Service dAnesthésie-Réanimation, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, 4 rue de la Chine, 75970 Paris cedex 20, France
*Corresponding author. E-mail: francis.bonnet@tnn.ap-hop-paris.fr
Accepted for publication: November 28, 2003
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Abstract |
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Methods. Using ultrasound, we measured the volume of the bladder contents at the time of discharge from the recovery room in 177 adult patients who had undergone thoracic, vascular, abdominal, orthopaedic or ENT surgery.
Results. Forty-four per cent of the patients had a bladder volume >500 ml and 54% of the 44%, who had no symptoms of bladder distension, were unable to void spontaneously within 30 min. The risk factors for urinary retention were age >60 yr (odds ratio (OR) 2.11, 95% confidence interval (CI) 1.014.38), spinal anaesthesia (OR 3.97, 95% CI 1.3211.89) and duration of surgery >120 min (OR 3.03, 95% CI 1.396.61).
Conclusion. Before discharge from the recovery room it seems worthwhile to systematically check the bladder volume with a portable ultrasound device in patients with risk factors.
Br J Anaesth 2004; 92: 5446
Keywords: complications, bladder distension; complications, urinary retention; complications, postoperative; monitoring, bladder ultrasound scanner
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Introduction |
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Methods |
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Data presentation and statistical analysis
The data are expressed as mean (standard deviation). For statistical analysis we used the t-test, 2-test or Fishers exact test as appropriate. The association of each potential risk factor with urinary retention was analysed by univariate and multivariate logistic regression analysis (Statview for Windows Version 5.0; SAS, Cary, NC, USA). A P-value of 0.05 or less was considered significant.
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Results |
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Discussion |
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The prevalence of bladder distension, diagnosed by traditional methods, varies widely, but, as previously mentioned, the accuracy of the diagnosis is questionable.1 3 Ultrasound allows an accurate measurement of bladder content.1 4 Rosseland and colleagues4 have recently documented a bias of 21 ml (95% CI 147 to 104 ml) when comparing ultrasound measurement with the urinary volume obtained by bladder catheterization in 39 patients. Pavlin and colleagues1 reported that, in 15 patients, the difference between ultrasound measurement and urine collection was less than 15 ml. They also pointed out that the diagnosis of bladder distension by nurses agreed with diagnosis by ultrasound in only 54% of cases. When the bladder content exceeded 500 ml, bladder stretching was experienced by only half of our patients. This is in agreement with a 56% discrepancy between ultrasound and patient evaluation of bladder content in the study of Pavlin and colleagues3 and may explain clinical underestimation of bladder distension in many previous studies and in daily clinical practice.
The prevalence of urinary retention depends on the bladder volume, the limit of tolerance and on the time allowed to void. Normal bladder capacity ranges between 400 and 600 ml. Healthy subjects usually experience the first need to void at a bladder volume of 150 ml and the urge to void at 300 ml. When the bladder does not feel full or stretched at volumes exceeding 300 ml, one can consider that micturition is abnormal. In a previous prospective study, Mulroy and colleagues5 found that urinary retention occurred when patients were unable to void at bladder volumes exceeding 400 ml, while others considered 600 ml as the bladder volume threshold:3 we chose 500 ml. The bladder volume was >500 ml in 20.5% of the patients included in the study of Pavlin and colleagues3 compared with 40.5% in the present study, but they included outpatients scheduled for shorter anaesthetic and surgical procedures. The prevalence of urinary retention was also higher in the present study (23.7%) than after ambulatory surgery (0.55%).6 An association between bladder retention and the duration of surgery has been documented1 and is confirmed by the present study. The shorter duration of surgical procedures in ambulatory surgery patients may explain the lower incidence of bladder distension.1 Longer operations may be associated with the infusion of greater amounts of fluid and with the administration of higher doses of opioid drugs; both of these factors are likely to promote urinary retention.
In this study, inability to void was experienced more frequently by patients who had spinal anaesthesia. The parasympathetic innervation of the bladder is through the pelvic nerves (S2S4), which promote detrusor contraction and bladder neck relaxation, and the pudendal nerves (S2S4), which innervate the external sphincter of the bladder. The sympathetic innervation of the bladder, from the spinal cord between T10 and L2, has an inhibitory effect on the detrusor activity and an excitatory effect on the bladder neck. Stretching of the sensory receptors located in the bladder wall activates parasympathetic and inhibits sympathetic pathways to promote micturition. After spinal anaesthesia, persisting sacral block may thus inhibit voiding, and the patients recover the ability to void normally only when anaesthesia has regressed to the second sacral segment.7 Kamphuis and colleagues7 have also demonstrated that recovery of detrusor function depends on the duration of action of the local anaesthetic, being more rapid with lidocaine than with bupivacaine. Thus, spinal anaesthesia of short duration is associated with a low prevalence of urinary retention.5
Age and certain types of surgical procedure, such as perineal surgery and inguinal hernia repair, are also considered to be risk factors for urinary retention.1 3 6 Our series of patients included too few who had such surgical procedures for us to be able to document them as risk factors, but the effect of age was confirmed.
Bladder distension and inability to void may have deleterious consequences for patients, especially if they are old.2 If bladder distension persists for some hours it may affect the function of the detrusor, resulting in decrease in muscle strength and impairment of micturition.2 It is likely that undiagnosed bladder distension may lead to urinary retention that lasts only 1 or 2 h in some patients. On the other hand, difficulties in micturition have also been observed several weeks after the surgical procedure.2 Nevertheless, the relation between new urinary symptoms and bladder distension is not clear.
In conclusion, systematic monitoring of bladder content at the end of stay in the recovery room showed a 44% incidence of bladder distension and a 23.7% incidence of at least transient urinary retention in non-ambulatory patients. These results suggest that it is worth checking for postoperative bladder content with ultrasound in the recovery room, especially in older patients and after long operations.
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References |
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2 Tammela T, Kontturi M, Lukarinen O. Postoperative urinary retention. II Micturition problems after the first catheterization. Scand J Urol Nephrol 1986; 20: 25760[ISI][Medline]
3 Pavlin JD, Pavlin EG, Gunn HC, Taraday JK, Koerschgen ME. Voiding in patients managed with or without ultrasound monitoring of bladder volume after outpatient surgery. Anesth Analg 1999; 89: 907
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5 Mulroy MF, Salinas FV, Larkin KL, Polissar NL. Ambulatory surgery patients may be discharged before voiding after short-acting spinal epidural anesthesia. Anesthesiology 2002; 97: 3159[CrossRef][ISI][Medline]
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7 Kamphuis ET, Ionescu TI, Kuipers PW, de Gier J, van Venrooij GEP, Boon TA. Recovery of storage and emptying functions of the urinary bladder after spinal anesthesia with lidocaine and with bupivacaine in men. Anesthesiology 1998; 88: 3106[ISI][Medline]