Effects of Analgesic and Anesthetic Medications on Lower Urinary Tract Function Sammy E

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Effects of Analgesic and Anesthetic Medications on Lower Urinary Tract Function Sammy E. Elsamra and Pamela Ellsworth

he lower urinary tract (LUT), which consists of © 2012 Society of Urologic Nurses and Associates the bladder, urethra, and Ellsworth, P., & Elsamra, S.E. (2012). Effects of analgesic and anesthetic medica- urinary sphincter, serves tions on lower urinary tract function. Urologic Nursing, 32(2), 60-68. Tto allow for the functional storage and elimination of urine. This Analgesic and anesthetic medications may affect lower urinary tract function via complex process is orchestrated a variety of mechanisms. This article reviews the more commonly used medications and their effects on lower urinary tract function. by reflexive neural pathways (which are under control from Key Words: Anesthetic, opioid, ketamine, lower urinary tract function, higher centers) that allow for the urinary retention, analgesia. coordination of bladder and sphincter. The impact of anesthet- Objectives: ics, general or regional, on this 1. Discuss the physiology of micturition. complex neural network may affect this delicate control and 2. Explain the effects of analgesics on the lower urinary tract. may result in urinary retention. 3. Describe the effects of general anesthesia on the lower urinary tract. Although the association between the use of certain medications and the occurrence of acute urinary Physiology of Micturition that converges to form a thickened retention is well established, the association is poorly defined Storage and voiding involves bladder neck controlled by the (Thomas, Chow, & Kirby, 2004). complex interactions between the autonomic nervous system, and a Limited information is available bladder, urethra, urethral sphinc- somatically controlled external regarding the effects of analgesic ter, and nervous system. The uri- component (striated muscle), and anesthetic medications on the nary bladder and urinary sphinc- must relax to allow for the con- LUT. This article provides a sum- ter are the principle components tracting bladder to expel its load. mary of the current available liter- of the LUT responsible for urinary Storage of urine is achieved by ature on the effects of non- storage and voiding. The urinary bladder relaxation and contrac- steroidal, anti-inflammatory drugs bladder, with a typical adult tion of both the bladder neck (NSAIDs); opiates; and spinal capacity of 400 to 500 ml, serves (internal urinary sphincter) and anesthetics on LUT function. to store or expel urine by way of the external urinary sphincter. relaxation or contraction of the Micturition occurs when the blad- detrusor muscle, respectively. The der neck and the external urinary Sammy E. Elsamra, MD, is a Resident, urinary sphincter, composed of an sphincter relax and the bladder Division of Urology, Alpert Medical School, internal component, a continua- contracts, allowing for the unob- Brown Medical School, Providence, RI. tion of detrusor smooth muscle structed expulsion of urine. Pamela Ellsworth, MD, FAAP, FACS, is an Associate Professor of Urology (Surgery) and Pediatrics, Alpert Medical School, Urologic Nursing Editorial Board Statements of Disclosure Brown University, Providence, RI. In accordance with ANCC-COA governing rules Urologic Nursing Editorial Board state- Note: Objectives and CNE Evaluation Form ments of disclosure are published with each CNE offering. The statements of disclosure for appear on page 68. this offering are published below. Statement of Disclosure: The authors Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants’ reported no actual or potential conflict of Bureau for Coloplast. interest in relation to this continuing nursing All other Urologic Nursing Editorial Board members reported no actual or potential education activity. conflict of interest in relation to this continuing nursing education activity.

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Bladder storage and emptying, Figure 1. as well as coordinated contraction Neurologic Pathways Involved in Lower Urinary Tract Function or relaxation of the urinary sphincter, are under the control of the sympathetic, parasympathetic, Stimulates and somatic nervous systems Cerebrum (Ouslander, 2004). In general, uri- Inhibits nary storage is a function of the PONS sympathetic nervous system, whereas micturition is a function of the parasympathetic nervous system. While both are autonomic Sympathetic — Hypogastric Nerve functions in nature, the somatic rusor Musc nervous system is responsible for Det le the control of the external urinary sphincter, allowing for volitional continence. As seen in Figure 1, storage of urine (bladder relaxation and internal sphincter contraction) is under sympathetic Internal Spinal Cord T10-L2 S1-S4 Sphincter control via impulses transmitted Parasympathetic — Pelvic Nerve through the hypogastric nerve. External Sphincter Somatic — Pudendal Nerve The pelvic nerve is the principle Urethra conduit of the parasympathetic input for the LUT and allows for coordinated voiding by stimulat- Description: