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C URRENTO PINION Maintaining micturition in the perioperative period:strategies to avoid urinary retention

Stephen Choi and Imad Awad

Purpose of reviewMaintaining micturition in the perioperative period can be challenging because of its low profile, othercompeting clinical criteria, poorly defined diagnostic criteria, and varying management strategies.Postoperative urinary retention, the main complication of micturition difficulties, has clinical implications interms of perioperative outcome such as delayed discharge, iatrogenic infection from catheterization withthe potential risk of systemic infection, and possible long-term bladder dysfunction. Factors contributing topostoperative micturition problems are multifactorial and anesthesiologists should consider the strategies tominimize the incidence of postoperative urinary retention.

Recent findingsSeveral factors have been identified as increasing the risk of perioperative micturition difficulties includingmedical comorbidities, surgical type, anesthetic type, and within anesthetic type specific agents such aslong-acting neuraxial opioids. Current literature indicates that long-term sequelae are unlikely, with bladderoverdistension lasting less than 4 h.

SummaryEmploying strategies aimed at minimizing the disruptions in bladder function can mitigate perioperativemicturition problems and subsequent complications. This requires a multifactorial approach. We presentidentified risk factors, considerations for their modification, as well as a classification and managementstrategy that incorporates the literature to date.

Keywordsbladder distension, micturition, neuraxial anesthesia, urinary retention

INTRODUCTION

Maintaining perioperative micturition can bechallenging because it is an outcome that is oftenunderreported in relation to other more clearlydefined postoperative outcomes such as surgicalsuccess, pain, cardiac morbidity/mortality, and hos-pital length of stay. Nonetheless, the inability toinitiate micturition postoperatively herein referredto as postoperative urinary retention (POUR) can

negatively affect each of these outcomes. Though ithas been associated with negative outcomes, POURitself is poorly defined with varying criteria inthe literature and little data regarding long-termsequelae. Recent reviews estimated an overall inci-dence as low as 2.1%, but as high as 36.6% in certainsubsets of patients [13] . This may be indicative of both the multiple contributors to the occurrenceof POUR and the heterogeneity of the diagnosticcriteria. POUR can occur when the parasympatheticoutflow from dermatomes S2 to S4 is impairedpharmacologically, damaged from surgical trauma,

damaged by pathologic processes in the perinealregion, or from overriding sympathetic activityfrom pain in the perineal region. A review byBaldini et al. [1] in 2009 thoroughly examinedthe pharmacology and physiology of POUR. Theprimary aim of this article is to discuss the clini-cal implications of POUR, factors associated withincreased risk of POUR, and present anesthesio-logists with options so that perioperative micturi-

tion can be maintained.

Department of Anesthesia, Sunnybrook Health Sciences Centre, Uni-versity of Toronto, Toronto, Ontario, Canada

Correspondence to Dr Stephen Choi, MD, FRCPC, Department ofAnesthesia, Sunnybrook Health Sciences Centre, University of Toronto,M3-200, 2075 BayviewAvenue,Toronto, ON, CanadaM4N 3M5. Tel: +1416 480 4864; fax: +1 416 480 6039; e-mail: [email protected]

Curr Opin Anesthesiol 2013, 26:361367

DOI:10.1097/ACO.0b013e32835fc8ba

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THE HETEROGENEOUS DEFINITION OFPOSTOPERATIVE URINARY RETENTION

Impaired micturition is a clinical entity that isunquestioned, withmostclinicians havingencoun-tered patients who despite having the urge to voidare unable to initiate micturition. This may sub-sequently require catheterization and result indelayed discharge from hospital. In general, theadult bladder has a cystometric capacity of approxi-mately 400 600 cc with an urge to void as early as60% of this volume [4,5] . Afferent signals fromthe receptors in the bladder initiate a spinal reflex,with parasympathetic efferent signals initiatingdetrusor contraction and subsequent micturition.The definition of POUR in the anesthesia literatureis heterogeneous and studies reporting its incidencehave widelyvarying definitions in terms of durationwithout mict ur ition and bladder volume that con-stitute POUR [6 & ]. Though never explicitly codified,clinicians howeverhave previously described POURas an inability to initiate micturition with a bladdervolume exceeding 500cc [7] . Importantly, thisvolume exceeds the volume at which micturitionis usually initiated and it provides a time framein the postoperative period from which to allow a

