Postoperative Bladder Dysfunction - Causes, Treatment, and Complications

Introduction

When a patient experiences postoperative urinary retention (POUR), even though their bladder is complete, it means they cannot urinate. Patients may experience severe discomfort from this, although they may not even be aware of it occasionally. POUR is not highly risky, but not identifying it can lead to problems like urinary tract infections, bladder dysfunction, and harm to surgical repair. Medical professionals can treat it quite simply, or it could result in long-term issues. The estimated occurrence ranges from 5 to 70 percent. Therefore, medical professionals must recognize and treat POUR whether a patient is at a clinic following surgery, an emergency room, or a hospital.

What Is Postoperative Bladder Dysfunction?

Postoperative urinary retention (POUR) indicates urine builds up in the bladder because it does not empty properly. POUR may occur immediately or later, and it may cause a minor issue or a major one. The patient can experience symptoms or go completely unnoticed. It might only be a temporary problem or go on for a while. The obstruction generating POUR may or may not physically obstruct the urine flow. Others monitor the amount of leftover urine after the patient urinates, while some claim it occurs when the bladder does not empty as rapidly as it should. It even occurs when the bladder does not sense the urge to adequately empty.

What Are the Causative Factors of Postoperative Bladder Dysfunction?

1. Normal Bladder Function:

Bladder function involves two main stages, filling and emptying. Sympathetic and parasympathetic nervous systems work together to control these stages. During filling, certain nerves slow down bladder muscle activity. During emptying, other nerves activate the bladder and relax muscles around the urethra.

2. Urinary Retention and Surgery:

Postoperative urinary retention (POUR) can result from surgery because it disrupts the bladder control mechanism.

3. Effects of Anesthesia and Medications:

Anesthesia and medications used during surgery can affect bladder function. Anesthesia can relax bladder muscles and interfere with nerve control. Pain medications, like opioids, impact bladder sensation and muscle function. Surgical pain can prevent the bladder from emptying properly.

4. Nerve Damage During Surgery:

Surgical procedures, especially in the pelvic area, can damage nerves that control the bladder. Special precautions are taken to protect these nerves during surgery, but POUR risk remains.

What Are the Risk Factors Associated With Postoperative Bladder Dysfunction?

Surgical Complications: Gynecologic and anorectal surgeries have a higher risk of causing POUR due to the sensitive areas involved. Anesthesia types that numb pelvic nerves, like spinal anesthesia, can contribute to POUR.

Opioid Pain Medication:

1. The use of opioid pain medication after surgery increases the chances of POUR.
2. Stronger anesthesia and specific opioids can more likely cause POUR.

Age and Sex:

1. Older women have a greater risk of POUR.
2. Gender also influences the risk, with women being more susceptible.

Bladder Problems:

Pre-existing bladder issues can raise the likelihood of POUR.

Surgical Procedures:

1. Surgeries for urinary incontinence and pelvic organ prolapse have higher POUR rates.
2. Pain medications used after these surgeries can worsen POUR risk.

Fluid Levels and Bladder Volume:

Fluid levels during surgery and bladder volume afterward affect POUR risk.

Duration of POUR:

The type of anesthesia and opioids used influence how long POUR might last.

Effect on Bladder Function:

These factors can impact bladder function after surgery, sometimes leading to urine retention.

What Are the Conditions to Be Considered in Treating POUR?

To prevent and manage postoperative urinary retention (POUR), doctors, nurses, and other medical personnel must work together as a team.

Before Surgery:

Patients more likely to experience POUR due to age, sex, kind of surgery, and pre-existing conditions should be recognized in advance.

1. POUR risk is increased by diabetes, prostate issues, and some procedures.
2. POUR risk can be decreased by using alpha-blocker drugs before surgery.

During Surgery:

1. POUR risk can increase with longer operating times and large fluid intake.
2. Surgeons ought to think about employing techniques that reduce these factors.
3. the following surgery

After Surgery:

1. After surgery, getting up and moving around can reduce the chance of POUR.
2. After surgery, taking opioids for pain management increases the risk of POUR.
3. Alternatives to opiate painkillers can help prevent the issue.

POUR Treatment:

1. The bladder needs to be emptied if POUR occurs.
2. There is disagreement over which is preferable, intermittent catheterization or a temporary tube (catheter). Each has benefits and drawbacks.
3. Alpha-blockers may be prescribed to patients to aid in bladder relaxation and emptying.
4. The situation and the patient's needs will determine which approach is best.
5. Patients may use alpha-blockers to support bladder function after catheter removal.
6. A urologist may need to be consulted if problems continue.

