Postoperative Voiding Dysfunction

Abstract

An often overlooked and minimized aspect of antiincontinence and pelvic reconstructive reparative procedures is the problem of postoperative voiding dysfunction and urinary retention. The focus of most surgical research centers around continence. How many patients are dry and for how long remains the mainstay of our discussions about surgical success. The prospect of ongoing urinary retention with chronic catheterization is difficult to contemplate, even for patients with severe urinary incontinence. It has been suggested that some patients may prefer the use of intermittent catheterization over urinary incontinence [1]. Most patients are not quite so accepting. True surgical success is judged by the return of normal voiding function along with long-lasting continence. The type of surgery performed is critical to such success. One of the mechanisms of success for anti-incontinence procedures is urethral obstruction through elevation of the posterior urethral vesical angle. Some procedures are more obstructive than others, leading to a greater chance of urinary retention. This is the case with many sling operations. To some extent, improvement in continence rates may occur at the risk of more postoperative voiding dysfunction. Appropriate patient and surgical selection are paramount to the prevention of this problem.Once voiding dysfunction has occurred, there are many treatment options available. This chapter will address postoperative voiding dysfunction from expected incidence and pathophysiology to appropriate diagnosis, treatment and management. IncidenceThe incidence of postoperative voiding dysfunction varies based upon the procedure performed. Procedures that are undertaken in close proximity to the bladder have the highest urinary retention risk postoperatively. Orthopedic operations, such as hip arthroplasties, and rectal operations for bowel carcinoma, such as low anterior or abdominoperineal resections, pelvic pouch procedures, proctectomies, and diversions, are particularly troublesome [9,10]. Both immediate and long-term urinary retention is very commonly reported. The etiology of retention following these types of surgeries is likely multifactorial, but interference to pelvic neuroanatomy plays a major role.All gynecological procedures may be associated with postoperative urinary retention and various other types of voiding dysfunction. The actual incidence is procedure specific with certain operations being notable for the problem. About 50% of patients require catheterization for urinary retention following hysterectomy [11]. Up to 35% may need catheterization for several days before effective bladder emptying is restored [4]. With routine hysterectomy and other common gynecological procedures not associated with bladder neck suspension, the urinary retention is usually temporary. An example is rectocele repair, with urinary retention being the most common postoperative complication, occurring in about 13% of cases [12]. Resolution usually occurs within days, but occasionally can extend hospitaliz...