REVIEW

URRENT C OPINION

Maintaining micturition in the perioperative period: strategies to avoid urinary retention

Stephen Choi and Imad Awad

Purpose of review Maintaining micturition in the perioperative period can be challenging because of its low profile, other competing clinical criteria, poorly defined diagnostic criteria, and varying management strategies. Postoperative urinary retention, the main complication of micturition difficulties, has clinical implications in terms of perioperative outcome such as delayed discharge, iatrogenic infection from catheterization with the potential risk of systemic infection, and possible long-term bladder dysfunction. Factors contributing to postoperative micturition problems are multifactorial and anesthesiologists should consider the strategies to minimize the incidence of postoperative urinary retention. Recent findings Several factors have been identified as increasing the risk of perioperative micturition difficulties including medical comorbidities, surgical type, anesthetic type, and within anesthetic type specific agents such as long-acting neuraxial opioids. Current literature indicates that long-term sequelae are unlikely, with bladder overdistension lasting less than 4 h. Summary Employing strategies aimed at minimizing the disruptions in bladder function can mitigate perioperative micturition problems and subsequent complications. This requires a multifactorial approach. We present identified risk factors, considerations for their modification, as well as a classification and management strategy that incorporates the literature to date. Keywords bladder distension, micturition, neuraxial anesthesia, urinary retention

INTRODUCTION
Maintaining perioperative micturition can be challenging because it is an outcome that is often underreported in relation to other more clearly defined postoperative outcomes such as surgical success, pain, cardiac morbidity/mortality, and hospital length of stay. Nonetheless, the inability to initiate micturition postoperatively herein referred to as postoperative urinary retention (POUR) can negatively affect each of these outcomes. Though it has been associated with negative outcomes, POUR itself is poorly defined with varying criteria in the literature and little data regarding long-term sequelae. Recent reviews estimated an overall incidence as low as 2.1%, but as high as 36.6% in certain subsets of patients [13]. This may be indicative of both the multiple contributors to the occurrence of POUR and the heterogeneity of the diagnostic criteria. POUR can occur when the parasympathetic outflow from dermatomes S2 to S4 is impaired pharmacologically, damaged from surgical trauma,

damaged by pathologic processes in the perineal region, or from overriding sympathetic activity from pain in the perineal region. A review by Baldini et al. [1] in 2009 thoroughly examined the pharmacology and physiology of POUR. The primary aim of this article is to discuss the clinical implications of POUR, factors associated with increased risk of POUR, and present anesthesiologists with options so that perioperative micturition can be maintained.

Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada Correspondence to Dr Stephen Choi, MD, FRCPC, Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, M3-200, 2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5. Tel: +1 416 480 4864; fax: +1 416 480 6039; e-mail: stephen.choi@sunny brook.ca Curr Opin Anesthesiol 2013, 26:361367 DOI:10.1097/ACO.0b013e32835fc8ba

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KEY POINTS
 Maintaining perioperative micturition is challenging because of its multifactorial nature, with many predisposing factors to postoperative urinary retention not in the control of anesthesiologists.  Perioperative micturition problems are poorly defined in the literature and management is heterogeneous.  The long-term implications of prolonged bladder overdistension remain poorly studied.  Long-acting, hydrophilic, neuraxial opioids increase the incidence of POUR.

trial of voiding. Clear, evidence-based recommendations suggesting when urinary catheterization is appropriate are lacking. A more rigorous and standardized definition of micturition problems was suggested by Breebaart et al. [8], though it is more labor intensive because it requires bedside ultrasound scanning (Table 1). Although these suggested classifications correlate well with the cystometric filling studies, their effects on driving intervention in the form of bladder catheterization and subsequent clinical outcome, either short or long term, remain unstudied.

CLINICAL IMPLICATION OF POSTOPERATIVE URINARY RETENTION THE HETEROGENEOUS DEFINITION OF POSTOPERATIVE URINARY RETENTION
Impaired micturition is a clinical entity that is unquestioned, with most clinicians having encountered patients who despite having the urge to void are unable to initiate micturition. This may subsequently require catheterization and result in delayed discharge from hospital. In general, the adult bladder has a cystometric capacity of approximately 400600 cc with an urge to void as early as 60% of this volume [4,5]. Afferent signals from the receptors in the bladder initiate a spinal reflex, with parasympathetic efferent signals initiating detrusor contraction and subsequent micturition. The definition of POUR in the anesthesia literature is heterogeneous and studies reporting its incidence have widely varying definitions in terms of duration without micturition and bladder volume that constitute POUR [6 ]. Though never explicitly codified, clinicians however have previously described POUR as an inability to initiate micturition with a bladder volume exceeding 500 cc [7]. Importantly, this volume exceeds the volume at which micturition is usually initiated and it provides a time frame in the postoperative period from which to allow a
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There are both indirect and direct complications of POUR resulting from either the physiologic response because of the full bladder or interventions associated with its management.

