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

2. 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 – 70 %
Vague definitions
Criteria unclear

3. 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.

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

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

6. 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

7. Diagnosis of POUR
Clinical Examination
Bladder Catheterization
USG

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

9. 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

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

11. 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

13. 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

14. Perioperative Risk Factors for POUR
Type of surgery
General surgery : 3.8 %
Joint surgery : % 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

15. 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.

16. 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 ??

17. 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

18. 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

19. 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.

20. 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)

21. 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

22. 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

23. 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

24. 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

25. OK – let POUR be there ??

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

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

28. 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

29. Rule out any cause of mechanical obstruction

30. 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

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

32. 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

33. 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

34. 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

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

36. 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 !!

37. 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 !!

38. Algorithm

39. Thank you all