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Postoperative urinary retention
DR TAHEREH FOROOGHIFAR
FELLOWSHIP OF PELVIC FLOOR
DISORDERS
 Postoperative urinary retention (POUR) refers to
impaired voiding after a procedure despite a full
bladder that results in an elevated postvoid residual.
 It is defined by the International Continence Society
and the International Urogynecological Association as
an “abnormally slow and/or incomplete micturition.
Incidence
 General surgical population (men and women)
4 to 13 percent
 Cesarean delivery done with epidural anesthesia
23 to 28 percent.
 Pelvic surgery range
2 to 43 percent
RISK FACTORSR
●Age over 50 years (doubles the risk of POUR)
●History of preexisting urinary retention
●Concurrent neurologic disease
●Administration >750 mL of intravenous fluid
●Duration of surgery >2 hours
●Intraoperative anticholinergic(atropine)
●Use of regional anesthesia
●History of prior pelvic surgery
●Incontinence surgery and radical pelvic surgery
 Women with these risk factors for voiding
dysfunction are counseled about the increased
risk of POUR and may be taught clean
intermittent catheterization prior to surgery.
Some risk factors can be lessened
 An indwelling bladder catheter:
epidural anesthesia
patient-controlled anesthesia
vaginal pack
 Constipation can worsen voiding dysfunction:
counseling about maintaining a bowel regimen
CLINICAL PRESENTATION
Slow urine stream
 straining to void
 feeling of incomplete bladder emptying have
 suprapubic pressure or pain the others
 need to immediately re-void
 position-dependent micturition.
poor
sensitivity ,
Specifity for
elevated PVR
CAUSES OF POUR
 Bladder (detrusor) dysfunction

Urethral obstruction

Failure of pelvic floor relaxation
Abnormal bladder function
 Preexisting voiding dysfunction
 Anesthetic agents
 Nerve injury secondary to surgery
 Cystotomy
 Bladder overdistention injury
 Postoperative agents used for analgesia
Preexisting voiding dysfunction
 Aggravate with:
Effects of anesthesia
Surgical intervention
Tissue edema, Medications
 Counseling prior to surgery:
increased risk of POUR
clean intermittent catheterization
Anesthetic agents
• Bupivacaine : seven to eight hours of neural blockade.
• Epidural ,spinal and combined spinal/epidural
Nerve injury secondary to surgery
 The main nerves at risk are:
parasympathetic and sympathetic nerves
in the pelvic and hypogastric plexus
Nerve injury after surjery
 The incidence of POUR:
hysterectomy for benign disease <
radical hysterectomy.
total hysterectomy = supracervical hysterectomy
open approach =laparoscopic approaches.
Cystotomy
 hysterectomy 0.9 to 2.9 percent.
 retropubic sling 2 to 5
percent.

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

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unable to void
void only small volumes
lack voiding sensation
suprapubic pain
elevated postvoid residual (PVR)
abdominal fullness
Cystotomy
The differentiation cystotomy from urinary retention:
 Irrigating the bladder with 75 mL to 100 mL of sterile
saline through a bladder catheter
Attempting to withdraw the same amount of fluid
 cystography or cystoscopy
Bladder overdistention injury
 The bladder is filled to volumes greater than 400
to 600 ml or greater than 120 percent of capacity.
 Ischemia and reperfusion damage to the bladder
wall
Urethral obstruction
 Mechanical
 Failure of pelvic floor relaxation
Mechanical
 Self-limited obstruction
 Sling obstruction
 Urethral foreign body
 Pelvic organ prolapse
 Urethral injury
 Constipation
Mechanical (urethral)
 Sling obstruction
compressing the midurethra (midurethral slings)
or the bladder neck (fascial slings and retropubic
suspensions)

Treatment:
Surgical lysis of sling
 We do not perform urethral dilation following
synthetic sling placement (increase the risk of urethral
mesh erosion ).
Sling obstruction
transobturator midurethral slings
retropubic midurethral slings
Burch urethropexy
fascial slings
tot< tvt< burch< fascial sling
Mechanical
 Urethral foreign body:
 Possible etiologies of urethral sling erosion
include :
excessive sling tension
postoperative transurethral dilation
 Cystoscopy and urethroscopy :
direct visualization of the eroded sling or suture
Urethral injury
Over time, foreign material in the urethra :
obstructs urine flow
stone formation
recurrent urinary tract infection
elevated PVR
 Requires surgical reconstruction of the urethra
and
removal of the causative agent.
Failure of pelvic floor relaxation
 Failure to relax the striated muscles of the urethra
and pelvic floor during normal voiding:
dysfunctional voiding can worsen after pelvic
surgery.

These women typically use abdominal
straining(Valsalva maneuver) to overcome the
urethral outlet resistance.
Diagnosis
 U/A, U/C
 POST VOIDING RESIDUAL VOLUME
 VOIDING TRIAL
 CYSTOSCOPY
 URODYNAMIC STUDY
PVR
 PVR of 50 mL to 100 mL is normal
 PVR greater than 200 mL is abnormal
 PVR between 100 mL and 200 mL requires clinical
correlation.
Diagnosis
 Voiding trials performed to confirm adequate
voiding and minimal postvoid residual (PVR) in
patients with symptoms or risk factors for
POUR.
VOIDING TRIALS
 Retrograde or spontaneous
adequate voiding and minimal PVR ?
 Retrograde method :
more predictive of need for continued
catheterization
required fewer catheterizations, and took less
time.
Spontaneous voiding trial
 Removing the bladder catheter
 Voiding until she has a strong urge to void or
four hours have passed.
 The voided volume is measured
PVR :straight catheterization or ultrasound
within 15 minutes of the completed void.
Voiding trial
 Success is typically defined:
PVR = 100 mL or less
or
The ability to void two-thirds or greater of the
total bladder volume .
(total bladder volume = voided volume + PVR).
 Two voiding trials
Retrograde voiding trial
 The bladder is retrograde filled through the catheter
with 300 mL of sterile saline or
until the patient says she is at maximum capacity
(whichever occurs first).