The function of the lower urinary tract is under the control of several ing bladder contraction with neurologic pathways. The sympathetic nervous system allows for bladder relaxation sphincter relaxation. The somatic and internal sphincter contraction. This is mediated through the hypogastric nerve, nervous system, through the and these signals originate from the spinal cord at levels T10-L2. The parasympa- pudendal nerve (and to a small thetic system allows for bladder contraction and internal sphincter relaxation. This is mediated through the pelvic nerve, and these signals originate from the spinal degree the pelvic nerve), allows cord levels at S2-S4. The somatic (voluntary) system allows for the control of the for the contraction or relaxation of external sphincter. All three of these systems are part of reflex pathways (not the external urinary sphincter depicted in this illustration) and are under the influence of upper neurologic control (striated pelvic diaphragm muscle (cerebrum and pons micturition center in the cerebellum). under voluntary control). These nerves are lower motor neurons and are under the control of spinal reflexes and upper motor neuron Sturkenboom, Stricker, & Bosch, Bladder Filling/Storage input from the central nervous 2008). Bladder filling/storage is reg- system (Ouslander, 2004). External sphincter motor neu- ulated by two separate storage Storage of urine is primarily a rons originate from Onuf’s nucle- reflexes – the sympathetic (auto- sympathetic and somatic func- us, located on the anterior horns of nomic) reflex and the somatic tion. Sympathetic input to the the sacral spinal cord at levels S2- reflex (Thor & Donatucci, 2004). LUT is mediated through stimu- S4, and send their axons into the The sympathetic-mediated stor- lation of adrenergic receptors. pudendal nerve (and to a lesser age reflex is involved with blad- The stimulation of alpha-1 adren - degree, the pelvic nerve) that stim- der filling and is mediated by ergic receptors at the bladder ulate the striated muscle to con- myelinated A-delta fibers. Affer- neck by post-ganglionic norepi- tract via the release of acetyl- ent activity travels in the pelvic nephrine results in bladder neck choline (Darrah, Griebling, & nerves to the spinal cord. At the contraction. The sympathetic Silverstein, 2009; deGroat, 2006). L1-L3 level, sympathetic activity nervous system also inhibits This acetylcholine then binds to is initiated, which leads to a parasympathetic input into the post-junctional nicotinic recep- decrease in excitatory parasym- bladder, thus inhibiting stimula- tors, resulting in contraction of pathetic stimulation of the blad- tory signals from reaching the the external sphincter. Both der. Postganglionic neurons re- detrusor. Further, stimulation of alpha-receptors and serotonin 5- lease noradrenaline, which binds beta-3-adrenergic receptors with HT2 receptors are located in to beta-adrenoreceptors in the norepinephrine, as shown in ani- Onuf’s nucleus and facilitate the detrusor, leading to detrusor mal models, allows for relaxation storage reflex (Verhamme et al., relaxation (Andersson, 2007). of the detrusor (Verhamme, 2008).

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The somatic storage reflex, post-operative use of opioid anal- capacity and compliance follow- often referred to as the “guarding gesia, and the administration of ing intravenous (IV) and intra- reflex,” occurs in response to large volumes [greater than 500 thecal injections of tramadol. In sudden increases in intra-abdom- ml] of perioperative intravenous humans, similar results on blad- inal pressure. In this reflex, affer- fluids) (Koch, Grinberg, & Farley, der capacity and compliance ent activity travels along the 2006). Further, the use of orally have been noted, with a reported myelinated A-delta fibers in the ingested opioids in patients out- increase in bladder capacity pelvic nerve to the sacral spinal side of the peri-operative setting varying from 20% to 65% cord, where efferent somatic ure- has been shown to result in depending on the opioid, dose, thral motor neurons in Onuf’s increased rates of urinary reten- patient group, and route of nucleus are located. Afferent tion (Meyboom, Brodie-Meijer, administration (Dray, 1988; activity is also relayed to the Diemont, & van Puijenbroek, Kuipers et al., 2004; Malinovsky periaqueductal gray (PAG) region 1999). Other risk factors include et al., 1998). and then on to the pontine mic- underlying detrusor dysfunction Studies suggest that the half- turition center (PMC). The PMC or bladder outlet obstruction. life of the opioid used has an sends impulses to motor neurons The effect of analgesics, both nar- impact on urinary function and in Onuf’s nucleus, and axons cotic and non-narcotic, and of risk of retention. One study found from these neurons travel in the anesthetics on the LUT will now that meperidine, an opioid with a pudendal nerve and stimulate be discussed. relatively long half-life, use was an the rhabdosphincter to contract independent predictor of difficul- (Andersson, 2007). ty voiding after elective cholecys- Analgesics tectomy (Kulacoglu, Dener, & Bladder Emptying Kama, 2001). In contrast, studies