Marta Alves

Servicio de Urología

POSTOPERATIVE URINARY RETENTION IN ABDOMINAL SURGERY

�  Introduction �  Incidence � Mechanism of micturition � Risk factors � Prevention � Diagnosis � Complications/Adverse effects associated with

POUR � Clinical management � Conclusions

�  POUR has been defined as the inability to void in the presence of a full bladder.

�  Slow urine stream �  Straining to void �  A feeling of incomplete bladder

emptying �  Suprapubic pressure or pain [1]

Incidences �  General surgery 3.8%

�  Anorectal surgery 1-52%

�  Hernia repair 5.9-38%

Mechanism of micturition

Preoperative risk factors �  Age ( 2.4 times in patients over 50) [1]

�  Gender (4.7% compare to women 2.9%) [1]

�  Benign prostate hyperplasia

�  Type of surgery

�  Previous pelvic surgery

�  Neurological diseases

Intraoperative risk factors �  Large amount of IV >750ml (anorectal and hernia repair surgery

2.3 times more) [2]

�  Duration of surgery [3]

�  Anesthetic and analgesia agents

Spinal anesthesia Spinal analgesia

�  Act on neurons segments S2-S4

�  Contraction of detrusor abolished in 2-5 min and recovery depends on sensory block

�  Use of long-acting local anesthetics is related to a higher incidence of POUR [4]

�  Decrease the parasympathetic effects

�  Impaired coordination between detrusor and internal urethral sphincter

�  The onset and the duration depends on the TYPE and DOSE of opiod

Epidural anesthesia Epidural analgesia

�  Similar to intrathecal anesthetic

�  Incidence of POUR with epidural anesthetics for inguinal herniorrhaphy is lower than with spinal anesthesia

�  Site of insertion: lumbar epidural>thoracic epidural

�  Not dose-dependence[5]

Postoperative risk factors �  Bladder volume at the arrival in PACU> 270ml[6]

�  Excessive liquid intake �  Higher incidence of POUR in continuos epidural infusion

compared with PCA

�  Constipation �  Mobilization

Prevention �  Identify patients at risk(type of surgeries, medical history…) �  Fluid restriction in anorectal surgery and inguinal hernia repair �  Appropiate anesthesia and analgesia strategy �  Fluid restriction in the postoperative period �  Avoid constipation and encourage an early mobilization

�  Prescription of daily drugs of patients

Diagnosis

Complications and adverse effects

�  Autonomic response

�  Infection

�  Bladder overdistension

Incidence of 44%

>500ml diagnose and treated 1-2h

Further investigation

Clinical management

1.  Alpha receptors antagonists

(Tamsulosine 0.4mg) [7]

2.  Ciprofloxacin 500mg

Removal within 4-5 days

Conclusions �  Multifactorial �  Identification of risk factors �  Proper anamnesis and exploration �  Ultrasound if doubts �  Removing avoidable causes

Surgery

Patient Anesthesia

References �  1. Tammela T, Kontturi M, Lukkarinen O. Postoperative Urinary Retention: I.Incidence and Predisposing Factors.

Scandinavian Journal of Urology and Nephrology. 1986;20(3):197-201.

�  2. Petros J, Rimer E, Robillard R, Argy O. Factors Influencing Postoperative Urinary Retention in Patients Undergoing Elective Inguinal Herniorrhaphy. Survey of Anesthesiology. 1991;35(4):232.

�  3. Pavlin D, Pavlin E, Gunn H, Taraday J, Koerschgen M. Voiding in Patients Managed With or Without Ultrasound Monitoring of Bladder Volume After Outpatient Surgery. Anesthesia & Analgesia. 1999;89(1):90-97.

�  4. Kamphuis E, Ionescu T, Kuipers P, de Gier J, van Venrooij G, Boon T. Recovery of Storage and Emptying Functions of the Urinary Bladder after Spinal Anesthesia with Lidocaine and with Bupivacaine in Men. Anesthesiology. 1998;88(2):310-316.

�  5. Rawal N, Millefors K, Axelsson K, Lingerdh G, Widman B. An Experimental Study of Urodynamic Effects of Epidural Morphine and of Naloxone Reversal. Anesthesia & Analgesia. 1983;62(7):641-647.

�  6. Predictive Factors of Early Postoperative Urinary Retention in the Postanesthesia Care Unit. Survey of Anesthesiology. 2005;49(6):329-330.

�  7. Cataldo P, Senagore A. Does alpha sympathetic blockade prevent urinary retention following anorectal surgery?. Diseases of the Colon & Rectum. 1991;34(12):1113-1116.

�  8. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative Urinary Retention. Anesthesiology. 2009;110(5):1139-1157.

�  1. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative Urinary Retention. Anesthesiology. 2009;110(5):1139-1157.