Indirect effects
The indirect effects of POUR include delayed hospital discharge as well as iatrogenic infection secondary to catheterization. POUR has resulted in prolonged hospital stay as well as delayed discharge from ambulatory procedures, resulting in higher total hospital costs [911]. Catheterization, whether indwelling or intermittent, increases the chance of infection with persistent bacteriuria after single catheterization lasting up to 6 days having been documented as well as bacteremia [12,13]. Though the incidence of both was relatively low, 21 and 8%, respectively, this should still be of concern as there is a small risk of systemic infection or colonization of prosthetic material. In a retrospective review of over 2 million patients, Wu et al. [3] reported that patients with POUR were at increased risk for urinary tract infections [odds ratio (OR) 2.3], catheter-related complications (OR 5.2), requiring

Table 1. Classification of micturition problems

No problems Minor problems Moderate problems A: Subjective difficulties in voiding or a feeling of incomplete voiding or PVRV <100 cc B: Volume >500 cc, no urge but no problems in voiding with PVRV <100 cc A: 2 minor problems with PVRV <100 cc B: Indication for single evacuation, patient able to void with difficulties within 15 min with PVRV <100 cc C: PVRV >300 cc, patient able to void with difficulties within 15 min with PVRV <100 cc Marked problems Serious problems A: PVRV 100300 cc after first micturition with subjective difficulties B: Indication for single evacuation, but voids within 15 min with PVRV 100300 cc Single evacuation necessary

Reproduced with permission from [8]. PVRV, postvoid residual volume.

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Maintaining micturition in the perioperative period Choi and Awad

home care (OR 1.3), and had a longer duration of admission (0.24 days).

Direct effects
There are direct complications that fall across the spectrum of common to rare and well defined to ill defined. Among the rare complications are the hemodynamic effects from sympathetic stimulation caused by pain from the overdistended bladder including dysrrhythmias and asystole [4]. Whereas urinary tract infection is more likely to result from catheterization, urine that is stagnant in the bladder can still result in cystitis [14]. Least studied, primarily because signs and symptoms are not readily apparent, are the urodynamic effects because of bladder ischemia from overdistension. Prolonged impairments in detrusor contractility have been demonstrated after overdistension as short as 4 h though there are no apparent lasting effects when the period of overdistension is less than 2 h [15]. Others have reported long-term bladder dysfunction and possible chronic kidney disease from longstanding POUR [16].

region resulting in sympathetic outflow inhibiting the relaxation of the urinary sphincter. It may also be a result of trauma to the pelvic floor from surgery itself or the pathologic process affecting the anatomic area [19,20]. With respect to lower limb joint arthroplasty, both age and male sex may be confounding factors as these have also been demonstrated to increase the likelihood of POUR several fold. This has been hypothesized to be because of age-related bladder dysfunction or pathology such as benign prostatic hypertrophy (BPH) [21]. Recent studies have demonstrated that among the male cohort of patients undergoing lower limb joint arthroplasty, those with more severe symptoms of BPH were at increased likelihood of developing POUR [22 ]. Other populations that may experience a higher incidence of POUR are those with pre-existing central or peripheral nervous system pathology and those with structural abnormalities in the pelvic floor from previous surgery or radiation [21].
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Modifiable risk factors

The following sections pertain to factors that are under the direct control of anesthesiologists and thus afford the opportunity to influence the incidence of POUR. Anesthetic/analgesic modality The anesthetic/analgesic modality can affect micturition via systemic effects on central cholinergic receptors or direct blockade of nerves. Systemic opioid analgesia Systemic opioid analgesia has a dose-dependent effect on the incidence of POUR. Systemic opioids exert their function in the spinal cord, blocking the parasympathetic activity of acetylcholine, resulting in decreased detrusor contractility [11]. It has been demonstrated that adjunctive medication (acetaminophen and nonsteroidal anti-inflammatories), because of opioid-sparing effects, reduces the incidence of POUR compared to patients receiving only intravenous opioid-based analgesia [4]. Neuraxial anesthesia Compared to systemic opioid analgesia, neuraxial anesthetic and analgesic techniques result in a higher incidence of POUR [1]. This occurs from sensorimotor blockade of the S2 to S4 dermatomal levels. Concomitant administration of opioids with local anesthetic in neuraxial techniques results in superior block characteristics and reduced local anesthetic dose; however, the incidence of POUR
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RISK FACTORS FOR POSTOPERATIVE URINARY RETENTION

The incidence of POUR across varied surgical populations, with different anesthetic modalities and heterogeneous definitions of POUR, is reportedly between 2.1 and 36.6%. Previously identified risk factors for POUR can be broadly defined according to those that cannot be modified versus those that can be modified by altering the practice.

