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Postoperative urinary retention

Postoperative urinary retention

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Postoperative urinary retention

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  1. Postoperative urinary retention Dr TaherehForooghifar Fellowship of pelvic floor disorders

  2. POSTOPERATIVE URINARY RETENTION (POUR): Impaired voidingafter a procedure despite a full bladder that results in anelevated postvoid residual.

  3. International Continence Society • International Urogynecological Association: Abnormally slow and/or incomplete micturition.

  4. Incidence • General surgical population: 4 to 13 percent • Cesarean with epidural anesthesia : 23 to 28 percent • Pelvic surgery range : 2 to 43 percent

  5. RISK FACTORS • Age over 50 years (double) • Concurrent neurologic disease • Administration >750 mLof intravenous fluid

  6. RISK FACTORSR • Duration of surgery >2 hours • Intraoperativeanticholinergic(atropine) • Use of regional anesthesia • Incontinence surgery and radical pelvic surgery.

  7. Women with these risk factors are counseled about the increased risk of POUR and clean intermitten catheterization.

  8. CLINICAL PRESENTATION • Slow urine stream • Straining to void • Incomplete bladder emptying • Suprapubic pressure or pain • Need to immediately re-void • Position-dependent micturition

  9. CAUSES OF POUR • Bladder (Detrusor) dysfunction • Urethral obstruction • Failure of pelvic floor relaxation

  10. Abnormal bladder function • Preexisting voiding dysfunction • Anesthetic agents • Nerve injury secondary to surgery • Cystotomy • Bladder overdistention injury • Postoperative agents used for analgesia

  11. Nerve injury after surgery Parasympathetic and sympathetic: pelvic and hypogastric plexus

  12. Cystotomy • Differentiationcystotomyfrom urinary retention: • Irrigating the bladder with 75 mL to 100 mL of sterile saline through a catheter then attempting to withdraw the same amount of fluid. • CystographyorCystoscopy

  13. Bladder overdistention injury • Acute prolonged bladder overdistention is defined as ≥120 percent of a normal bladder capacity for ≥24 hours. • Wall ischemia : 30 minutes during acute overdistention.

  14. Urethral obstruction • Mechanical • Failure of pelvic floor relaxation

  15. Mechanical • Self-limited obstruction • Sling obstruction • Urethral foreign body • Pelvic organ prolapse • Urethral injury • Constipation

  16. Mechanical (urethral) • Sling obstruction Midurethral sling or Bladder neck (fascial slings and retropubic suspensions) • Treatment: Surgical lysis of sling • We do not perform urethral dilation : increase risk of urethral mesh erosion

  17. Sling obstruction Transobturatormidurethral slings< Retropubicmidurethral slings< Burch urethropexy< Fascial slings TOT< TVT< BURCH<FASCIAL SLING

  18. Mechanical • Urethral foreign body: • Excessive sling tension • Postop transurethral dilation • Cystoscopy and Urethroscopy : Direct visualization of the eroded sling or suture

  19. Diagnosis • U/A, U/C • POST VOIDING RESIDUAL VOLUME • VOIDING TRIAL • CYSTOSCOPY • URODYNAMIC STUDY (rarely requires)

  20. PVR • There is no standardized PVR • 50 mL to 100 mL normal • >200 mLabnormal • Between 100 mL and 200 mL requires clinical correlation

  21. Voiding trials • Retrograde or spontaneous • To confirm adequate voiding and minimal PVR in patients with symptoms or risk factors for POUR

  22. VOIDING TRIALS Retrograde method : • More predictive for continued catheterization • Preferred by patients • Greater ease of use • Fewer catheterizations • Took less time

  23. Spontaneous voiding trial • Removing the catheter • Voiding until she has a strong urge or four hours have passed. • The voided volume is measured • PVR : straight catheterization or ultrasound within 15 minutes of the completed void.

  24. Voiding trial • Success is defined: • PVR = 100 mL or less or • Void two-thirds or greaterof the total bladder volume • Two voiding trials

  25. Retrograde voiding trial • The bladder is retrograde filled through the catheter with 300 mL of sterile saline or the patient says she is at maximum capacity (whichever occurs first).

  26. Retrograde voiding trial • Void of 200 mL or greater is considered successful (two- thirds of instilled volume) • Two voiding trials

  27. Fail (voiding trial) • Physical exam: • Self-limited obstruction : (CIC) until the obstructing process resolves

  28. Fail (voiding trial) • Physical exam: • No evidence of obstruction: • Discharg withCIC or indwelling catheter • Short interval (days) follow-up in the office • Retrograde voiding trial

  29. Persistent voiding dysfunction • Pelvic muscle tone • Prolapse • Incision of midurethral sling

  30. Pelvic muscle tone (passive) • Place one or two digits of your right hand 8 cm into the vagina. • Press firmly on the muscles of right and left pelvic floor • Start from muscle attachment to the pubic bone at 12 o’clock and rotate to the coccyx. • Assess for excessive/imbalanced muscle tone and pain at each pressure point.

  31. Pelvic muscle tone (contraction) • Placing your left hand lateral to the patient’s right knee • Asking her to abduct her knee into the palm of our left hand • Asymmetric muscle tone or pain (pelvic floor muscle therapy)

  32. Prolapse • Digital vaginal exam with the patient in the standing position. • Anterior or apical prolapse can cause bladder neck or urethral obstruction. • If prolapse is found pessary

  33. Incision of midurethral sling Absence of prolapse: • Over-tight incontinence sling: • Midline incision of sling • Success rates : 86 to 100%

  34. The optimal time to perform the sling transection is unclear. • Synthetic sling lysisone to three weeks post op. • Fascial sling lysisone to two months following initial surgery.

  35. Urodynamic testing • No obstruction on exam • The patient’s symptoms are inconsistent with the medical and surgical history

  36. Postoperative urodynamics • Bladder contractility • Urethral tone • Urethral obstruction

  37. Detrusorhypocontractility • Radical pelvic surgery Urodynamics does not change the treatment plan • CIC until the patient can adequately void (>6 to 8 months) • Radical hysterectomy Symptoms may never resolve

  38. Complications of untreated retention • Overdistention injury (CIC) • Detrusoroveractivity • Overactive voiding symptoms

  39. If the need for catheterization continues, CIC rather than an indwelling urethral or suprapubiccatheter is suggested (Grade 2C)

  40. Clean intermittent catheterization • CIC rather than an indwelling urethral or suprapubic catheter • Required four to six times a day and possibly once overnight • Reusable catheters can be used for up to four weeks

  41. CIC • CIC frequency is inadequate: Indwelling catheter (choice to avoid overdistention) • Lower urinary complication rates •  Systemic antimicrobial agents are not used

  42. Clean intermittent catheterization • Catheterization continues: PVRs are less than one third of the voided volume and total bladder volumes are not causing overdistention.

  43. POSTPARTUM URINARY RETENTION

  44. Postpartum urinary retention • OVERT PUR • COVERT PUR

  45. OVERT PUR • Absence of micturitionwithin six hours of vaginal delivery or removal of indwelling catheter after cesarean delivery.

  46. COVERT PUR • PVR > 150 mL • No symptom • No urge to void • Overflow incontinence

  47. Incidence • 0.7–4% of deliveries