Does a patient 48 hours post-hysterectomy with a bladder sling and cystocele and rectocele repair, who had a Foley catheter re-inserted due to urinary retention, require another voiding trial today or can she be discharged home with the Foley catheter for a week?

Management of Postoperative Urinary Retention After Pelvic Surgery

For a patient 48 hours post-hysterectomy with bladder sling and cystocele/rectocele repair who has urinary retention requiring Foley catheter reinsertion, the patient should be discharged home with the Foley catheter in place for one week rather than attempting another voiding trial today.

Rationale for Sending Patient Home with Foley Catheter

• Pelvic surgery, especially procedures involving bladder sling placement and prolapse repair, carries a high risk of postoperative urinary retention 1, 2
• After failed voiding trial at 48 hours post-surgery with significant residual volume (400 mL), immediate repeat voiding trial is unlikely to be successful and may increase risk of complications 2
• Urinary retention rates after pelvic surgery range from 2.5% to 43%, with higher rates specifically associated with incontinence and prolapse repairs 2

Risk Factors for Urinary Retention in This Patient

• Recent pelvic surgery (hysterectomy with bladder sling, cystocele and rectocele repair) is a major risk factor for urinary retention 1, 2
• Bladder sling procedures specifically have higher retention rates (approximately 8% for autologous fascial slings and 3% for synthetic midurethral slings) 1
• Combined procedures (hysterectomy plus prolapse repair) increase the risk of postoperative voiding dysfunction 2, 3

Management Algorithm

1. Initial management (already done):

   • Bladder scan confirming significant residual volume (400 mL)
   • Foley catheter reinsertion 1, 2

2. Current recommendation:

   • Discharge with indwelling Foley catheter for one week 1, 2
   • This allows time for post-surgical edema and inflammation to resolve 2, 3

3. Follow-up plan:

   • Schedule voiding trial in one week 2
   • Most cases of postoperative urinary retention resolve within 4-6 weeks 2

Evidence Supporting This Approach

• Enhanced Recovery After Surgery (ERAS) guidelines note that while early catheter removal (24 hours) is ideal in many cases, patients with pelvic surgery specifically may require extended catheterization 1
• Guidelines specifically state: "A catheter may continue to be needed in cases of pelvic surgery, patient immobility, sedation, or epidural analgesia" 1
• The risk of urinary retention is particularly high after bladder sling procedures and prolapse repairs, justifying extended catheterization 1, 2
• Failed initial voiding trial with significant residual volume indicates need for continued bladder decompression 2, 3

Potential Complications to Monitor

• Catheter-associated urinary tract infections increase with duration of catheterization 1
• Patient should be educated about signs of UTI and proper catheter care 2
• If retention persists beyond 4 weeks, more active management may be required, including potential sling adjustment 2

Alternative Approaches (Not Recommended in This Case)

• Immediate repeat voiding trial: Not recommended as the patient has just failed a trial and has significant residual volume 2
• Pharmacological management: Alpha-blockers may be considered in men but have limited evidence in women following pelvic surgery 4, 5
• Intermittent catheterization: While an option, continuous drainage with indwelling catheter is more practical immediately following pelvic surgery with significant retention 1, 2

This approach balances the need to protect bladder function through adequate drainage while allowing time for post-surgical inflammation to resolve before attempting another voiding trial.