Studies in cats and rats indi- Opioids that evaluated orthopedic pa tients cate that the voiding reflex Opioids are products, both who received fentanyl (short half- involves the PMC as well as other natural and synthetic, that bind life) for post-operative analgesia regions in the brain, including to opioid receptors and result in noted that these pa tients experi- the hypothalamus and the cere- analgesia. Morphine is common- enced significantly less risk for bral cortex (Griffiths, 2004; ly used in the post-operative urinary retention than those who Griffiths, Derbyshire, Stenger, & period for analgesia and is a well- received morphine (intermediate Resnick, 2005; Holstege, 2005). known risk factor for POUR. The half-life) (Gallo, Durand, & Pshon, The PAG receives afferent activi- treatment of pain with opiates or 2008). Thus, the half-life of the ty from the bladder as well as its analogues decreases the sen- narcotic may affect the risk for from the cerebral cortex and sation of bladder fullness by par- POUR; however, no prospective, hypothalamus. This activity is tially inhibiting the parasympa- comparative studies have been integrated in the PAG and PMC. thetic nerves that innervate the performed. The PMC controls the descend- bladder. In addition, opiates have The mode of opioid delivery ing pathways involved in the been shown to increase the appears to also play a role in the micturition reflex, activating or sphincter tone of the urinary risk of urinary retention (Chaney, inhibiting the parasympathetic bladder via sympathetic over- 1995; Petros, Mallen, Howe, pathways depending on the level stimulation, resulting in in- Rimm, & Robillard, 1993; Petros, of activity in the afferent fibers creased bladder outlet resistance Rimm, & Robillard, 1992). While, (Andersson, 2007). (Durant & Yaksh, 1988). The orally ingested opioids have been combination of decreased sensa- associated with an increased risk tion of fullness and increased of urinary retention, the risk of Effects of Analgesics on the Lower outlet resistance may increase POUR is higher with intravenous Urinary Tract the risk of urinary retention. (IV) and epidural administration LUT function is complex, Further, animal and human stud- (Dolin & Cashman, 2005). A and the addition of medications ies have shown that intravenous recent systematic review studied to this intricate physiologic bal- morphine directly binds to the occurrence of adverse effects ance may result in LUT dysfunc- spinal opioid receptors and (nausea, vomiting, sedation, pru- tion. Post-operative urinary re- results in total bladder relaxation ritis, and urinary retention) relat- ten tion (POUR) has been report- rather than having targeted ed to post-operative pain man- ed to occur in 6% to 50% of pa- effects on the detrusor alone agement. Three analgesic tech- tients (Malinovsky et al., 1998). (Chen, Shen, & Pan, 2005), and niques were compared: intra- Many surgically related risk fac- has been reported with epidural muscular (IM) analgesia, patient- tors for POUR have been de- anesthesia (Malinovsky et al., controlled analgesia (PCA), and scribed (type of anesthesia used, 1998). Animal studies have epidural analgesia. Overall, uri- duration and location of surgery, demonstrated increased bladder nary retention occurred in 23%

62 UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 SERIES of all patients, and the frequency sensations and may delay the sis, Remy, Marret, and Bonnet was highest for the epidural micturition threshold, thus in - (2005) showed that morphine use group at 29% (Dolin & Cashman, creasing compliance and bladder can be reduced significantly by 2005). capacity. Furthermore, a direct the combination of acetamino- Several authors have demon- effect of opioid receptor activa- phen and morphine; however, strated that the risk of retention is tion at the sacral parasympathet- there was no effect in the inci- increased in patients using PCA ic innervations also im proves dence of morphine-related side compared to those receiving compliance (Drenger, Magora, effects, including urinary reten- intermittent IV or IM opioids Evron, & Caine, 1986). tion. Another recent meta-analy- (Petros et al., 1992, 1993). The The role of opioid antidotes sis demonstrated that while the highest rates of opioid-mediated has been assessed in the manage- addition of NSAIDs to PCA may urinary retention have generally ment of opioid-related urinary decrease nausea and vomiting, been associated with epidural retention. Opioid-mediated de- the risk of urinary retention, pru- administration (Darrah et al., pression of bladder motility is ritis, and respiratory depression 2009). A meta-analysis of 12,513 largely secondary to action at the was not significantly reduced patients found that the use of mu-opioid receptor, and can be (Marret, Kurdi, Zufferey, & epidural anesthesia for post- reversed by intravenous nalox- Bonnett, 2005). Similarly, a third operative pain control was asso- one (Narcan®), which results in meta-analysis concluded that ciated with urinary retention in the promotion of detrusor con- while the concurrent use of COX- nearly 25% of patients, a signifi- traction and sphincter relaxation. 