Postoperative urinary retention Dr Tahereh Forooghifar Fellowship of pelvic floor disorders

POSTOPERATIVE URINARY RETENTION (POUR): Impaired voiding after a procedure despite a full bladder that results in an elevated postvoid residual.

International Continence Society International Urogynecological Association: Abnormally slow and/or incomplete micturition.

Incidence General surgical population: 4 to 13 percent   General surgical population: 4 to 13 percent Cesarean with epidural anesthesia : 23 to 28 percent Pelvic surgery range : 2 to 43 percent

RISK FACTORS Age over 50 years (double) Concurrent neurologic disease Administration >750 mL of intravenous fluid

RISK FACTORSR Duration of surgery >2 hours Intraoperative anticholinergic(atropine) Use of regional anesthesia Incontinence surgery and radical pelvic surgery.

Women with these risk factors are counseled about the increased risk of POUR and clean intermitten catheterization.

CLINICAL PRESENTATION Slow urine stream Straining to void Incomplete bladder emptying Suprapubic pressure or pain Need to immediately re-void Position-dependent micturition

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

Nerve injury after surgery Parasympathetic and sympathetic: pelvic and hypogastric plexus

Cystotomy Differentiation cystotomy from urinary retention: Irrigating the bladder with 75 mL to 100 mL of sterile saline through a catheter then attempting to withdraw the same amount of fluid. Cystography or Cystoscopy

Bladder overdistention injury  Acute prolonged bladder overdistention is defined as ≥120 percent of a normal bladder capacity for ≥24 hours. Wall ischemia : 30 minutes during acute overdistention.

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  Midurethral sling or Bladder neck (fascial slings and retropubic suspensions) Treatment: Surgical lysis of sling We do not perform urethral dilation : increase 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: Excessive sling tension Postop transurethral dilation Cystoscopy and Urethroscopy : Direct visualization of the eroded sling or suture

Diagnosis U/A, U/C POST VOIDING RESIDUAL VOLUME VOIDING TRIAL CYSTOSCOPY URODYNAMIC STUDY (rarely requires)

PVR There is no standardized PVR 50 mL to 100 mL normal >200 mL abnormal Between 100 mL and 200 mL requires clinical correlation

Voiding trials Retrograde or spontaneous To confirm adequate voiding and minimal PVR in patients with symptoms or risk factors for POUR

VOIDING TRIALS Retrograde method : More predictive for continued catheterization Preferred by patients Greater ease of use Fewer catheterizations Took less time

Spontaneous voiding trial Removing the catheter Voiding until she has a strong urge 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 defined: PVR = 100 mL or less or Void two-thirds or greaterof the total bladder volume Two voiding trials

Retrograde voiding trial The bladder is retrograde filled through the catheter with 300 mL of sterile saline or the patient says she is at maximum capacity (whichever occurs first).

Retrograde voiding trial Void of 200 mL or greater is considered successful (two- thirds of instilled volume) Two voiding trials

Fail (voiding trial) Physical exam: Self-limited obstruction : (CIC) until the obstructing process resolves

Fail (voiding trial) Physical exam: No evidence of obstruction: Discharg with CIC or indwelling catheter Short interval (days) follow-up in the office Retrograde voiding trial

Persistent voiding dysfunction Pelvic muscle tone Prolapse Incision of midurethral sling

Pelvic muscle tone (passive) Place one or two digits of your right hand 8 cm into the vagina. Press firmly on the muscles of right and left pelvic floor Start from 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) Placing your left hand lateral to the patient’s right knee Asking her to abduct her knee into the palm of our left hand Asymmetric muscle tone or pain (pelvic floor muscle therapy)

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 pessary

Incision of midurethral sling   Absence of prolapse: Over-tight incontinence sling: Midline incision of sling Success rates : 86 to 100%

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

Urodynamic testing No obstruction on exam The patient’s symptoms are inconsistent with the medical and surgical history

Postoperative urodynamics Bladder contractility Urethral tone Urethral obstruction

Detrusor hypocontractility Radical pelvic surgery Urodynamics does not change the treatment plan CIC until the patient can adequately void (>6 to 8 months) Radical hysterectomy Symptoms may never resolve

Complications of untreated retention Overdistention injury (CIC) Detrusor overactivity Overactive voiding symptoms

If the need for catheterization continues, CIC rather than an indwelling urethral or suprapubic catheter is suggested (Grade 2C)

Clean intermittent catheterization CIC rather than an indwelling urethral or suprapubic catheter Required four to six times a day and possibly once overnight Reusable catheters can be used for up to four weeks

CIC CIC frequency is inadequate: Indwelling catheter (choice to avoid overdistention) Lower urinary complication rates  Systemic antimicrobial agents are not used

Clean intermittent catheterization Catheterization continues: PVRs are less than one third of the voided volume and total bladder volumes are not causing overdistention.

POSTPARTUM URINARY RETENTION

Postpartum urinary retention OVERT PUR COVERT PUR

OVERT PUR Absence of micturition within six hours of vaginal delivery or removal of indwelling catheter after cesarean delivery.

COVERT PUR PVR > 150 mL No symptom No urge to void Overflow incontinence

Incidence 0.7–4% of deliveries

Ethiology Injury to the pudendal nerve during labour..

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

Management 4hrs post birth has the woman passed urin No 2 hrly check Adequate hydration Fluid balanc chart Measure first passage urin (250)

Management Adequate analgesic Ambulation Perineal exam : Swollen or painful : Catheter

Management U/A-U/C (mid stream) UTI(Antibiotic therapy) Constipation Avoid and treatment

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 CIC Patient is able to void a small volume, then self-catheterization (PVR) Discontinue CIC PVR <150 mL and no longer significat symptoms

Trial without catheter (TWOC) Catheter is removed (two or three days) Fill bladder slowly by drinking fluid (a glass liquid every 45-60 minutes) Trial to pass urine spontaneously Unable to pass urine New catheter or CIC

Persistence voiding dysfunction postpartum Neurological examination (pudendal) Intermittent catheterisation Urodynamic study