Nonmodifiable risk factors

Several risk factors for POUR have been identified that are intrinsic to either patients themselves or the surgical procedure itself and therefore not amenable to modification by anesthesiologists. Though not modifiable, anesthesiologists should remain cognizant of these risk factors, monitor patients who are at higher risk of POUR in the immediate postoperative period, and consider anesthetic techniques that may minimize the incidence of POUR. Among the surgical types that consistently demonstrate higher incidences of POUR, anorectal surgery and joint arthroplasty are prominent. Those undergoing anorectal surgeries have POUR with reported incidences as high as 34% [17]. Up to 36.6% of patients undergoing lower limb joint arthroplasty experience POUR regardless of anesthetic modality [18]. In the case of anorectal surgery, POUR may reflect pain in the perineal

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is increased over that of local anesthetic alone because of the synergistic effects on the bladder. Similar to systemic opioids, short and long acting neuraxial opioids reduce the strength of detrusor contraction. Several patterns emerge when examining the specific opioid utilized and these will be discussed in the context of epidural and intrathecal techniques. Epidural The incidence of POUR when utilizing epidural anesthesia or analgesia is higher than with systemic opioids alone [1]. Because epidural local anesthetics are most often utilized as infusions, the type of local anesthetic utilized has less of an effect on developing POUR. During the infusion, many institutions have patients catheterized as a matter of protocol, therefore making it impossible to accurately determine the incidence during the infusion. Differences occur when the epidural infusion is terminated and the opioid that is co-administered with the local anesthetic influences the return of detrusor function. Patients administered any type of neuraxial opioid demonstrate higher incidences of POUR compared with only local anesthetic. In particular, patients who are administered, long-acting, hydrophilic opioids in the epidural space demonstrate a higher incidence of POUR than those administered no opioids or only short-acting opioids [6 ,23 ]. Hydrophilic opioids exert similar but prolonged effects both in terms of analgesia and inhibition of detrusor function. This suggest that if opioids are co-administered into the epidural space along with local anesthetics, shorter acting, lipophilic opioids should be utilized to decrease the incidence of POUR, particularly if there are no significant differences in their analgesic efficacy other than duration.
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local anesthetics such as lidocaine and mepivacaine [6 ,25]. Predictably, the likelihood of POUR is also dose dependent within the same local anesthetic, in which the requirement for catheterization was halved and the duration of block regression to the S2 level was reduced by 1 h by reducing the dose of intrathecal bupivacaine from 10 to 5 mg [26 ]. Furthermore, the addition of opioids to intrathecal local anesthetic, in particular long-acting hydrophilic opioids, increases the risk of POUR in a manner similar to epidural analgesia [6 ,23 ]. To reduce the incidence of POUR, anesthesiologists should consider utilizing the shortest duration and lowest dose of local anesthetic feasible along with lipophilic opioids.
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Neuraxial adjuvants other than opioids In addition to opioids, both epinephrine and clonidine have been used neuraxially to produce longer, denser blocks. Epinephrine has been demonstrated to prolong the time to first micturition primarily because of its action in prolonging the activity of local anesthetics [27]. Clonidine, an a-2 agonist, does not seem to increase the incidence of POUR when utilized in the subarachnoid or epidural space [28]. Peripheral nerve block Peripheral nerve block anesthesia and analgesia reduce the incidence of POUR compared to other anesthetic modalities [29 ]. Regardless of the surgery type, the incidence of POUR is reduced because of the opioid-sparing effect and obviating the need for central neuraxial block.
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FLUID MANAGEMENT
Varying strategies for fluid management in various surgical specialties exist. For example, in thoracic surgery, there is a tendency to restrict fluid administration to minimize lung edema. There is a similar trend in the colorectal surgery literature. The primary concern is with the surgical outcome rather than any secondary outcomes such as POUR. However, a restrictive fluid strategy may have unintended effects in terms of reducing the incidence of POUR. There are several studies suggesting that liberal fluid administration (>1000 cc) in the ambulatory setting increases the risk of bladder distension in the recovery room, which is a risk factor for POUR [30]. Obviously in the case of major surgery or significant blood loss, fluids for resuscitation should be administered as necessary, but in cases where there are minimal fluid shifts and blood loss, consideration should be given to limiting fluid administration.