Voiding Trial Methods:

1. The voiding trial method may vary with complexity.
2. Two standard methods are spontaneous fill and retrograde fill.
3. Adequate bladder volume (around 300 milliliter) is essential for an accurate assessment.
4. Retrograde fill uses a catheter to fill the bladder, then removed for voiding.

Determining Voiding Trial Success:

1. Success is determined by PVR (post-void residual volume) measurement.
2. Passing criteria vary; PVR less than 100 to 200 mL is generally considered passing.
3. The percentage of total bladder volume may also be used.

Delayed POUR and Symptoms:

1. Delayed POUR can occur after leaving the hospital.
2. Symptoms include urinary hesitancy, slow stream, incomplete emptying, etc.

Bladder Drainage and Management:

1. Immediate catheterization is the first step for managing POUR.
2. Indwelling catheters can lead to increased UTI risk.
3. Clean intermittent catheterization (CIC) and suprapubic catheter (SPC) are alternatives.
4. SPC has advantages, including lower infection rates and better bladder assessment.

Discontinuing Bladder Drainage:

1. PVR measurements guide the decision to stop bladder drainage.
2. PVR levels decrease as bladder function returns.
3. PVR less than or equal to 100 mL and a voided volume of at least 200 mL are criteria for passing.

Surgical Management and Nonsurgical Options:

• Surgical options include sling stretching, sling release, partial sling resection, or urethrolysis.
• Timing for intervention should consider a spontaneous resolution timeframe (4-6 weeks).
• Nonsurgical options like medications and unconventional techniques (moxibustion, acupuncture) have been explored.

Things to Remember:

• POUR may be uncomfortable, but it can be controlled appropriately.
• POUR should not imply hospitalization; many patients can receive care at home.
• To prevent problems, POUR must be addressed.

What Are the Complications Associated With Postoperative Bladder Dysfunction?

POUR, when not managed well, can cause several problems during a hospital stay. POUR can be very painful and cause the body to react in ways that lead to vomiting, low or high blood pressure, and even heart rhythm issues.

1. Urinary Tract Infections (UTIs): POUR can make it hard to empty the bladder properly, leading to UTIs directly due to leftover urine or indirectly from using catheters.

2. Serious Bladder Distention: If POUR is not noticed or dealt with in time, it can lead to severe bladder stretching, causing changes that affect its function.

3. Harmful Effects of Prolonged Retention: If diagnosed and treated within two hours, smaller amounts of retained urine (less than 1000 mL) might not be harmful. However, if left untreated, it can cause significant issues.

4. Extended Hospital Stay: Having POUR can make a hospital stay longer. Not taking care of POUR properly can cause pain, lead to infections, make the bladder get big and not work well, and even make the hospital stay longer.

How Postoperative Bladder Dysfunction Is Prevented?

• POUR risk cannot be eliminated, but certain factors can be changed to reduce it.
• Women planning incontinence or prolapse surgery should know about the temporary POUR possibility.
• A low likelihood of prolonged retention can provide comfort.
• Patients might need catheter use and can learn CIC before surgery.
• Factors increasing POUR risk: being female, age over 50, lower body mass index, prior incontinence surgery, and advanced prolapse.
• Managing fluid levels, bladder volume, and blood loss during surgery helps lower POUR risk.
• Shorter-acting anesthetics and limited opioids can be requested to lower the risk of spinal anesthesia.
• In recovery, minimizing bladder fullness and opioids while managing pain can reduce POUR risk.
• Urodynamic tests usually cannot predict POUR, except for those with existing voiding issues, mixed incontinence, or advanced prolapse.
• Performing a standing stress test and measuring PVR before surgery is often sufficient for stress-related urinary incontinence without prior surgeries.

Conclusion

After surgery, surgeons, nurses, anesthesiologists, and others work together to treat urination problems. Doctors identify at-risk patients before surgery, educate them about the problem, and may give Tamsulosin. Fluid levels and operation time influence urination difficulties during surgery. Based on the particular technique, the type of anesthesia is selected. Nurses monitor urination after surgery, promote exercise, and use warm packs for comfort. Painkillers may make urinating issues worse. When patients have problems urinating, nurses notify doctors, who may prescribe a catheter or medicines. Chemists provide drug assistance. Urination is carefully monitored when the catheter is removed. Urine left over after a successful catheter-free trial is low. If that does not work, a urologist can be contacted.