PVR between 100 mL and 200 mL requires clinical correlation.

Diagnosis Voiding trials performed to confirm adequate voiding and minimal postvoid residual (PVR) in patients with symptoms or risk factors for POUR.

VOIDING TRIALS Retrograde or spontaneous adequate voiding and minimal PVR ? Retrograde method : more predictive of need for continued catheterization required fewer catheterizations, and took less time.

Spontaneous voiding trial Removing the bladder catheter Voiding until she has a strong urge to void or four hours have passed. The voided volume is measured PVR :straight catheterization or ultrasound within 15 minutes of the completed void.

Voiding trial Success is typically defined: PVR = 100 mL or less or The ability to void two-thirds or greater of the total bladder volume. (total bladder volume = voided volume + PVR). Two voiding trials

Retrograde voiding trial The bladder is retrograde filled through the catheter with 300 mL of sterile saline or until the patient says she is at maximum capacity (whichever occurs first). A void of 200 mL or greater is considered successful (two-thirds of instilled volume). Two voiding trials

Fail an initial retrograde voiding trial physical exam Self-limited obstruction continued drainage or (CIC) until the obstructing process resolves. No evidence of obstruction CIC or indwelling bladder catheter discharg, short interval (days) follow-up in the office. retrograde voiding trial in the outpatient setting.

Persistent postoperative voiding dysfunction Examination of pelvic muscle tone Examination for prolapse Incision of midurethral sling

Examination of pelvic muscle tone Assessment of the pelvic floor tone and muscles to confirm appropriate pelvic floor relaxation Significant pain or discomfort during examination: pelvic floor physical therapy( pelvic floor muscle relaxation)

pelvic muscle tone (passive) Place one or two digits of your right hand approximately 8 cm into the vagina. press firmly on the muscles of the patient’s right pelvic floor starting with the muscle attachment to the pubic bone at 12 o’clock and rotate to the coccyx. Assess for excessive/imbalanced muscle tone and pain at each pressure point.

pelvic muscle tone( contraction) We place our left hand lateral to the patient’s right knee, and ask her to abduct her knee into the palm of our left hand. Patients who have asymmetric muscle tone or frank pain are referred for pelvic floor muscle therapy.

Examination for prolapse Digital vaginal exam with the patient in the standing position. Anterior or apical prolapse can cause bladder neck or urethral obstruction. If prolapse is found on exam pessary

Incision of midurethral sling In the absence of prolapse: over-tight incontinence sling Midline incision of the sling. Success rates : from 86 to 100 percent

Sling incision The optimal time to perform the sling transection is unclear. Synthetic sling lysis one to three weeks postoperatively Fascial sling lysis one to two months following initial surgery.

Role of urodynamic testing No obstruction on exam The patient’s symptoms are inconsistent with the medical and surgical history Completely unable to void( a pressure-flow study is often helpful) Postoperative urodynamics: the bladder contractility, urethral tone, and urethral obstruction.

Detrusor acontractility or hypocontractility Following radical pelvic surgery Urodynamics does not change the treatment plan. CIC until the patient can adequately void (>6 to 8 months) In the settings of radical hysterectomy and pelvic exenteration, the symptoms may never resolve.

COMPLICATIONS OF UNTREATED URINARY RETENTION Overdistention injury (CIC) Detrusor overactivity Overactive voiding symptoms

Clean intermittent catheterization Low complication rates Systemic antimicrobial agents are not used Required four to six times a day and possibly once overnight. Reusable catheters are also available and can be used for up to four weeks.

Clean intermittent catheterization every four to six hours or urge to void, but unable  catheterization If the patient is able to void a small volume, then she is instructed to perform self-catheterization (PVR) the residual urine volume is <150 mL and no longer significat symptoms  discontinue catheterization

CIC If the CIC frequency is inadequate: indwelling catheter is the treatment. Catheterization continues: until PVRs are less than one-third of the TVV total bladder volumes are not causing overdistention.

DR TAHEREH FOROOGHIFAR Fellowship of pelvic floor disorders

Postpartum urinary retention Overt PUR Absence of micturition within six hours of vaginal delivery or removal of an indwelling catheter after cesarean delivery. Covert PUR Post void residual bladder volume of at least 150 mL with no symptoms of urinary retention.

Ethiology incidence : 0.7–4% of deliveries injury to the pudendal nerve during labour..

Risk Factors Epidural anesthesia Primiparity Instrument assisted delivery Episiotomy Prolonged labour Perineal trauma

Symptoms Asymptomatic or small voided volumes urinary frequency or urgency slow or intermittent stream hesitancy…..

Management and treatment Sample of urine analysed (by dipstick) and culture If a urinary tract infection is suspected: antibiotic therapy should be initiated The perineal exam : swollen or painful, a catheter should be sited. Adequate analgesia (perineal pain) Constipation avoid and treatment

Postpartum warning signs Inability to pass urine 6 hours following delivery Voided volume of less than 250 ml Women who are symptomatic of voiding dysfunction

Treatment of overt PUR Intermittent catheterization Routine use of antibiotics is not necessary Pharmacological therapies are not effective.

Clean intermittent catheterization every four to six hours or urge to void, but unable  catheterization If the patient is able to void a small volume, then she is instructed to perform self-catheterization (PVR) the residual urine volume is <150 mL and no longer significat symptoms  discontinue catheterization

Trial without catheter (TWOC): Catheter is removed from the bladder for a trial period to determine whether patient is able to pass urine spontaneously. fill bladder slowly by drinking sufficient fluid(a glass or cupful of liquid approximately every minutes) unable to pass urine, a new catheter may be or intermittent self-catheterisation.

Voiding dysfunction after this period requires careful assessment, including a neurological examination, and is treated by intermittent self catheterisation.