What is the best approach to manage urinary retention in a patient following a left subcapital hip fracture?

Management of Urinary Retention Following Left Subcapital Hip Fracture

Urinary catheters should be removed as soon as possible following hip fracture surgery to reduce the attendant risk of urinary tract infection, while implementing a structured program for early detection and management of urinary retention. 1

Prevalence and Risk Factors

• Urinary retention is extremely common following hip fracture surgery, with incidence reported as high as 82% before surgery and 56% after surgery 2
• Risk factors for postoperative urinary retention include:
  • Use of opioid medications (relative risk = 8.0) 3
  • Use of anticholinergic medications (relative risk = 1.3) 3
  • Advanced age 4
  • Postoperative cognitive dysfunction (occurs in 25% of hip fracture patients) 1

Assessment of Urinary Retention

• Urinary retention following hip fracture is frequently asymptomatic (88% of cases), necessitating active screening 3
• Ultrasound bladder scanning should be used to measure post-void residual (PVR) volume 2, 4
• Chronic urinary retention is defined as PVR volume greater than 300 mL measured on two separate occasions and persisting for at least six months 4

Management Algorithm

Immediate Management

• Perform prompt and complete bladder decompression by catheterization for acute retention 5, 4
• Consider suprapubic catheterization over urethral catheterization for short-term management as it:
  • Improves patient comfort 4
  • Decreases bacteriuria 4
  • Reduces need for recatheterization 4
• If urethral catheterization is used, silver alloy-impregnated catheters may help reduce urinary tract infection 5

Pharmacological Management

• Consider alpha-blocker therapy (e.g., tamsulosin 0.4 mg daily) at the time of catheter insertion to increase the chance of returning to normal voiding 6, 5
• Tamsulosin has been shown to significantly improve urinary symptoms and peak urine flow rates in clinical trials 6
• Avoid medications that can worsen urinary retention:
  • Oral opioids should be avoided 1
  • Reduce dose and frequency of intravenous opioids (e.g., halved) 1
  • Avoid codeine as it is constipating, emetic, and associated with perioperative cognitive dysfunction 1
  • Use cyclizine with caution due to its antimuscarinic side effects 1

Ongoing Management

• Remove urinary catheters as soon as possible to reduce infection risk 1
• For patients requiring ongoing catheterization, intermittent catheterization is preferred over indwelling catheters as it leads to:
  • Earlier voiding satisfaction 2
  • Lower rates of repeated urinary retention 2
• Encourage early oral fluid intake to prevent hypovolemia 1
• Implement multimodal optimization of postoperative care:
  • Adequate analgesia 1
  • Proper hydration 1
  • Electrolyte balance 1
  • Appropriate medication management 1
  • Bowel habit management 1
  • Early mobilization 1

Monitoring and Follow-up

• Monitor for complications of urinary retention:
  • Urinary tract infections 7
  • Delirium 3, 7
  • Long-term urinary incontinence 7
• Patients with urinary retention should receive regular follow-up as they have:
  • Lower functioning levels 7
  • Four times higher rates of nursing home placement 7
  • More than twice the mortality rate 7

Common Pitfalls to Avoid

• Failing to screen for asymptomatic urinary retention (present in 88% of cases) 3
• Leaving indwelling catheters in place longer than necessary (should be removed within 24 hours of surgery) 7
• Not following structured programs for detection and management of urinary retention 2
• Overlooking the significant impact of medications (especially opioids and anticholinergics) on urinary retention 3
• Neglecting the association between urinary retention and increased risk of delirium, which affects 25% of hip fracture patients 1, 3