Prevention and management of postoperative urinary retention after urogynecologic surgery

Abstract

Postoperative urinary retention (POUR) is a frequent consequence of gynecologic surgery, especially with surgical correction of urinary incontinence and pelvic organ prolapse. Estimates of retention rates after pelvic surgery range from 2.5%–43%. While there is no standard definition for POUR, it is characterized by impaired bladder emptying, with an elevation in the volume of retained urine. The key to management of POUR is early identification. All patients undergoing pelvic surgery, especially for the correction of incontinence or prolapse, should have an assessment of voiding function prior to discharge. There are several ways to assess voiding function – the gold standard is by measuring a postvoid residual. Management of POUR is fairly straightforward. The goal is to decompress the bladder to avoid long-term damage to bladder integrity and function. The decision regarding when to discontinue catheter-assisted bladder drainage in the postoperative period can be assessed in an ongoing fashion by measurement of postvoid residual. The rate of prolonged POUR beyond 4 weeks is low, and therefore most retention can be expected to resolve spontaneously within 4–6 weeks. When POUR does not resolve spontaneously, more active management may be required. Techniques include urethral dilation, sling stretching, sling incision, partial sling resection, and urethrolysis. While some risk of POUR is inevitable, there are risk factors that are modifiable. Patients that are at higher risk – either due to the procedures being performed or their clinical risk factors – should be counseled regarding the risks and management options for POUR prior to their surgery. Although POUR is a serious condition that can have serious consequences if left untreated, it is easily diagnosed and typically self-resolves. Clinician awareness of the condition and vigilance in its diagnosis are the key factors to successful care for patients undergoing surgical repair.

ISC in women following urogynaecologic surgery

“…If the timing is appropriate to void, the cortex will send an efferent nerve signal to the pontine micturition centre, which activates parasympathetic motor neurons leading to detrusor contraction. At the same time the pontine micturition centre inhibits the somatic efferent motor neurons in the pelivc floor and urethral tissue leading to urethral sphincter relaxation (Geller, 2014). Surgery can lead to oedema, inflammation and damage to the peripheral nerves, which along with postoperative pain and discomfort can affect bladder filling sensation and the voiding nerve pathway resulting in POUR (Baldini et al, 2009).…”

“…A post void residual urine is the measurement of urine remaining in the bladder less than 20 minutes after voiding (Buchko and Robinson, 2012). Although there is no standard definition, POUR has been defined as 100mls, however cut off values vary between clinicians (Geller, 2014 andKaplan et al, 2008). Urinary retention can be either acute or chronic.…”

“…A percentage volume has also been used by practitioners where less than one-half to one-third of total volume. Thus is a patient's bladder is filled to 300mls, and voids 200mls the PVR would be 100mls and this would be considered successful voiding (Geller, 2014). However this method is considered less reliable.…”

“…All patients undergoing urogynecologic surgery should have an assessment of voiding function using urodynamics prior to surgery (NICE, 2013 andGeller, 2014). Pre-operative risk factors include older age, neurological disease, use of anticholinergic medication and a diagnosis of diabetes mellitus (Dreijer., Moller and Bartholdy, 2011).…”

“…The rates of retention reported following transurethral injection of bulking agents such as collagen are around 15% with a low risk of prolonged retention ( (National Institute for Health and Clinical Excellence (NICE) , Stothers, Goldenberg andLeone, 1998). The rate of retention following surgery to repair vaginal prolapse, without incontinence procedures is estimated at 29% (Hakvoort, 2009), however, in practice, women will undergo a combination of procedures aimed at treating both prolapse and incontinence, which increases their rsik of developing post-operative retention (Geller, 2014).…”