2 inhibitors reduced opioid con- cant increase over the rate found Small doses of IV naloxone (0.1 sumption by 35%, as well as in patients receiving IM or PCA mg) have been shown to decrease decreased the risks of associated (Darrah et al., 2009; Dolin & bladder distention without re - nausea, vomiting, pruritis, and Cashman, 2005). A meta-analysis versing analgesia (Gallo et al., constipation, there was no of patients undergoing colorectal 2008; Wren, 1996). decrease in the risk of acute uri- surgery found that the incidence Naloxone, an antidote to nary retention (Romsing, of urinary retention increased morphine and its analogues, has Moiniche, Mathiesen, & Dahl, from 1% to 10% when patients been tested for the treatment of 2005). received epidural anesthesia urinary retention after epidural instead of parenteral opioids and intrathecal anesthesia. Al - NSAIDs (Darrah et al., 2009; Marret, though naloxone was found to be NSAIDs are commonly used Remy, & Bonnet – Postoperative very effective in reversing uri- in surgical and nonsurgical set- Pain Forum Group, 2007). nary retention, it also reversed tings. Pharmacologically, NSAIDs An imal studies have demon- the analgesic effect, and thus, inhibit the metabolism of arachi- strated that opioid mu-receptors was not recommended for the donic acid to prostaglandins and are concentrated in the dorsal treatment of POUR (Rawal, thromboxanes by cycloxegenase horn of the spinal cord, where Mollefors, Axelsson, Lingardh, & (COX)-1 and 2. Prostaglandins, the bladder afferents merge Widman, 1981; Verhamme et al., especially prostaglandin E 2 (Coggeshall & Carlton, 1997; 2008). In fact, low dose naloxone (PGE2), play an important role in Singh, Agarwal, Batra, Kishore, & in the treatment of urinary reten- LUT function. PGE2 is up-regu- Mandal, 2008). Delta and kappa tion during extradural fentanyl lated within the bladder as a receptors are also present, but in (Actiq®, Fentora™, Duragesic®) result of bladder inflammation, lower concentrations. Both mu use resulted in excessive reversal trauma, or over distention. PGE2 and delta (but not kappa) recep- of analgesia (Wang, Pennefather, stimulates the release of ta- tors are involved in bladder real- & Russel, 1993). However, nal- chykinins, which stimulate neu- ization and impaired sensations buphine, another opioid receptor rokinin receptors on afferent by inhibiting the sensory input at inhibitor, appears to be effective nerves and the detrusor smooth the level of the dorsal horn and in reversing urinary retention muscle and as a result promote PAG. This is supported by the without compromising the anal- detrusor contraction (Andersson absence of such action by non- gesic effect (Verhamme et al., & Hedlund, 2002; Verhamme et mu-agonist opioids (such as nal- 2008), although further studies al., 2008). buphine [Nubain®] [kappa ago- are warranted. One recent study discovered nist and mu antagonist] or penta- In an effort to decrease the that NSAID users have a two-fold zocine [Talwin®] [kappa and effects of opioids on the LUT, increased risk of acute urinary delta agonist]) (Malinovsky et al., studies have evaluated whether a retention (Verhamme et al., 1998; Singh et al., 2008). The decrease in the dose of opioid 2005). Similar outcomes were inhibition of bladder afferents at administered (by combining with seen even with COX-2 specific the dorsal horn via mu-receptor NSAIDs) results in a decreased inhibitors because there have activation diminishes bladder risk of POUR. In one meta-analy- been reports of acute urinary re-

UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 63 SERIES tention that occurred within one general anesthesia (pre-medica- the bladder volume to signifi- week of starting such medication or reversal of neuromuscular cantly exceed preoperative blad- tions (Gruenenfelder, McGuire, & blockade) on the LUT, has been der capacity. This over-distention Faerber, 2002). By inhibiting the evaluated. Glycopyrrolate (Rob- can impair voiding function COX-2, PGE2, and tachykinin/ inul®) and atropine, two agents (Darrah et al., 2009; Kamphuis et neurokinin pathway, NSAIDs used for preventing bradycardia, al., 1998). may decrease bladder contractili- do not appear to affect the inci- The effect of neuraxial opi- ty (Andersson & Hedlund, 2002; dence of urinary retention (Orko oids on voiding function may Darrah et al., 2009). & Rosenberg, 1984). Sympatho - reflect peripheral, spinal, or The effect of NSAIDs on uri- mimetic agents used to treat supraspinal activity. Healthy vol- nary retention may be dose-spe- intraoperative hypotension can unteers given intrathecal mor- cific. Verhamme et al. (2005) increase the risk of urinary reten- phine or sufentanil (Transdur®) studied the association between tion as a result of their effects on demonstrate impaired bladder NSAIDs and acute urinary reten- beta-adrenergic receptors in the contraction within 15 to 60 min- tion and found the risk of acute bladder and alpha-adrenergic utes (Kuipers et al., 2004). The urinary retention increased with receptors in the bladder neck and rapid onset suggests that intra - higher doses of NSAIDs. proximal urethra. In patients thecal opioids affect micturition treated with