What are the causes and management of postoperative urinary retention in women?

From the Guidelines

Postoperative urinary retention in women is best managed through early removal of urinary catheters, ideally within 12 hours after surgery, to reduce the risk of urinary tract infections and promote early ambulation. The causes of postoperative urinary retention in women are multifactorial, including disruption of the normal micturition reflex due to anesthetic agents, pain medications, surgical trauma, or inflammation affecting neural pathways controlling bladder function 1. Initial management includes ensuring adequate pain control, early mobilization, and creating a private, comfortable environment for voiding.

Key Management Strategies

• Ensuring adequate pain control to reduce the risk of urinary retention
• Early mobilization to promote bladder function and reduce the risk of complications
• Creating a private, comfortable environment for voiding to reduce anxiety and promote relaxation If a woman cannot void within 6-8 hours after surgery or has a post-void residual volume greater than 200-300 mL, intermittent catheterization is recommended rather than indwelling catheters to reduce infection risk 1.

Prevention Strategies

• Limiting intravenous fluids to reduce the risk of fluid overload and urinary retention
• Avoiding anticholinergic medications that can exacerbate urinary retention
• Using ultrasound bladder scanning to assess retention and guide management Pharmacological options include alpha-blockers like tamsulosin 0.4 mg daily or bethanechol 10-50 mg three times daily to improve bladder contractility, though evidence for their effectiveness is limited 1. Risk factors that should prompt vigilance include pelvic or urologic surgeries, neuraxial anesthesia, prolonged surgery duration, and older age. Most cases resolve within 24-48 hours with appropriate management, but persistent retention requires urological consultation. A recent study found that immediate removal of the urinary catheter after elective cesarean delivery was associated with a lower incidence of postoperative bacteriuria, dysuria, and urinary frequency compared to delayed removal 1.

From the FDA Drug Label

Bethanechol Chloride Tablets, USP are indicated for the treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention and for neurogenic atony of the urinary bladder with retention.

The causes of postoperative urinary retention in women are not directly stated in the provided drug labels. The management of postoperative urinary retention in women may include the use of bethanechol chloride to stimulate the detrusor urinae muscle and initiate micturition, as it is indicated for the treatment of acute postoperative nonobstructive urinary retention 2.

From the Research

Causes of Postoperative Urinary Retention in Women

• Comorbidities, type of surgery, and anesthesia can influence the development of postoperative urinary retention (POUR) 3
• The incidence of POUR varies between 5% and 70% 3
• POUR is a frequent consequence of gynecologic surgery, especially with surgical correction of urinary incontinence and pelvic organ prolapse, with estimates of retention rates after pelvic surgery ranging from 2.5%-43% 4

Management of Postoperative Urinary Retention in Women

• The key to management of POUR is early identification, with all patients undergoing pelvic surgery having an assessment of voiding function prior to discharge 4
• Management of POUR is fairly straightforward, with the goal of decompressing the bladder to avoid long-term damage to bladder integrity and function 4
• Catheterization is generally regarded as the optimal management method, but is associated with risks, and pharmacological treatment of post-operative urinary retention may be desirable as an alternative or adjunct to catheterization 5
• Techniques such as urethral dilation, sling stretching, sling incision, partial sling resection, and urethrolysis may be required when POUR does not resolve spontaneously 4
• Intermittent catheterization is a safe and practical management option, with several advantages over indwelling catheterization 6
• Promising interventions for POUR include replacing morphine in a regional anaesthetic regimen, using alpha-blockers, the antispasmodic drug drotaverine, early postoperative mobilization, and employing hot packs or gauze soaked in warm water 7
• The decision regarding when to discontinue catheter-assisted bladder drainage in the postoperative period can be assessed in an ongoing fashion by measurement of postvoid residual 4