What is the management for postoperative urinary retention?

Management of Postoperative Urinary Retention

The management of postoperative urinary retention requires prompt catheterization for immediate relief, with removal of the catheter as early as possible to reduce infection risk, unless the patient has undergone pelvic surgery which may require extended catheterization. 1, 2

Assessment and Diagnosis

• Postoperative urinary retention is identified by the inability to void despite a full bladder following surgery 3
• Assessment of urine output is effective in identifying patients with urinary retention 1
• Catheterization should be performed when post-void residual volume exceeds 100 mL 2
• Risk factors include:
  • Male sex 4
  • Advanced age 4
  • Pelvic surgery (especially procedures involving bladder sling placement and prolapse repair) 5, 2
  • Preexisting prostatism 1
  • Neoadjuvant therapy 1

Initial Management

• Immediate catheterization is necessary for patients who cannot void spontaneously 2
• Options include:
  • Intermittent catheterization: preferred for short-term management 3
  • Indwelling urethral catheter: may be necessary for prolonged retention 3
• Conservative measures to try before catheterization:
  • Early mobilization (NNT 5) 6
  • Application of hot packs or gauze soaked in warm water (NNT 2) 6
  • Providing privacy and a comfortable position for voiding 4

Timing of Catheter Removal

• For general surgery patients: remove the catheter as early as possible, ideally within 24 hours 1
• For pelvic surgery patients: extended catheterization may be necessary 5
  • After pelvic surgery with low risk of retention: catheter may be safely removed on postoperative day 1, even with epidural analgesia 1
  • After high-risk procedures (bladder sling, prolapse repair): may require catheterization for up to one week to allow post-surgical edema to resolve 5

Pharmacological Management

• Alpha-blockers can be effective for prevention (NNT 5) 6
• Bethanechol chloride is FDA-approved for treatment of acute postoperative urinary retention 7
  • Mechanism: increases tone of the detrusor urinae muscle 7
  • Effects typically appear within 60-90 minutes after oral administration 7
  • Duration of action is typically one hour 7
• Intravesically administered prostaglandin has shown efficacy (Risk Ratio 3.07) 8
• Cholinergic agents combined with sedatives may improve likelihood of spontaneous voiding compared to placebo (Risk Ratio 1.39) 8

Prevention Strategies

• Replace morphine in regional anesthetic regimens when possible 6
• Early postoperative mobilization is highly effective (NNT 5) 6
• Consider prophylactic alpha-blockers for high-risk patients 6
• Avoid overhydration during surgery 4, 9
• Have patient void immediately before surgery 9

Complications to Monitor

• Bladder overdistention (>500 mL) can lead to detrusor muscle damage 2
• Catheter-associated urinary tract infections increase with duration of catheterization 1, 2
• Prolonged retention can lead to long-term bladder dysfunction and kidney damage 8

Special Considerations

• Daily evaluation of catheter necessity is recommended 2
• For patients discharged with catheters, provide clear instructions on care and follow-up 5
• Patients with pelvic surgery have higher risk of retention and may require extended catheterization 5, 2