ephedrine, a statisti- primarily by inhibiting the spinal cally significant increase in reflex responsible for detrusor General Anesthetics retention to 43.8% was noted contraction. A primary lumbar- General anesthetics cause (Darrah et al., 2009; Olsen & spinal site of action is also sup- decreased bladder contractility Nielsen, 2007). ported by the increased inci- by acting as smooth muscle dence of urinary retention associ- relaxants. They also interfere ated with lumbar compared with Neuraxial Anesthesia with autonomic regulation of thoracic epidurals (Basse, detrusor tone (Darrah et al., Intrathecal local anesthetics, Werner, & Kehlet, 2000). Intra- 2009). Some anesthetics substan- spinal or epidural administered, thecal opioids depress pregan- tially increase bladder capacity are techniques in regional anes- glionic neurons in the sacral (Darrah et al., 2009; Doyle & thesia that depend on the instil- parasympathetic nucleus, de - Briscoe, 1976). In vitro work with lation of nerve-blocking agents creasing pelvic nerve activity. isolated human bladder strips with or without analgesics into They also activate gamma, mu, demonstrated that clinical doses the epidural space and interrupt and delta receptors in the dorsal of halothane (Fluothane®) and afferent and efferent nerve im- horn of the spinal cord, inhibit- thiopentone (Trapanal®) decrease pulses from and to that region’s ing bladder afferents and the response of the bladder to nerve supply. Two main bladder decreasing bladder sensation. As cholinergic stimulation (Doyle & considerations are the inhibition a result, bladder capacity and Briscoe, 1976). Petros, Rimm, of the afferent and efferent fibers compliance are increased, and Robillard, and Argy (1991) noted as they enter and exit the spinal the initiation of the micturition that patients undergoing inguinal cord that are a part of the micturi- reflex is delayed (Dray, 1988). herniorrhaphy under general tion reflex arc and the inhibition The liphophilicity of intra the - anesthesia with halothane, a of the upward relaying of these cal opioids affects POUR. Uro - potent smooth muscle relaxant, signals to higher centers (PMC) dynamic studies have demon- had a significantly higher rate of within the spinal cord (Darrah et strated that hydrophilic opioids, urinary retention compared with al., 2009; Kamphuis et al., 1998). such as morphine, adversely similar cases performed via a Blockade of afferent nerves affect bladder function to a greater lidocaine (Lidoderm®) spinal results in bladder analgesia, degree than more lipophilic opi- anesthetic. Furthermore, seda- while lack of transmission in oids (such as sufentanil). En - tive-hypnotics and volatile anes- efferent fibers causes a detrusor hanced systemic uptake of thetics inhibit the PMC and vol- blockade that outlasts motor lipophilic agents limits local untary cortical control of the blockade by as much as several activity at the sacral level, which bladder, suppressing detrusor hours. Most patients will be inca- accounts for the difference contraction and the micturition pable of spontaneous voiding (Baldini, Bagry, Aprikian, & Carli, reflex (Combrisson, Robain, & until the sensory level has 2009; Kuipers et al., 2004). In a Cotard, 1993; Darrah et al., 2009; regressed to the S3 level (Darrah prospective double-blinded, ran- Matsuura & Downie, 2000). et al., 2009; Kamphuis et al., domized, placebo-controlled trial, The urodynamic effect of 1998). The use of longer-acting sufentanil was associated with a volatile anesthetics and sedative- local anesthetics for spinal injec- lower risk of POUR compared to hypnotics, when combined with tion results in a duration of morphine (Kim et al., 2006). other agents commonly used for detrusor blockade sufficient for Many authors have identi-

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Table 1. Summary of Medications and the Effect on the Lower Urinary Ttract

Class of Risk of Urinary Medication Retention Mechanism of Effect on Lower Urinary Tract 1. Decreases the sensation of bladder fullness by partially inhibiting the parasympathetic nerves that innervate the bladder. 2. Increase the tonus of the sphincter of the urinary bladder via sympathetic over- Opiods Increases stimulation, resulting in increased resistance in the outflow tract from the bladder. 3. Intravenous morphine directly binds to spinal opioid receptors and causes total bladder relaxation rather than having targeted effects on the detrusor alone. Inhibit the production of PGE2. (PGE2 stimulates the release of tachykinins, which NSAIDs Increases stimulate neurokinin receptors on afferent nerves and detrusor smooth muscle, and as a result, promote detrusor contraction.) General 1. Smooth muscle relaxant. Increases Anesthetics 2. Interfere with autonomic regulation of detrusor tone. 1. Inhibition of the afferent and efferent fibers as they enter and exit the spinal cord Neuraxial (part of the micturition reflex arc). Increases Anesthetics 2. Inhibition of the up-ward relaying of these signals to higher centers (PMC) within the spinal cord. Unclear mechanism; 80% with overactive bladder, causes irreversible irritative Ketamine Decreases eosinophilic ulcerative cystitis.

