What is the best course of management for a patient, status post right inguinal hernia open surgery about one week ago, presenting with urinary complaints and back pain?

Post-Inguinal Hernia Surgery with Urinary Complaints and Back Pain

The most critical immediate step is to verify urinary catheter patency if present, or assess for urinary retention with bladder scanning or catheterization, as postoperative urinary retention occurs in 8-22% of inguinal hernia repairs and can present with back pain from bladder distension. 1, 2

Immediate Assessment

Rule Out Urinary Retention First

• Check for bladder distension through physical examination (suprapubic fullness/tenderness) or bladder ultrasound, as this is the most common urinary complication one week post-hernia repair 3, 1
• Measure post-void residual (PVR) volume if the patient reports voiding; >200-300 mL suggests significant retention 3
• If catheter is in place, flush it to confirm patency before pursuing other diagnoses 3

Assess for Rare but Serious Bladder Injury

• Obtain urinalysis immediately to check for hematuria, which could indicate iatrogenic bladder injury during surgery (occurs in 1-5% of inguinal hernias involving bladder) 4, 5
• If hematuria is present without infection, urgent imaging with CT cystogram is indicated to rule out bladder perforation or injury 4
• Back pain combined with urinary symptoms and elevated creatinine suggests possible post-renal obstruction from unrecognized bladder herniation or injury 4

Risk Stratification

High-Risk Features Requiring Urgent Intervention

• Age >50 years increases urinary retention risk 2.8-fold 1
• Narcotic use ≥6.5 mg morphine equivalent postoperatively increases retention risk 2.5-fold 1, 2
• New-onset inability to void or significantly decreased urine output 1
• Acute kidney injury on laboratory testing (elevated creatinine) suggests bilateral obstruction 4

Management Algorithm

If Urinary Retention Confirmed

• Perform immediate bladder decompression with straight catheterization or Foley placement 3, 1
• Reduce or eliminate narcotic analgesics; substitute with NSAIDs, acetaminophen, or regional blocks 1, 2
• Limit IV fluid administration, as excessive postoperative fluids significantly increase retention risk 2
• Trial of voiding after 24-48 hours of decompression; if unsuccessful, maintain catheter and reassess 3

If Bladder Injury Suspected

• Obtain CT cystogram or retrograde cystography (most sensitive test for bladder herniation/injury) 4, 5
• Consult urology urgently if imaging confirms bladder involvement 5
• Maintain Foley catheter drainage while awaiting definitive management 4

If Chronic Pain Syndrome Developing

• Examine for point tenderness over genitofemoral nerve distribution (most common), ilioinguinal nerve, or medial scar 6
• Consider targeted nerve blocks (genitofemoral or ilioinguinal) with local anesthetic and corticosteroid if specific nerve distribution identified 6
• Note that chronic severe pain occurs in approximately 9% of open hernia repairs, with mesh repairs having higher incidence than suture repairs (17% vs 3%) 6

Critical Pitfalls to Avoid

• Do not assume urinary symptoms are unrelated to the hernia repair—bladder involvement in inguinal hernias is rare but occurs in 1-5% of cases and is often diagnosed only intraoperatively or post-injury 4, 5
• Do not continue high-dose narcotics if retention develops; this is a modifiable risk factor 1, 2
• Do not miss bilateral hydronephrosis on imaging, which indicates significant bladder outlet obstruction requiring urgent decompression 4
• Do not delay catheterization in elderly patients with risk factors, as prolonged retention can cause permanent bladder dysfunction 1

Follow-Up Monitoring

• Recheck renal function if initially elevated to ensure improvement with bladder decompression 4
• If catheter placed, attempt voiding trial within 24-48 hours with PVR measurement 3
• Evaluate daily whether continued catheterization is necessary to prevent complications 3
• If pain persists beyond 3 months despite conservative measures, consider formal pain management consultation for chronic post-herniorrhaphy pain syndrome 6