Post op Urinary retention Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio), FICA

Definition and incidence POUR has been defined as the inability to void in the presence of a full bladder in the postoperative set up. Incidence --- 5 – 70 % Vague definitions Criteria unclear

POUR is considered to be an acute, unobstructive urinary retention precipitated by surgery and/or anesthesia spontaneous remission should be expected when the precipitating stimuli are gone.

Catheterization was just done like that previously but ?? Outpatient surgeries No infection Patient does not like ?? Perop catheter ??

Bladder physiology Detrusor muscle Internal urethral sphincter External urethral sphincter Parasympathetics contract detrusor, relax sphincters – voiding system Sympathetic – retention S2,S3,S4

Micturition and the guarding reflex Stretch receptors – sacral nerves – PNS – motor detrusor and relax sphincters – micturition They also send signals to brain which inhibits micturition through sympathetic – external sphincter

Diagnosis of POUR Clinical Examination Bladder Catheterization USG

Clinical Examination Pain and discomfort in the lower part of the abdomen ? Anesthesia - regional Stroke patients Sedated Can they tell ??

Palpation and percussion 500 ml or 750 ml – can we ?? Deep palpation can elicit vagal reflexes Clinical and USG correlation ??? After a major upper limb ortho surgery , end op restlessness – palpate for urinary bladder

Catheterize Diagnosis and management But due to decreased IV fluids then ?? catheter-related infections, urethral trauma, prostatitis, and patient discomfort

Ultrasound Assessment Diagnosis is 100 % Volume assessment can be done Correlation good if single observer at different times Risk factor > 650 ml can be identified Can withhold discharge

Perioperative Risk Factors for POUR AGE : Increasing by 2.4 times in patients over 50 yr of age. Progressive neural degeneration SEX : 4.7 % Vs 2.9 % May be prostate

Perioperative Risk Factors for POUR Type of surgery General surgery : 3.8 % Joint surgery : 10 .7 % may increase Anal surgeries : upto 52 % - WHY ? Injury to the pelvic nerves pain evoked reflex increase in the tone of the internal sphincter Hernia – may be upto 38 % Gynaec – either we empty or catheterize Even previous pelvic surgeries

Surgical roles !! Surgical trauma to the pelvic nerves or to the bladder, postoperative edema around the bladder neck, pain-induced reflex spasm of the external and internal urethral.

Peri operative Risk Factors for POUR Concurrent neurologic diseases such as stroke poliomyelitis, cerebral palsy, multiple sclerosis, spinal lesions, and diabetic and alcoholic neuropathy In the PAC ask if he / she can void normally ??

can interfere with the bladder function ?? anticholinergic agents, ß-blockers, sympathomimetics, When ephinephrine is injected intraperitoneally in rats, the intravesical pressure increases without raising urine output- think of FESS !! Clonidine IV can cause problems but intrathecal no effect

IV fluids Intravenous infusion of more than 750 ml intraop Increased incidence by 2.7% more bladder volume more than 270 ml is an independent risk factor

More agents , more Iv fluids Increased duration surgery increased chance anesthetics sedative-hypnotic agents and volatile anesthetics suppress micturition reflex. Diazepam, pentobarbital, and propofol all decrease detrusor contractions. inhibition of pontine micturition center and the voluntary control of the cortex on the bladder.

Conduction Blockade. Urgency to void goes in 60 seconds Detrusor power goes away in few minutes 15 minutes after L5 regression – detrusor is just ok Time for sensory block to regress to S3 is 7–8 h after spinal injection of isobaric bupivacaine (20 mg), hyperbaric bupivacaine (21.5 mg), and hyperbaric tetracaine (7.5 mg)

Spinal opioids spinal opioids influence bladder functions and cause urinary retention. decrease the urge sensation and detrusor contraction, increasing the bladder capacity and the residual volume. altering sphincter function, resulting in impaired coordination between the detrusor contraction and internal urethral sphincter relaxation

Low dose intrathecal fentanyl less action on sphincters than morphine Mechanisms Mu and delta receptors in the spinal cord and the brain Why spinal !! Intrathecal naloxone reverses retention !! Buprenorphine – no effect .. Low dose intrathecal fentanyl less action on sphincters than morphine

Epidural Sacral segments affected – POUR Thoracic epidural – less incidence Short acting ligno – less incidence In infusions motor block present = POUR Morphine more than fentanyl Doses of fentanyl do not matter Buprigesic – less incidence

POUR has not been reported with interscalene Paravertebral and intercostal blocks In patients undergoing anorectal surgery, bilateral pudendal block decreases also the incidence of POUR. Infiltration anaesthesia after hernia or fissures – less incidence

OK – let POUR be there ??

Complications Autonomic Response Painful stimulation resulting from an over distended bladder can cause vomiting, bradycardia, hypotension, hypertension, cardiac dysrhythmias, Prolonged hospital stay

Infection direct complication of persistent POUR (consequence of bladder hypotonia and the inability to completely empty the bladder) an indirect complication of bladder catheterization

Even with single episode of overdistension On urodynamics Overfilling of the bladder can stretch and damage the detrusor muscle, leading to atony of the bladder wall, so that recovery of micturition may not occur when the bladder is emptied. Even with single episode of overdistension

Rule out any cause of mechanical obstruction

Prevention Tamsulosin 0.4 mg from pre op decreases incidence Phenoxybenzamine prevents POUR ?? Go into the high risk group Anorectal and high IVFluids Hernia and intrathecal morphine Old age and anticholinergics

Psychological Encourage Talk Overstraining may not help ?? Pour water into genitals Regional has waned off ?? Massage the abdomen ?? Take to wash rooms Traditional

When to catheterize ?? The normal maximum bladder volume of 400–500 ml -- recommended in the adult population USG – more than 600 ml ( 300 ml is enough !!few studies ) catheterize.. In-out catheter is the choice for normal anorectal surgeries . Three in out – keep it in

But major onco surgeries , IV shifts keep the catheter .. Many studies agree that intermittent vesical catheterization must be the procedure of choice in the treatment of urinary retention, can reduce asymptomatic bacteriuria and urinary tract infection relatively frequent in patients with indwelling catheters Put in and take out

Indwelling till how long ?? patients at high risk (rectal cancer preoperative dysuria, and metastatic lymph nodes) should keep the catheter for 5 days Other wise one day only

Before putting the catheter nicely apply jelly Wait We will get the analgesia Or patient may sometimes void with local only

Can we discharge out patients ?? Ability to void has always been considered as one of the criteria to discharge outpatients. By stratifying preoperative risk for POUR, selected patients could be discharged without voiding Wait for 8 hours there --- If in doubt USG to see 600 ml !!

Orchiectomy for Ca prostate and then SPC !! Other options 1.Perineal urethrostomy. Ascending infection less but ?? 2. Suprapubic aspiration. easy, prostate people better 3. Suprapubic catheterization. Orchiectomy for Ca prostate and then SPC !!

Algorithm

Thank you all