Why do orthopedic patients need to urinate before discharge?

Why Orthopedic Patients Need to Urinate Before Discharge

Orthopedic patients are required to urinate prior to discharge primarily to ensure bladder function has returned to normal after surgery and to prevent complications associated with urinary retention, which can lead to increased morbidity and decreased quality of life.

Rationale Behind Pre-Discharge Urination Requirement

Prevention of Urinary Retention Complications

• Postoperative urinary retention (POUR) is a common complication after orthopedic surgery, with an overall incidence of approximately 2.3% 1
• Untreated urinary retention can lead to:
  • Bladder overdistention causing detrusor muscle damage
  • Increased risk of urinary tract infections
  • Potential for systemic infection
  • Possible long-term bladder dysfunction 2

Risk Assessment for Orthopedic Patients

Orthopedic patients have specific risk factors that increase their likelihood of developing urinary retention:

• Patient-specific factors:

  • Advanced age (OR 1.035) 1
  • Male sex (OR 1.522) 1
  • History of hypertension (OR 1.288) 1
  • History of diabetes mellitus (OR 2.038) 1
  • Pre-existing prostatism 3

• Procedure-related factors:

  • Joint replacement surgery (higher risk than other orthopedic procedures) 1
  • Longer operative time 4
  • Higher volume of intraoperative fluid administration 4

Enhanced Recovery Protocols

Enhanced Recovery After Surgery (ERAS) protocols recommend:

• Early removal of urinary catheters (ideally within 24 hours) to reduce catheter-associated urinary tract infections 3
• Confirmation of normal voiding before discharge to ensure bladder function has returned 3

Management Algorithm for Pre-Discharge Urination

1. Risk Stratification

• Low-risk patients: Non-pelvic surgery, no history of urinary retention, younger age, female sex
• High-risk patients: Joint replacement surgery, history of retention, male sex, advanced age, diabetes, hypertension 1

2. Monitoring Approach

• Low-risk patients: May be discharged when otherwise ready without being required to void 5
• High-risk patients: Should demonstrate ability to void before discharge or undergo bladder volume assessment via ultrasound 5

3. Management of Inability to Void

• If unable to void and bladder distention confirmed:
  • In-and-out catheterization may be required
  • For patients with significant retention, indwelling catheterization may be necessary 4

Special Considerations

Bladder Overdistention

• A single episode of bladder overdistention can damage the detrusor muscle, potentially leading to long-term dysfunction 6
• Current evidence suggests that bladder overdistention lasting less than 4 hours is unlikely to cause long-term sequelae 2

Catheter Management

• The World Health Organization recommends evaluating urinary catheters daily and removing them as soon as possible to reduce infection risk 7
• Suprapubic catheters may offer advantages over urethral catheters for patients requiring longer-term catheterization 7

Common Pitfalls and Caveats

1. Overuse of indwelling catheters: Can lead to urinary tract infections, urethral trauma, and prolonged hospital stays 6

2. Failure to recognize retention: Some patients may not report inability to void due to lack of sensation; bladder scanning can identify silent retention

3. Premature discharge: Discharging high-risk patients without confirming voiding ability may lead to emergency department visits for acute urinary retention

4. Excessive fluid administration: Perioperative fluid overload can contribute to urinary retention and should be avoided 2

In conclusion, while low-risk patients may be safely discharged without demonstrating voiding, high-risk orthopedic patients should be required to urinate before discharge to prevent complications associated with urinary retention that could negatively impact their recovery and quality of life.