Andrew Siegel MD 12/17/2022
Post-Operative Urinary Retention (“POUR”)
Isn’t it ironic that the acronym for post-op urinary retention – POUR – is exactly what the bladder at times cannot do following an operation!
Thank you pxhere.com: https://pxhere.com/en/photo/1568951
Basics
POUR is the inability to urinate after a surgical procedure and a common reason for urology consultation. The surgical procedure that incurred the problem does not necessarily have to involve the urinary tract and the patient may have had no issues with urination prior to the surgical procedure. The key factors that contribute to this problem are anesthesia, medications, pain, and confinement to a bed or stretcher.
Any form of anesthesia – general, spinal, or regional – can suppress urination at the level of the central nervous system (pontine micturition center) as well as the peripheral nervous system (sacral spinal cord). General anesthetics are smooth muscle relaxants that may decrease the ability of the bladder to contract effectively. Spinal and epidural anesthetics interfere with nerves going from the spinal cord to and from the bladder. POUR occurs most commonly with spinal anesthesia, followed by epidural anesthesia, followed by general anesthesia.
When my wife had an epidural immediately prior to the delivery of our first daughter, she was unable to urinate and had to have a catheter placed for over one liter of urine in her bladder.
Pain medications – particularly opioids – may profoundly adversely affect urination by blunting the sensation of bladder filling as well as by increasing the resistance to bladder outflow via stimulation of the sympathetic nervous system.
Post-operative pain triggers the sympathetic nervous system and the adrenaline released by the adrenal glands in response to pain and stress decreases bladder contractility and increases the sphincteric resistance to urinary flow. This occurs in both genders but is particularly pronounced in men because of the presence of the prostate gland that is highly responsive to adrenaline release, resulting in contraction and tightening.
The supine, non-ambulatory position– often necessary for several hours following a surgical procedure — does not lend itself to efficient bladder emptying.
Risk Factors
Risk factors for POUR are the following: male gender, aging, diabetes, benign prostate enlargement, pre-existing unrecognized urinary symptoms, neurological diseases, spinal surgery, orthopedic procedures including total knee and total hip replacement, anal-rectal and colon surgery (particularly those procedures that can affect the pelvic nerves going to the bladder such as colon resection and abdominal-perineal resection), uro-gynecological procedures, prolonged surgical procedures, when greater volumes of infused intravenous fluids are used, spinal anesthesia, delayed time to ambulation, and post-operative opioid use.
Symptoms
The typical symptoms are an intense urgency to urinate, pain or discomfort in the bladder region, inability to urinate, and perhaps leakage of urine when the bladder becomes over-distended (overflow incontinence). Anesthesia can make these symptoms less apparent by blunting bladder sensation. Physical exam demonstrates fullness in the supra-pubic region because of the distended bladder. A bladder scan is a form of ultrasound technology that non-invasively determines the amount of urine in the bladder.
Note: The urinary bladder typically holds 10-12 ounces under normal circumstances. A patient with POUR may have over one liter of urine in the bladder, and at times, significantly more than one liter.
Management
A bladder catheter (see image below) needs to be placed to drain the urinary bladder. This is a hollow, straw-like tube that is inserted into the urethra and advanced into the bladder, It can be left indwelling and attached to a drainage bag as the image demonstrates, or alternatively, an intermittent catheterization regimen can be utilized in which a catheter is not left in but used as necessary to drain the urinary bladder. If the bladder has been significantly over-distended with more than one liter of urine, it is considered to be a physical “insult” and may take time for healing and recovery from the over-stretching and loss of tone and contractility. These changes are reversible with bladder decompression by use of the catheter. Typically, if an indwelling catheter is used, it is left in for 1-3 days prior to removal and a trial of voiding. There is no need to keep the patient hospitalized for this as POUR can be managed on an outpatient basis.
BruceBlaus, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
The patient with POUR is typically placed on an alpha-blocker medication to decrease outlet resistance and facilitate the resumption of spontaneous voiding. Prostate relaxing medications include the following:
- Flomax (Tamsulosin)
- Uroxatral (Alfuzosin)
- Cardura (Doxazosin)
- Hytrin (Terazosin)
- Rapaflo (Silodosin)
Prevention of POUR
Anticipation is key. Men who have obstructive lower urinary tract symptoms and/or perhaps a history of prior POUR should be considered for prophylactic and peri-operative alpha blocker medication. Completing surgical procedures in as timely a fashion as possible, not overdoing it with intravenous fluids, minimizing intra-operative and post-operative opioid use, and encouraging early ambulation are helpful measures to mitigate the risk of POUR. Those who are at significantly high risk for POUR may be considered for catheter placement during the surgical procedure with continued use until fully ambulatory.
For more information on bladder catheters please see the video that I created a few years ago: Bladder catheters
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, one of the largest urology practices in the United States. He is the co-founder of PelvicRx and Private Gym. His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families.
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
Tags: Andrew Siegel MD, anesthesia, bladder, catheter, opioids, pain, post-operative urinary retention, POUR
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