A void of 200 mL or greater is considered successful
(two-thirds of instilled volume).

Two voiding trials
Fail an initial retrograde voiding
trial
 physical exam
 Self-limited obstruction
continued drainage or (CIC) until the obstructing
process resolves.
 No evidence of obstruction
CIC or indwelling bladder catheter
discharg, short interval (days) follow-up in the
office.
 retrograde voiding trial in the outpatient setting.
Persistent postoperative voiding
dysfunction
 Examination of pelvic muscle tone
 Examination for prolapse
 Incision of midurethral sling
Examination of pelvic muscle tone
 Assessment of the pelvic floor tone and muscles
to confirm appropriate pelvic floor relaxation
 Significant pain or discomfort during
examination:
pelvic floor physical therapy( pelvic floor muscle
relaxation)
pelvic muscle tone (passive)
 Place one or two digits of your right hand
approximately 8 cm into the vagina.
 press firmly on the muscles of the patient’s right
pelvic floor starting with the 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.
pelvic muscle tone( contraction)
 We place our left hand lateral to the patient’s
right knee, and ask her to abduct her knee
into the palm of our left hand.
 Patients who have asymmetric muscle tone
or frank pain are referred for pelvic floor
muscle therapy.
Examination for 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 on exam
pessary
Incision of midurethral sling
 In the absence of prolapse:
over-tight incontinence sling
 Midline incision of the sling.
 Success rates : from 86 to 100 percent
Sling incision
The optimal time to perform the sling
transection is unclear.
Synthetic sling lysis one to three weeks
postoperatively
Fascial sling lysis one to two months
following initial surgery.
Role of urodynamic testing
 No obstruction on exam
 The patient’s symptoms are inconsistent
with the medical and surgical history
 Completely unable to void( a pressure-flow
study is often helpful)
 Postoperative urodynamics:
the bladder contractility, urethral tone, and
urethral obstruction.
Detrusor acontractility or
hypocontractility
 Following radical pelvic surgery
Urodynamics does not change the treatment
plan.

CIC until the patient can adequately void
(>6 to 8 months)
 In the settings of radical hysterectomy and pelvic
exenteration, the symptoms may never resolve.
COMPLICATIONS OF UNTREATED
URINARY RETENTION
 Overdistention injury (CIC)
 Detrusor overactivity
 Overactive voiding symptoms
Clean intermittent catheterization
 Low complication rates
 Systemic antimicrobial agents are not used
 Required four to six times a day and possibly
once overnight .
 Reusable catheters are also available and can be
used for up to four weeks.
Clean intermittent catheterization
 every four to six hours
or urge to void, but unable  catheterization
 If the patient is able to void a small volume, then
she is instructed to perform
self-catheterization (PVR)

the residual urine volume is <150 mL and
no longer significat symptoms 
discontinue catheterization
CIC
 If the CIC frequency is inadequate:
indwelling catheter is the treatment .
 Catheterization continues:
until PVRs are less than one-third of the TVV
total bladder volumes are not causing
overdistention.
DR TAHEREH FOROOGHIFAR
Fellowship of pelvic floor disorders
Postpartum urinary retention
 Overt PUR
Absence of micturition within six hours of
vaginal delivery or removal of an indwelling
catheter after cesarean delivery.
 Covert PUR
Post void residual bladder volume of at least
150 mL with no symptoms of urinary retention.
Ethiology
 incidence :
0.7–4% of deliveries
 injury to the pudendal nerve during labour..
Risk Factors
Epidural anesthesia
Primiparity
Instrument assisted delivery
Episiotomy
Prolonged labour
Perineal trauma
Symptoms
Asymptomatic or
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small voided volumes
urinary frequency or urgency
slow or intermittent stream
hesitancy…..
Management and treatment
 Sample of urine analysed (by dipstick) and culture
 If a urinary tract infection is suspected:
antibiotic therapy should be initiated
 The perineal exam :
swollen or painful, a catheter should be sited.
 Adequate analgesia (perineal pain)
 Constipation avoid and treatment
Postpartum warning signs
 Inability to pass urine 6 hours following delivery
 Voided volume of less than 250 ml
 Women who are symptomatic of voiding
dysfunction
Treatment of overt PUR
 Intermittent catheterization
 Routine use of antibiotics is not necessary
 Pharmacological therapies are not effective.
Clean intermittent catheterization
 every four to six hours
or urge to void, but unable  catheterization
 If the patient is able to void a small volume, then
she is instructed to perform
self-catheterization (PVR)

the residual urine volume is <150 mL and
no longer significat symptoms 
discontinue catheterization
Trial without catheter (TWOC):
 Catheter is removed from the bladder for a trial
period to determine whether patient is able to
pass urine spontaneously.
 fill bladder slowly by drinking sufficient fluid(a
glass or cupful of liquid approximately every 45-60
minutes)
 unable to pass urine, a new catheter may be
or intermittent self-catheterisation.
 Voiding dysfunction after this period requires
careful assessment, including a neurological
examination, and is treated by intermittent
self catheterisation.