What is the recommended management for preventing or treating Post-Operative Urinary Retention Syndrome (POURS) in patients undergoing hernia surgery?

Management of Post-Operative Urinary Retention (POUR) in Hernia Surgery

Remove the urinary catheter on postoperative day 1 in patients at low risk for urinary retention, even if epidural analgesia is used, as prolonged catheterization beyond 24 hours significantly increases urinary tract infection rates without reducing retention risk. 1

Risk Assessment for POUR

Identify high-risk patients preoperatively based on established risk factors:

• Male sex, particularly age >50 years (OR 2.8 for retention) 1, 2
• Pre-existing prostatism or benign prostatic hyperplasia 1, 3
• Open surgical approach (versus laparoscopic) 1
• Bilateral hernia repair 2
• History of lower urinary tract symptoms (LUTS) with International Prostate Symptom Score >7 4

Approximately 48% of men over 50 undergoing inguinal hernia repair have significant LUTS, with those having maximal urine flow <10 mL/second and post-void residual >100 mL representing the highest risk group. 4

Prevention Strategies

Anesthetic and Analgesic Management

Minimize postoperative opioid use, as narcotic consumption ≥6.5 mg morphine equivalents significantly increases POUR risk (OR 2.5). 2, 5

• Utilize multimodal analgesia with NSAIDs, acetaminophen, or regional blocks to reduce opioid requirements 2
• Avoid long-acting local anesthetics in spinal anesthesia when possible 6
• Mid-thoracic epidural analgesia does not contraindicate early catheter removal on postoperative day 1 1

Fluid Management

Avoid excessive intravenous fluid administration, as increased postoperative IV fluid volume is a significant risk factor for POUR. 5

• Target cardiac output optimization rather than liberal fluid administration 1
• Use balanced crystalloid solutions over 0.9% saline 1
• Transition to oral fluids as early as possible 1

Pharmacologic Prophylaxis in High-Risk Patients

Consider perioperative alpha-blocker therapy (tamsulosin) in high-risk men with significant LUTS undergoing hernia repair, as this reduces POUR incidence from 41.6% to 12.5% in this population. 4

Catheter Management Protocol

Timing of Removal

Remove transurethral catheters on postoperative day 1 in standard-risk patients, as this approach:

• Reduces UTI rates from 14% to 2% 1
• Does not increase urinary retention rates (8% vs 2% requiring single catheterization) 1
• Remains safe even with concurrent epidural analgesia for 48-72 hours 1

Daily Reassessment

Evaluate catheter necessity daily in all patients, removing as soon as strict fluid monitoring is no longer required. 1, 3

Diagnosis and Treatment of POUR

Diagnostic Threshold

Perform bladder catheterization when post-void residual volume exceeds 100 mL or when bladder volume reaches 600 mL to prevent detrusor muscle damage from overdistention. 3, 6

• Utilize portable ultrasound for rapid, accurate bladder volume assessment 6
• The most common presentation is complete failure to void (82% of POUR cases) 2

Management of Established POUR

Perform immediate catheterization in patients unable to void spontaneously:

• Use intermittent straight catheterization when possible 1
• If indwelling catheter required, remove as early as feasible (ideally <24 hours) 1, 3
• Refer patients with prolonged retention (>72 hours postoperatively) to urology 1

Common Pitfalls to Avoid

• Do not leave catheters in place for the duration of epidural analgesia - this outdated practice increases UTI risk without benefit 1
• Verify catheter patency and position before diagnosing high urine output or retention 7
• Avoid bladder overdistention >500-600 mL, which can cause permanent detrusor dysfunction 3, 6
• Do not use prolonged catheterization (>3 days) as infection risk increases dramatically with duration 1, 3

The overall incidence of POUR after laparoscopic inguinal hernia repair ranges from 8-22%, making prevention and early recognition critical for optimal outcomes. 2, 5