What is the next step in managing a 54-year-old woman with postoperative urinary retention following retropubic sling surgery, who has suprapubic pain, abdominal fullness, and a urethral catheter with low return on irrigation?

From the Guidelines

The next step in managing this patient is to perform cystoscopy to evaluate for potential urethral injury or obstruction, as the low return on urethral catheter irrigation and symptoms of suprapubic pain and abdominal fullness suggest a possible issue with the urethra or bladder. The patient's presentation of postoperative urinary retention following retropubic sling surgery, combined with the findings of fluid wave and abdominal tenderness to palpation, raises concern for a urethral stricture or other obstruction 1.

The low return on irrigation of the urethral catheter with 100 mL of saline, yielding only 20 mL of return, indicates a potential blockage or kinking of the catheter, which may be due to a urethral stricture or other obstruction 1. Given the patient's stable vital signs and normal laboratory studies, the focus should be on evaluating and managing the potential urethral or bladder issue.

The American Urological Association guideline for male urethral stricture 1 recommends the use of urethro-cystoscopy, retrograde urethrography (RUG), voiding cystourethrography (VCUG), or ultrasound urethrography to make a diagnosis of urethral stricture, which can be applied to this female patient with similar symptoms.

Key considerations in the management of this patient include:

• Evaluating for urethral stricture or other obstruction using cystoscopy
• Assessing for bladder injury or other complications related to the retropubic sling surgery
• Ensuring proper catheter placement and function to prevent further complications
• Monitoring for post-void residual volumes after catheter removal to ensure complete bladder emptying has been restored.

Given the potential for urethral stricture or other obstruction, cystoscopy is the most appropriate next step in managing this patient, as it will allow for direct visualization of the urethra and bladder, and guide further management 1.

From the Research

Next Steps in Managing Postoperative Urinary Retention

The patient's symptoms of suprapubic pain, abdominal fullness, and low return on irrigation of the urethral catheter suggest a potential obstruction or blockage of the catheter. The following options should be considered:

• Cystoscopy: This procedure allows for direct visualization of the urethra and bladder to identify any obstructions or blockages 2. It can also facilitate the placement of a new catheter or the removal of any blockages.
• Remove and Replace Urethral Catheter: If the catheter is blocked or obstructed, removing and replacing it with a new one may resolve the issue 3.
• Other Options: Beginning doxazosin or oxybutynin may not be directly relevant to addressing the patient's current symptoms, as these medications are typically used to treat urinary retention or overactive bladder, rather than catheter obstruction.

Rationale for Cystoscopy

Cystoscopy is a valuable diagnostic tool in this scenario, as it can help identify the cause of the patient's symptoms and guide further management 2. The procedure can be performed at the bedside using a flexible cystoscope, and it has been shown to be safe and effective in diagnosing and treating urethral obstructions.

Considerations for Urinary Catheter Management

When managing urinary catheters, it is essential to consider the potential complications, such as obstruction, bladder spasm, and urine leakage 4. Regular monitoring and maintenance of the catheter can help prevent these complications and ensure optimal patient outcomes.