trial of voiding. Clear, evidence-based recom-mendations suggesting when urinary catheteriza-tion is appropriate are lacking. A more rigorous andstandardized definition of micturition problemswas suggested by Breebaart et al. [8] , though itis more labor intensive because it requires bedsideultrasound scanning ( Table 1 ). Although these

suggested classifications correlate well with the cys-tometric filling studies, their effects on drivingintervention in the form of bladder catheterizationand subsequent clinical outcome, either short orlong term, remain unstudied.

CLINICAL IMPLICATION OFPOSTOPERATIVE URINARY RETENTION

There are both indirect and direct complicationsof POUR resulting from either the physiologicresponse because of the full bladder or interventionsassociated with its management.

Indirect effectsThe indirect effects of POUR include delayedhospital discharge as well as iatrogenic infectionsecondary to catheterization. POUR has resultedin prolonged hospital stay as well as delayed dis-charge from ambulatory procedures, resulting inhigher total hospital costs [911] . Catheterization,whether indwelling or intermittent, increases thechance of infection with persistent bacteriuria aftersingle catheterization lasting up to 6 days havingbeen documented as well as bacteremia [12,13] .Though the incidence of both was relatively low,21 and 8%, respectively, this should still be of con-cern as there is a small risk of systemic infection orcolonization of prosthetic material. In a retrospec-tive review of over 2 million patients, Wu et al. [3]reported that patients with POUR were at increasedrisk for urinary tract infections [odds ratio (OR) 2.3],catheter-related complications (OR 5.2), requiring

KEY POINTS

Maintaining perioperative micturition is challengingbecause of its multifactorial nature, with manypredisposing factors to postoperative urinary retentionnot in the control of anesthesiologists.

Perioperative micturition problems are poorly defined inthe literature and management is heterogeneous.The long-term implications of prolonged bladderoverdistension remain poorly studied.

Long-acting, hydrophilic, neuraxial opioids increase theincidence of POUR.

Table 1. Classification of micturition problems

No problems

Minor problems A: Subjective difficulties in voiding or a feeling of incomplete voiding or PVRV< 100ccB: Volume> 500cc, no urge but no problems in voiding with PVRV< 100cc

Moderate problems A: 2 minor problems with PVRV< 100ccB: Indication for single evacuation, patient able to void with difficulties within 15min with PVRV< 100ccC: PVRV> 300cc, patient able to void with difficulties within 15 min with PVRV< 100cc

Marked problems A: PVRV 100300cc after first micturition with subjective difficultiesB: Indication for single evacuation, but voids within 15min with PVRV 100300 cc

Serious problems Single evacuation necessary

Reproduced with permission from[8]. PVRV, postvoid residual volume.

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home care (OR 1.3), and had a longer duration of admission (0.24 days).

Direct effectsThere are direct complications that fall across thespectrum of common to rare and well defined to

ill defined. Among the rare complications are thehemodynamic effects from sympathetic stimulationcaused by pain from the overdistended bladderincluding dysrrhythmias and asystole [4]. Whereasurinary tract infection is more likely to resultfrom catheterization, urine that is stagnant in thebladder can still result in cystitis [14] . Least studied,primarily because signs and symptoms are notreadily apparent, are the urodynamic effects becauseof bladder ischemia from overdistension. Prolongedimpairments in detrusor contractility have beendemonstrated after overdistension as short as 4 hthough there are no apparent lasting effects whenthe period of overdistension is less than 2 h [15] .Others have reported long-term bladder dys-function and possible chronic kidney disease fromlongstanding POUR [16] .

RISK FACTORS FOR POSTOPERATIVEURINARY RETENTION

The incidence of POUR across varied surgical popu-lations, with different anesthetic modalities andheterogeneous definitions of POUR, is reportedlybetween 2.1 and 36.6%. Previously identified riskfactors for POUR can be broadly defined accordingto those that cannot be modified versus those thatcan be modified by altering the practice.