fied an association between were limited to 200 ml +/- 2 Ilstrup, 1998). Injury to the pelvic spinal anesthesia with long-act- ml/kg/hour of Lactated Ringers nerves and pain evoked reflex ing local anesthetics and POUR. (Kau et al., 2003). increase in the tone of the inter- Ryan, Adye, Jolly, and Mulroy Patients undergoing lumbar nal sphincter and are thought to (1984) demonstrated a decrease spinal surgery experience in - account for the high incidence of in the need for catheterization creased rates of POUR when POUR in patients undergoing among patients undergoing her- intrathecal local anesthetics are anorectal surgery (Benoist et al., nio rrhaphy with lidocaine spinal administered with opioids. The 1999; Cataldo & Senagore, 1991; anesthesia (6%) compared to bu- addition of fentanyl to spinal Hojo, Vernava, Sugihara, & piv a caine (Marcaine®, Sensor- anesthesia and the choice of Katumata, 1991). The duration of caine®) or tetracaine (Ponto caine®, spinal over epidural anesthesia spinal and epidural anesthesia Dicaine®) (30%). In another study, were found to significantly can affect how long it takes to two of 201 ambulatory patients increase time to discharge of void postoperatively. Longer receiving short-acting epidural or ambulatory surgical patents operations may increase the risk spinal anesthesia developed uri- (Mulroy et al., 2002). Local anes- of urinary retention because nary retention (Mulroy, Salinas, thesia does not affect bladder more IV fluids may be adminis- Larkin, & Polissar, 2002). function and is associated with a tered or higher total doses of opi- In male patients undergoing lower incidence of POUR than oids and anesthetic agents may inguinal herniorrhaphy, the risk neuraxial or general anesthesia. be used (Darrah et al., 2009; of POUR was greater after spinal A review of 72 studies found that Wynd, Wallace, & Smith, 1996). anesthesia than epidural anes- urinary retention occurred in thesia (Faas et al., 2002). Other only 0.37% of patients undergo- Ketamine factors in addition to local anes- ing hernia repair when local thetic dose and duration of anesthesia was used, as opposed Ketamine is an anesthetic action may affect the likelihood to an incidence of 2.42% with commonly used in pediatric and of neuraxial anesthesia-related regional anesthesia and 3.0% veterinary procedures, and has POUR (Darrah et al., 2009). A with general anesthesia (Darrah recently gained some attention prospective, randomized trial et al., 2009; Jensen, Mikkelsen, & within the urologic community. demonstrated that the use of Kehlet, 2002). It is a non-competitive N-methyl- epidural anesthesia did not The incidence of POUR after D-aspartic acid receptor antago- increase the incidence of reten- anorectal surgery ranges between nist that achieves short-lived tion after hemorrhoidectomy 1% and 52% (Lau & Lam, 2004; general anesthesia and has when intra-operative IV fluids Zaheer, Reilly, Pemberton, & become a drug of abuse. It is

UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 65 SERIES metabolized by the liver to nor- continuous epidural analgesia after intrathecal morphine and metha- ketamine and ultimately excret- colonic resection? Regional Ane- done on the lower urinary tract in sthesia and Pain Medicine, 25(5), the dog. Journal of Urology, 15, 852- ed in the urine as hydroxynorke- 498-501. 855. tamine conjugated with glu- Benoist, S., Panis, Y., Denet, C., Mauvais, Durant, P.A., & Yaksh, T.L. (1988). Drug conate. Several recent case series F., Mariani, P., & Valleur, P. (1999). effects on urinary bladder tone dur- have demonstrated severe irrita- Optimal duration of urinary ing spinal morphine-induced inhibi- drainage after rectal resection: A ran- tion of the micturition reflex in tive LUT symptoms associated domized controlled trial. Surgery, unanesthetized animals. Anesthesi- with eosino philic ulcerative cys- 125(2), 135-141. ology, 68(3), 325-334. titis after ketamine use (Chu et Cataldo, P.A., & Senagore, A.J. (1991). Faas, C.L., Acosta, F.J., Campbell, M.D., al., 2008; Tsai et al., 2009). One Does alpha sympathetic blockade O’Hagan, C.E., Newton, S.E., & review of 59 patients who abused prevent urinary retention after Zagalaniczny K. (2002). The effects anorectal surgery? Diseases of the of spinal anesthesia versus epidural ketamine revealed 71% had cys- Colon and Rectum, 34(12), 1113- anesthesia on 3 potential postopera- toscopic findings that were con- 1116. tive complications: Pain, urinary sistent with chronic interstitial Chaney, M.A. (1995). Side-effects of retention and mobility following cystitis, and 80% had detrusor intrathecal and epidural opioids. inguinal herniorrhaphy. American Canadian Journal of Anesthesia, Association of Nurse Anesthestists overactivity or decreased bladder 42(10), 891-903. Journal, 