Post-operative urinary retention

Question 1

You are asked to review a 72 year old man on the ward who underwent bilateral inguinal hernia repair earlier in the day. He has been unable to pass urine for the last 8 hours. Outline your management.

Answer 1

Impression
Given the anuria, this is likely a post-op urinary retention. This is a common complications after abdominal surgery which is due to bladder muscle spasm secondary to dissection around that area.

Important DDx to consider
- surgical complication with damage to ureter/bladder
- mechanical obstruction of catheter
- BPH, urothelial malignancy, prostate cancer, prostatitis
- constipation, pain, infection, anaesthetic agents
Also concerned about an AKI (pre-renal/renal)

Goals of management

• rapid A to E assessment to rule out life-threatening causes of AKI (hypovolaemic shock)
• conduct targeted Hx/Ex/Ix including a bladder scan to determine aetiology (making urine?)
• manage with conservative and active measures including uro consult,

Question 2

Post-operative urinary retention - Assessment

Answer 2

Assessment
- call for uro consult/review

A
B
C - HR, BP, assess vitals. consider fluid status with hydration status examination (?pre-renal). Bladder scan to confirm diagnosis (bladder full vs not-full). Perform decompression with in-dwelling catheter insertion. consider 2 way vs 3 way catheter (Advice from uro). continue monitoring urine output.

Question 3

Post-operative urinary retention - History

Answer 3

History

• review surgical notes, look for any reports of relevant complications, blood loss, fluid input/output
• sx: bladder fullness, lower abdo pain.
• risks: previous urinary retention: older age, loco regional abdominal surgery, anaesthetic administration,

Question 4

Post-operative urinary retention - Examination

Answer 4

Exam

• general appearance + vitals
• abdominal examination: distension, suprapubic discomfort, renal angle tenderness
• assess IDC (if in-situ)

Question 5

Post-operative urinary retention - Investigation

Answer 5

Investigations
- as per A to E, diagnostic is bladder scan (US) looking for over-filling. if empty, then concerned about AKI (pre-renal/renal causes)

• bloods: VBG, FBC, CRP/ESR, UEC
• imaging

Question 6

Post-operative urinary retention - Management

Answer 6

Management
- consult renal +/- urology

Definitive

• in bladder retention: decompression with catheter insertion and leave in overnight
• TOV next day, if failed, can be discharged with catheter in situ to be removed in the community at 1-2 weeks

Supportive

• strict fluid balance (prevent over-hydration), discuss with renal re AKI
• treat any complications of retention (hydronephrosis, post-renal AKI
• manage any electrolyte disturbances