Nonmodifiable risk factorsSeveral risk factors for POUR have been identifiedthat are intrinsic to either patients themselves or thesurgical procedure itself and therefore not amenableto modification by anesthesiologists. Though notmodifiable, anesthesiologists should remain cogni-zant of these risk factors, monitor patients who are

at higher risk of POUR in the immediate post-operative period, and consider anesthetic tech-niques that may minimize the incidence of POUR.

Among the surgical types that consistentlydemonstrate higher incidences of POUR, anorectalsurgery and joint arthroplasty are prominent.Those undergoing anorectal surgeries have POURwith reported incidences as high as 34% [17] . Up to36.6% of patients undergoing lower limb jointarthroplasty experience POUR regardless of anes-thetic modality [18] . In the case of anorectalsurgery, POUR may reflect pain in the perineal

region resulting in sympathetic outflow inhibitingthe relaxation of the urinary sphincter. It may alsobe a result of trauma to the pelvic floor from surgeryitself or the pathologic process affecting the ana-tomic area [19,20] . With respect to lower limbjoint arthroplasty, both age and male sex may beconfounding factors as these have also been

demonstrated to increase the likelihood of POURseveral fold. This has been hypothesized to bebecause of age-related bladder dysfunction or patho-logy such as benign prostatic hypertrophy (BPH)[21] . Recent studies have demonstrated that amongthe male cohort of patients undergoing lower limbjoint arthroplasty, those with more severe symp-toms of BPH we re at increased likelihood of devel-oping POUR [22 & ].

Other populations that may experience a higherincidence of POUR are those with pre-existingcentral or peripheral nervous system pathologyand those with structural abnormalities in the pelvicfloor from previous surgery or radiation [21] .

Modifiable risk factorsThe following sections pertain to factors that areunder the direct control of anesthesiologists andthus afford the opportunity to influence the inci-dence of POUR.

Anesthetic/analgesic modalityThe anesthetic/analgesic modality can affect mic-turition via systemic effects on central cholinergicreceptors or direct blockade of nerves.

Systemic opioid analgesiaSystemic opioid analgesia has a dose-dependenteffect on the incidence of POUR. Systemic opioidsexert their function in the spinal cord, blocking theparasympathetic activity of acetylcholine, resultingin decreased detrusor contractility [11] . It has beendemonstrated that adjunctive medication (acetami-nophen and nonsteroidal anti-inflammatories),because of opioid-sparing effects, reduces the inci-dence of POUR compared to patients receiving onlyintravenous opioid-based analgesia [4].

Neuraxial anesthesiaCompared to systemic opioid analgesia, neuraxialanesthetic and analgesic techniques result in ahigher incidence of POUR [1]. This occurs fromsensorimotor blockade of the S2 to S4 dermatomallevels. Concomitant administration of opioids withlocal anesthetic in neuraxial techniques results insuperior block characteristics and reduced localanesthetic dose; however, the incidence of POUR

Maintaining micturition in the perioperative period Choi and Awad

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is increased over that of local anesthetic alonebecause of the synergistic effects on the bladder.Similar to systemic opioids, short and longacting neuraxial opioids reduce the strength of detrusor contraction. Several patterns emergewhen examining the specific opioid utilized andthese will be discussed in the context of epidural

and intrathecal techniques. Epidural The incidence of POUR when utilizing epiduralanesthesia or analgesia is higher than with systemicopioids alone [1]. Because epidural local anestheticsare most often utilized as infusions, the type of localanesthetic utilized has less of an effect on develop-ing POUR. During the infusion, many institutionshave patients catheterized as a matter of protocol,therefore making it impossible to accurately deter-mine the incidence during the infusion. Differences

occur when the epidural infusion is terminatedand the opioid that is co-administered with thelocal anesthetic influences the return of detrusorfunction. Patients administered any type of neura-xial opioid demonstrate higher incidences of POURcompared with only local anesthetic. In particular,patients who are administered, long-acting, hydro-philic opioids in the epidural space demonstrate ahigher incidence of POUR than those admi ni ster edno opioids or only short-acting opioids [6 & ,23 & ].Hydrophilic opioids exert similar but prolongedeffects both in terms of analgesia and inhibitionof detrusor function. This suggest that if opioidsare co-administered into the epidural space alongwith local anesthetics, shorter acting, lipophilicopioids should be utilized to decrease the incidenceof POUR, particularly if there are no significantdifferences in their analgesic efficacy other thanduration.