70, 441-447. compliance on urodynamics. On Chen, Y.P., Shen, S.R., & Pan, H.L. (2005). Gallo, S., Durand, J., & Pshon, N. (2008). radiologic imaging, 51% had Systemic morphine inhibits dorsal A study of naloxone effect on uri- either unilateral or bilateral horn projection neurons through nary retention in the patient receiv- hydronephrosis, and 7% had fea- spinal cholinergic system independ- ing morphine patient-controlled ent of descending pathways. Journal analgesia. Orthopedic Nursing, tures suggestive of papillary of Pharmacology and Experimental 27(2), 111-115. necrosis. Renal in sufficiency was Therapeutics, 314(2), 611-617. Griffiths, D.J. (2004). Cerebral control of identified in 14%. These changes Chu P.S., Ma, W.K., Wong, S.C., Chu, bladder function. Current Urology may be irreversible (Chu et al., R.W., Cheng, C.H., Wong, S., … Man Reports, 174(5), 348-352. C.W. (2008). The destruction of the Griffiths, D., Derbyshire, S., Stenger, A., & 2008). lower urinary tract by ketamine Resnick, N. (2005). Brain control of abuse: A new syndrome? British normal and overactive bladder. Journal of Urology, International, Journal of Urology, 174(5), 1862- Conclusion 102(9), 1178-1179. 1867. Commonly used anesthetic Coggeshall, R.E., & Carlton, S.M. (1997). Gruenenfelder, J., McGuire, E.J., & Receptor localization in the mam- Faerber, G.J. (2002). Acute urinary and analgesic agents can have malian dorsal horn and primary affer- retention associated with use of predictable effects on the LUT ent neurons. Brain Research, Brain cyclooxygenase-2 inhibitors (letter). system. A condensed summary Research Reviews, 24(1), 28-66. Journal of Urology, 168(3), 1106. of the effect of anesthetics and Combrisson, H., Robain, G., & Cotard, J.P. Hojo, K., Vernava, A.M. III, Sugihara, K., (1993). Comparative effects of & Katumata, K. (1991). Preservation analgesics on the LUT has been xylazine and propofol on the ure- of urine voiding and sexual function provided in Table 1. Opioids, thral pressure profile of healthy after rectal cancer surgery. Diseases NSAIDS, and anesthetics all tend dogs. American Journal of Vet- of the Colon and Rectum, 34(7), 532- to result in increased risk of uri- erinary Research, 54(12), 1986-1989. 539. nary retention, with intrathecal Darrah, D.M., Griebling, T.L., & Silverstein, Holstege, G. (2005). Micturition and the J.H. (2009). Postoperative urinary soul. Journal of Comparative delivery resulting in the highest retention. Anesthesiology Clinics, Neurology, 493(1), 15-20. rates of POUR. Ketamine, an 27, 465-484. Jensen, P., Mikkelsen, T., & Kehlet H. anesthetic of abuse, is associated deGroat, W.C. (2006). Integrative control (2002). Post herniorrhaphy urinary with severe and irreversible LUT of the lower urinary tract: Preclinical retention – Effect of local, regional perspective. British Journal of and general anesthesia: A review. damage. Pharmacology, 147(Suppl. 2), S25- Regional Anesthesia Pain Medicine, S40. 27(6), 612-617. References Dolin, S.J., & Cashman, J.N. (2005). Kamphuis, E.T., Ionesco, T.I., Kuipers, Andersson, K.E. (2007). Neurophysiology Tolerability of acute postoperative P.W., de Gier, J., van Venrooij, G.E., & and pharmacology of the lower uri- pain management: Nausea, vomit- Boon, T.A. (1998). Recovery of stor- nary tract. In E.A. Tanagho & J.W. ing, sedation, pruritus and urinary age and emptying functions of the McAninch (Eds.), Smith’s general retention. Evidence from published urinary bladder after spinal anesthe- urology (17th ed., pp. 426-437). New data. British Journal of Anaesthesia, sia with lidocaine and with bupivi- York: McGraw Hill. 95(5), 584-591. caine in men. Anesthesiology, 88(2), Andersson, K.E., & Hedlund, P. (2002). Doyle, P.T., & Briscoe, C.E. (1976). The 310-316. Pharmacologic perspective on the effects of drugs and anaesthetic Kau, Y.C., Lee, Y.H., Li, J.Y., Noh, S.H., physiology of the lower urinary agents on the urinary bladder and Kil, H.K., Kim, H.S., & Ban, S.Y. tract. Urology, 60(5, Suppl. 1), 1-20. sphincters. British Journal of (2003). Epidural anesthesia does not Baldini, G., Bagry, H., Aprikian, A., & Urology, 48(5), 329-335. increase the incidence of urinary Carli, F. (2009). Postoperative uri- Dray, A. (1988). Epidural opiates and uri- retention and hesitancy in micturi- nary retention: Anesthetic and peri- nary retention: New models provide tion after ambulatory hemorrhoidec- operative considerations. Anesthesi - new insights. Anesthesiology, 68(3), tomy. Acta Anesthesiologica Sinica, ology, 110(5), 1139-1157. 323-324. 41(2), 61-64. Basse, L., Werner, M., & Kehlet, H. (2000). Drenger, B., Magora, F., Evron, S., & Kim, J.Y., Lee, S.J., Koo, B.N., Noh, S.H., Is urinary drainage necessary during Caine, M. (1986). The action of Kil, H.K., Kim, H.S., & Ban, S.Y.