Intrathecal anesthesia Similar to the epidural techniques, intrathecal anesthesia demonstrates a higher incidence of POUR when compared with systemic opioid analgesia [1]. Because intrathecal local anesthetics block conduction at sacral nerve roots and sensorimotor function of the bladder is impaired until the block resolves to the S2 level, the duration of dysfunction necessarily depends on the pharmacologic duration of the local anesthetic injected. After bupivacaine anesthesia, detrusor dysfunction persists up to 3.5 h after resolution of the sensory block [24]. Indeed, it has been clearly demonstrated that the incidence of POUR increases as local anesthetics of greater potency and longer duration, such as tetracaine and bupivacaine, are employed over shorter acting

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Maintaining micturition in the perioperative period Choi and Awad

MONITORING PATIENTS FOR PROBLEMS WITH MICTURITION

The following is a strategy for monitoring inpatients adapted from the classification system developed by Breebaart et al. [8] (Fig. 1). It incorporates known cystometric capacities as well as studies that have determined when bladder damage from overdistension occurs. The principle goal is to prevent the bladder overdistension from lasting longer than 4 h. Readers should refer the recent article by Mulroy and Alley [31 ] for an outpatient management strategy. Patients should void prior to all surgical procedures. For postoperative patients without urinary catheters, a trial of voiding should be performed prior to any catheterization. Bladder volume should be assessed by ultrasound 4 h postoperatively or 4 h following the removal of an indwelling catheter. If a patient is unable to void and has a bladder volume of greater than 500 cc by ultrasound, the approximate cystometric capacity, single catheterization should be performed. The patient should then be monitored on the subsequent voiding attempt. Once the patient successfully voids for the first time, the postvoid residual volume (PVRV) should be assessed. If the PVRV is greater than 300 cc, the bladder should be scanned again in 2 h to ensure the bladder volume is not greater than 500 cc. If the volume is greater than 500 cc, the patient should be catheterized again if unable to void spontaneously. If however, the PVRV is less than 100 cc, monitoring can be discontinued.
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Patients with a long surgical duration (>4 h), extensive fluid shifts, or postoperative epidural infusion for analgesia should have indwelling urinary catheters. When the urinary catheter is removed on the postoperative ward, after discontinuation of the epidural, the above strategy should be employed.

PHARMACOLOGIC INTERVENTIONS
Several studies have attempted to use selective a-1 adrenergic receptor blocking agents utilized in patients with BPH to decrease the incidence of POUR. A recent Cochrane review that included 230 patients determined that there was no benefit a-1 adrenergic receptor blocking agent prazosin [16]. This review did find a mild association between administration of cholinergic agents concomitantly with the sedatives and spontaneous voiding [relative risk (RR) 1.39], as well as intravesicular administration of prostaglandins (RR 3.07) [16]. Tamsulosin, a more selective a-1 blocking agent, has recently been investigated. Two contemporary randomized trials comparing tamsulosin to placebo reported different conclusions [32,33]. One study of 80 patients demonstrated a significant reduction in POUR (absolute risk difference of 12.5%, P 0.04) [33], the other study of 94 patients did not (absolute risk difference of 2.1%, P 0.80) [32]. Although this might be a result of differing doses of tamsulosin (0.4 vs. 0.2 mg), the evidence for a-1 adrenergic receptor blocking agents is still equivocal.

Assess bladder volume with US 4 h after removal of indwelling urinary catheter or 4 h after surgery if no catheter

Unable to void

Able to void

US bladder

US bladder

> 500cc

< 500cc

PVRV 100 300cc

PVRV < 100cc

Single evacuation

Rescan 2 h

Next void

Discontinue monitoring

FIGURE 1. Suggested algorithm for inpatients. PVRV, postvoid residual volume; US, ultrasound.

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Conversely, a-2 receptor agonists such as clonidine or dexmedetomidine, which stimulate urinary production, have no demonstrated effect on the incidence of urinary retention in the current literature [28,3437]. Currently, pharmacologic options, either by administering or omitting, have limited demonstrable effect in decreasing POUR and resultant catheterization.