Intrathecal anesthesiaSimilar to the epidural techniques, intrathecal anes-thesia demonstrates a higher incidence of POURwhen compared with systemic opioid analgesia[1]. Because intrathecal local anesthetics blockconduction at sacral nerve roots and sensorimotorfunction of the bladder is impaired until the blockresolves to the S2 level, the duration of dysfunctionnecessarily depends on the pharmacologic durationof the local anesthetic injected. After bupivacaineanesthesia, detrusor dysfunction persists up to 3.5 hafter resolution of the sensory block [24] . Indeed,it has been clearly demonstrated that the incidenceof POUR increases as local anesthetics of greaterpotency and longer duration, such as tetracaineand bupivacaine, are employed over shorter acting

lo cal anesthetics such as lidocaine and mepivacaine[6 & ,25] . Predictably, the likelihood of POUR is alsodose dependent within the same local anesthetic,in which the requirement for catheterization washalved and the duration of block regression to theS2 level was reduced by 1 h by reducing the d ose of intrathecal bupivacaine from 10 to 5 mg [26 & ].

Furthermore, the addition of opioids to intrathecallocal anesthetic, in particular long-acting hydro-philic opioids, increases the risk of POUR in amanner similar to epidural analgesia [6 & ,23 & ]. Toreduce the incidence of POUR, anesthesiologistsshould consider utilizing the shortest durationand lowest dose of local anesthetic feasible alongwith lipophilic opioids.

Neuraxial adjuvants other than opioidsIn addition to opioids, both epinephrine and cloni-dine have been used neuraxially to produce longer,

denser blocks. Epinephrine has been demonstratedto prolong the time to first micturition primarilybecause of its action in prolonging the activity of localanesthetics [27] . Clonidine, an a -2 agonist, doesnot seem to increase the incidence of POUR whenutilized in the subarachnoid or epidural space [28] .

Peripheral nerve block Peripheral nerve block anesthesia and analgesiareduce the incidence of POUR compared to otheranesthetic modalities [29 & ]. Regardless of the surgerytype, the incidence of POUR is reduced becauseof the opioid-sparing effect and obviating the needfor central neuraxial block.

FLUID MANAGEMENT

Varying strategies for fluid management invarious surgical specialties exist. For example, inthoracic surgery, there is a tendency to restrict fluidadministration to minimize lung edema. There is asimilar trend in the colorectal surgery literature.The primary concern is with the surgical outcomerather than any secondary outcomes such as POUR.However, a restrictive fluid strategy may have un-intended effects in terms of reducing the incidenceof POUR. There are several studies suggesting thatliberal fluid administration ( > 1000cc) in the ambu-latory setting increases the risk of bladder distensionin the recovery room, which is a risk factor for POUR[30] . Obviously in the case of major surgery orsignificant blood loss, fluids for resuscitationshould be administered as necessary, but in caseswhere there are minimal fluid shifts and bloodloss, consideration should be given to limiting fluidadministration.





MONITORING PATIENTS FOR PROBLEMS WITH MICTURITION

The following is a strategy for monitoring inpatientsadapted from the classification system developedby Breebaart et al. [8] (Fig. 1). It incorporatesknown cystometric capacities as well as studiesthat have determined when bladder damage from

overdistension occurs. The principle goal is toprevent the bladder overdistension from lastinglonger than 4 h. Readers s hou ld refer the recentarticle by Mulroy and Alley [31 & ] for an outpatientmanagement strategy.

