Postoperative Urinary Retention After Inguinal Hernia Repair
This patient most likely has postoperative urinary retention (POUR), a common complication occurring in approximately 6% of male patients after inguinal hernia repair, and requires immediate bladder decompression with urethral catheterization. 1
Immediate Assessment and Management
Confirm Urinary Retention
- Assess for bladder distension through physical examination (suprapubic fullness and tenderness) 2
- Measure post-void residual volume if the patient reports incomplete emptying or difficulty voiding 3
- If the patient cannot void at all and has a palpably distended bladder, this constitutes acute urinary retention requiring urgent intervention 2
Urgent Bladder Decompression
- Perform immediate urethral catheterization (straight catheterization or indwelling Foley catheter) to decompress the bladder 2, 4
- The American College of Radiology emphasizes that acute urinary retention is a urological emergency requiring immediate decompression to prevent bladder rupture and upper tract damage 2
- Document the volume drained, as this confirms the diagnosis and severity 4
Risk Factor Assessment
This 26-year-old male patient has several considerations:
Age-Related Risk
- While age >50-60 years is the strongest risk factor for POUR (odds ratio 2.8), younger patients can still develop retention 4, 5, 1
- Male patients aged 65+ have a 9.5% incidence, but all male patients carry baseline risk 1
Perioperative Factors to Investigate
- Postoperative opioid use ≥6.5 mg morphine equivalents significantly increases POUR risk (odds ratio 2.5) 4
- Operative duration and type of anesthesia used (neuraxial regional anesthesia carries higher risk than local) 1
- Intraoperative fluid administration, though the evidence is mixed on whether restriction prevents POUR 6
- Whether temporary intraoperative urethral catheterization was performed (increases risk) 1
Short-Term Management Strategy
If Retention is Confirmed
- Place indwelling Foley catheter for 24-48 hours to allow bladder recovery 3
- Minimize or eliminate opioid analgesics; transition to NSAIDs, acetaminophen, or regional blocks for pain control 4
- Avoid anticholinergic medications which impair bladder contractility 7, 1
- Ensure adequate but not excessive hydration 6
Trial of Void After Catheter Removal
- Remove catheter after 24-48 hours and assess voiding ability 3
- Measure post-void residual; volumes >200-300 mL suggest incomplete recovery 3
- If patient voids successfully with minimal residual (<100 mL), no further intervention needed 5
Follow-Up and Monitoring
If Retention Persists Beyond Initial Management
- Reassess for underlying urological pathology (though unlikely in a 26-year-old without prior symptoms) 3
- Consider intermittent self-catheterization if unable to void after second catheter removal 3
- Most cases resolve within days to weeks postoperatively 1
Red Flags Requiring Urological Referral
- Persistent inability to void after 1 week despite catheter trials 3
- Development of urinary tract infection (occurs in 30-day period in high-risk patients) 5
- Pre-existing lower urinary tract symptoms that were unrecognized preoperatively 1
Prevention Considerations for Future Cases
The most recent high-quality evidence from the 2025 study on sugammadex demonstrates that using sugammadex for neuromuscular blockade reversal instead of neostigmine/glycopyrrolate eliminates POUR (0% vs 9.8%) in laparoscopic inguinal hernia repair 7. This is because glycopyrrolate's anticholinergic effects impair bladder contraction, while sugammadex has no cholinergic properties 7.
Expected Outcomes
- POUR is the primary reason for 27.8% of unplanned admissions and 51.8% of 30-day readmissions after inguinal hernia repair 1
- With appropriate catheter management, most patients recover normal voiding function within days 3
- This complication does not typically indicate long-term urological dysfunction in young patients without risk factors 1