When should catheterization be performed in a patient experiencing urinary retention after surgery?

When to Catheterize Patients with Urinary Retention After Surgery

Urinary catheterization should be performed immediately in patients with postoperative urinary retention who cannot void spontaneously, with the catheter removed as early as possible when strict fluid management is no longer required. 1

Assessment of Urinary Retention

• Urinary retention should be suspected in patients who are unable to void despite having a full bladder after surgery 2
• Bladder ultrasound should be used to confirm retention, with catheterization indicated when:
  • Patient is unable to void with a distended bladder
  • Post-void residual volume exceeds 100 mL 3
  • Patient has reached their individual maximum bladder capacity 4

Timing of Catheter Removal

• For patients who do not require strict fluid monitoring, the urinary catheter should be removed as early as possible to:
  • Encourage mobility
  • Reduce catheter-associated urinary tract infections (CAUTIs)
  • Decrease length of hospital stay 1
• In women undergoing cesarean delivery without need for ongoing strict assessment of urine output, the urinary catheter should be removed immediately after surgery 1

Special Considerations by Surgery Type

General Surgery

• Evaluate catheter necessity daily and remove as early as possible 1
• Most low-risk patients void within 3 hours of outpatient surgery without requiring catheterization 5

Pelvic Surgery

• Extended catheterization may be required after pelvic procedures due to higher risk of retention 6
• Patients undergoing bladder sling placement and prolapse repair are at particularly high risk of postoperative urinary retention 6

Risk Factors for Postoperative Urinary Retention

• Spinal anesthesia (highest modifiable risk factor - RR 8.1 for hyperbaric bupivacaine, RR 3.1 for articaine) 4
• Maximum bladder capacity <500 mL (RR 6.7) 4
• Surgery duration ≥60 minutes (RR 5.5) 4
• First post-anesthesia care unit bladder volume ≥250 mL (RR 2.1) 4
• Age ≥60 years (RR 2.0) 4

Management Algorithm

1. Initial Assessment:

   • Monitor bladder volume with ultrasound every 3 hours postoperatively 4
   • Patients at high risk (hernia/anal surgery, spinal/epidural anesthesia) benefit most from bladder monitoring 5

2. Intervention Thresholds:

   • Catheterize when patient cannot void and:
     • Bladder is distended beyond individual maximum capacity 4
     • Post-void residual volume >100 mL 3
     • Signs of discomfort or pain are present 2

3. Catheterization Options:

   • For short-term retention: Intermittent catheterization every 4-6 hours until patient can void with PVR <100 mL 3
   • For prolonged retention (especially after pelvic surgery): Indwelling catheter may be necessary 6

4. Trial Without Catheter (TWOC):

   • Consider TWOC after 1-3 days of catheterization 7
   • Alpha-1 blockers before TWOC may increase chances of successful voiding 7

Complications to Avoid

• Prolonged catheterization (>3 days) is associated with higher rates of:

  • Catheter-associated urinary tract infections 1, 3
  • Increased comorbidity 7
  • Extended hospitalization 7

• Bladder overdistention (>500 mL) can lead to:

  • Detrusor muscle damage 3
  • Long-term bladder dysfunction 8
  • Kidney damage leading to chronic kidney disease 8