CONCLUSION
Maintaining micturition in the perioperative period can be challenging for several reasons. Firstly, as a perioperative outcome it is often an afterthought to many other outcomes except when it impairs discharge. Secondly, POUR, the result of an inability to micturate, is poorly defined and its clinical implications, particularly those that are long term, are not immediately apparent. Thirdly, strategies to maintain micturition, such as restricting fluid administration, catheterization, changing medications, and frequent monitoring, may have competing interests with other concerns such as surgical/anesthetic outcomes, analgesia, and nursing workload. This does not absolve clinicians of the need to consider strategies to maintain perioperative micturition. In patients who are at high risk of POUR (high-risk surgeries, medications known to cause POUR, analgesic regimens known to increase POUR, or structural abnormalities such as BPH), the strategies presented above should be considered and utilized as the clinical situation permits. Furthermore, utilizing bladder ultrasound for micturition problems in these high-risk patients should be employed and drainage should be instituted if greater than 4 h of overdistension is imminent to prevent chronic detrusor damage. Acknowledgements None. Conflicts of interest There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 398399). 1. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009; 110: 11391157. 2. Hansen BS, Soreide E, Warland AM, Nilsen OB. Risk factors of postoperative urinary retention in hospitalised patients. Acta Anaesthesiol Scand 2011; 55:545548.

3. Wu AK, Auerbach AD, Aaronson DS. National incidence and outcomes of postoperative urinary retention in the Surgical Care Improvement Project. Am J Surg 2012; 204:167171. 4. Kamphuis ET, Ionescu TI, Kuipers PW, et al. Recovery of storage and emptying functions of the urinary bladder after spinal anesthesia with lidocaine and with bupivacaine in men. Anesthesiology 1998; 88:310 316. 5. Wyndaele JJ. The normal pattern of perception of bladder lling during cystometry studied in 38 young healthy volunteers. J Urol 1998; 160: 479481. 6. Choi S, Mahon P, Awad IT. Neuraxial anesthesia and bladder dysfunction in & the perioperative period: a systematic review. Can J Anaesth 2012; 59:681 703. This systematic review specically addresses the issue of POUR in relation to neuraxial anesthesia. It identies the heterogeneous denition and demonstrates that administration of hydrophilic opioids greatly increases the incidence of POUR. 7. Kaplan SA, Wein AJ, Staskin DR, et al. 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29. Balderi T, Mistraletti G, DAngelo E, Carli F. Incidence of postoperative urinary retention (POUR) after joint arthroplasty and management using ultrasoundguided bladder catheterization. Minerva Anestesiol 2011; 77:1050 1057. This is the rst trial, in which the primary outcome is POUR, demonstrating peripheral nerve block analgesia decisively reduces the incidence of POUR. 30. Dal Mago AJ, Helayel PE, Bianchini E, et al. Prevalence and predictive factors of urinary retention assessed by ultrasound in the immediate postanesthetic period. Rev Bras Anestesiol 2010; 60:383390. 31. Mulroy MF, Alley EA. Management of bladder volumes when using neuraxial & anesthesia. Int Anesthesiol Clin 2012; 50:101110. A clear, focused review with a management strategy for POUR after neuraxial anesthesia in ambulatory surgery. 32. Jang JH, Kang SB, Lee SM, et al. Randomized controlled trial of tamsulosin for prevention of acute voiding difculty after rectal cancer surgery. World J Surg 2012; 36:27302737.
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33. Mohammadi-Fallah M, Hamedanchi S, Tayyebi-Azar A. Preventive effect of tamsulosin on postoperative urinary retention. Korean J Urol 2012; 53:419 423. 34. Carabine UA, Milligan KR, Mulholland D, Moore J. Extradural clonidine infusions for analgesia after total hip replacement. Br J Anaesth 1992; 68: 338343. 35. Jellish WS, Abodeely A, Fluder EM, Shea J. The effect of spinal bupivacaine in combination with either epidural clonidine and/or 0.5% bupivacaine administered at the incision site on postoperative outcome in patients undergoing lumbar laminectomy. Anesth Analg 2003; 96:874880. 36. Niyogi S, Santra S, Chakraborty J, et al. A comparative study of duration of postoperative analgesia between epidural bupivacaine and epidural clonidine plus bupivacaine in lumbar laminectomy surgery under general anaesthesia. J Indian Med Assoc 2011; 109:230233. 37. Vandermeulen E. Systemic analgesia and co-analgesia. Acta Anaesthesiol Belg 2006; 57:113120.

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