Patients should void prior to all surgicalprocedures. For postoperative patients withouturinary catheters, a trial of voiding should be per-formed prior to any catheterization. Bladder volumeshould be assessed by ultrasound 4 h postoperativelyor 4 h following the removal of an indwellingcatheter. If a patient is unable to void and hasa bladder volume of greater than 500cc by ultra-sound, the approximate cystometric capacity, singlecatheterization should be performed. The patientshould then be monitored on the subsequent void-ing attempt. Once the patient successfully voids forthe first time, the postvoid residual volume (PVRV)should be assessed. If the PVRV is greater than300cc, the bladder should be scanned again in 2 hto ensure the bladder volume is not greater than500 cc. If the volume is greater than 500 cc, thepatient should be catheterized again if unableto void spontaneously. If however, the PVRV is lessthan 100 cc, monitoring can be discontinued.

Patients with a long surgical duration ( > 4h),extensive fluid shifts, or postoperative epiduralinfusion for analgesia should have indwellingurinary catheters. When the urinary catheter isremoved on the postoperative ward, after discon-tinuation of the epidural, the above strategy shouldbe employed.

PHARMACOLOGIC INTERVENTIONS

Several studies have attempted to use selective a -1adrenergic receptor blocking agents utilized inpatients with BPH to decrease the incidence of POUR. A recent Cochrane review that included230 patients determined that there was no benefita -1 adrenergic receptor blocking agent prazosin[16] . This review did find a mild association betweenadministration of cholinergic agents concomitantlywith the sedatives and spontaneous voiding[relative risk (RR) 1.39], as well as intravesicularadministration of prostaglandins (RR 3.07) [16] .

Tamsulosin, a more selective a -1 blocking agent,has recently been investigated. Two contemporaryrandomized trials comparing tamsulosin to placeboreported different conclusions [32,33] . One studyof 80 patients demonstrated a significant reductionin POUR (absolute risk difference of 12.5%, P 0.04)[33] , the other study of 94 patients did not (absoluterisk difference of 2.1%, P 0.80) [32] . Although thismight be a result of differing doses of tamsulosin(0.4 vs. 0.2 mg), the evidence for a -1 adrenergicreceptor blocking agents is still equivocal.

Next void

PVRV 100 300cc PVRV < 100cc

US bladder

Able to void

Assess bladder volume with US 4 h afterremoval of indwelling urinary catheter or4 h after surgery if n o catheter

Discontinuemonitoring

US bladder

Unable to void

> 500cc

Singleevacuation

Rescan 2 h

< 500cc

FIGURE 1. Suggested algorithm for inpatients. PVRV, postvoid residual volume; US, ultrasound.


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Conversely, a -2 receptor agonists such asclonidine or dexmedetomidine, which stimulateurinary production, have no demonstrated effecton the incidence of urinary retention in the currentliterature [28,3437] . Currently, pharmacologicoptions, either by administering or omitting, havelimited demonstrable effect in decreasing POUR and

resultant catheterization.

CONCLUSION

Maintaining micturition in the perioperative periodcan be challenging for several reasons. Firstly, as aperioperative outcome it is often an afterthoughtto many other outcomes except when it impairsdischarge. Secondly, POUR, the result of an inabilityto micturate, is poorly defined and its clinicalimplications, particularly those that are long term,are not immediately apparent. Thirdly, strategiesto maintain micturition, such as restricting fluidadministration, catheterization, changing medi-cations, and frequent monitoring, may havecompeting interests with other concerns such assurgical/anesthetic outcomes, analgesia, and nursingworkload.

This does not absolve clinicians of the needto consider strategies to maintain perioperativemicturition. In patients who are at high risk of POUR(high-risk surgeries, medications known to causePOUR, analgesic regimens known to increase POUR,or structural abnormalities such as BPH), the strat-egies presented above should be considered andutilized as the clinical situation permits. Further-more, utilizing bladder ultrasound for micturitionproblems in these high-risk patients should beemployed and drainage should be instituted if greater than 4 h of overdistension is imminent toprevent chronic detrusor damage.

AcknowledgementsNone.

Conflicts of interestThere are no conflicts of interest.

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