66 UROLOGIC NURSING / March-April 2012 / Volume 32 Number 2 SERIES

(2006). The effect of epidural sufen- Orko, R., & Rosenberg, P.H. (1984). Thomas, K., Chow, K., & Kirby, R.S. tanil in ropivacaine on urinary Comparison of some postanaesthetic (2004). Acute urinary retention: A retention in patients undergoing gas- effects of atropine and glycopyrro- review of the aetiology and manage- trectomy. British Journal of late with particular emphasis on uri- ment. Prostate Cancer Prostatic Anesthesia, 97(3), 414-418. nary problems. Acta Anaesthesio - Diseases, 7(1), 32-37. Koch, C.A., Grinberg, G.G., & Farley, D.R. logica Scandinavica, 28(1), 112-115. Thor, K.B., & Donatucci, C. (2004). (2006). Incidence and risk factors for Ouslander, J.G. (2004). Management of Central nervous system control of urinary retention after endoscopic overactive bladder. New England the lower urinary tract: New phar- hernia repair. American Journal of Journal of Medicine, 350(8), 786- macological approaches to stress uri- Surgery, 191(3), 381-385. 799. nary incontinence in women. Kuipers, P.W., Kamphuis, T., van Petros, J.G., Mallen, J.K., Howe, K., Rimm, Journal of Urology, 172(1), 27-33. Venrooij, G.E., van Roy, J.P., Ionescu, E.B., & Robillard, R.J. (1993). Patient- Tsai, T.H., Cha, T.L., Lin, C.M., Tsao, C.W., T.I., Knape, J.T., & Kalkman, C.J. controlled analgesia and postopera- Tang, S.H., Chuang, F.P., … Chang (2004). Intrathecal opioids and tive urinary retention after open S.Y. (2009). Ketamine-associated lower urinary tract function: A uro- appendectomy. Surgery, Gynecology, bladder dysfunction. International dynamic evaluation. Anesthesiology, Obstetrics, 177(2), 172-175. Journal of Urology, 16(10), 826-829. 100(6), 1497-1503. Petros, J.G., Rimm E.B., & Robillard, R.J. Verhamme, K.M, Dieleman, J.P., Van Kulaçoglu, H., Dener, C., & Kama, N.A. (1992). Factors influencing urinary Wijk, M.A., Vander Lei J., Bosch, (2001). Urinary retention after elec- tract retention after elective open J.L., Stricker, B.H., & Sturkenboom, tive cholecystectomy. American cholecystectomy. Surgery, Gyne - H.C. (2005). Non-steroidal anti- Journal of Surgery, 182(3), 226-229. cology, Obstetrics, 174(6), 497-500. inflammatory drugs and increased Lau, H., & Lam, B. (2004). Management of Petros, J.G., Rimm, E.B., Robillard, R.J., & risk of acute urinary retention. postoperative urinary retention: A Archives of Internal Medicine, randomized trial of in-out versus Argy, O. (1991). Factors influencing postoperative urinary retention in 165(13), 1547-1551. overnight catheterization. Australia Verhamme, K.M., Sturkenboom, M.C., patients undergoing elective in- New Zealand Journal of Surgery, Stricker, B.H., & Bosch, R. (2008). guinal herniorrhaphy. American 74(8), 658-661. Drug-induced urinary retention: Journal of Surgery, 161(4), 431-433. Malinovsky, J.M., Le Normand, L., Incidence, management and preven- Rawal, N., Mollefors, K., Axelsson, K., Lepage, J.Y., Malinge, M., Cozian, A., tion. Drug Safety, 1(5), 373-388. Lingårdh, G., & Widman, B. (1981). Pinaud, M., & Buzelin, J.M. (1998). Wang, J., Pennefather, S., & Russel, G. Naloxone reversal of urinary reten- The urodynamic effects of intra- (1993). Low-dose naloxone in the venous opioids and ketoprofen in tion after epidural morphine. treatment of urinary retention dur- humans. Anesthesia Analgesia, Lancet, 318(8260), 1411. ing extradural fentanyl causes exces- 87(2), 456-461. Remy, C., Marret, E., & Bonnet, F. (2005). sive reversal of analgesia. British Marret, E., Kurdi, O., Zufferey, P., & Effects of acetaminophen on mor- Journal of Anaesthesia, 80(4), 565- Bonnett, F. (2005). Effects of nons- phine side-effects and consumption 566. teroidal anti-inflammatory drugs on after major surgery: Meta-analysis of Wren, T.L. (1996). Postsurgical urinary patient-controlled analgesia mor- randomized controlled trials. British retention. Urologic Nursing, 16, 45- phine side effects: Meta-analysis of Journal of Anaesthesia, 94(4), 505- 49. randomized controlled trials. 513. Wynd, C.A., Wallace, M., & Smith, K.M. Anesthesiology, 102(6), 1249-1260. Romsing, J., Moiniche, S., Mathiesen, O., (1996). Factors influencing postop- Marret, E., Remy, C., & Bonnet, F.; & Dahl, J.B. (2005). Reduction of opi- erative urinary retention following Postoperative Pain Forum Group. oid-related adverse events using opi- orthopaedic surgical procedures. (2007). Meta-analysis of epidural oid-sparing analgesia with COX-2 Orthopedic Nursing, 15(1), 43-50. analgesia versus parenteral opioid inhibitors lacks documentation: A Zaheer, S., Reilly, W.T., Pemberton, J.H., & analgesia after colorectal surgery. systematic review. Acta Anaesthe- Ilstrup, D. (1998). Urinary retention British Journal of Surgery, 94(6), sioligica Scandinavica, 49(2), 133- after operations for benign anorectal 665-673. 142. diseases. Diseases of the Colon and Matsuura, S., & Downie, J.W. (2000). Ryan, J.A., Adye, B.A., Jolly, P.C., & Rectum, 41(6), 696-704. Effect of anesthetics on reflex mic- Mulroy, M.F. (1984). Outpatient turition in the chronic cannula- inguinal herniorrhaphy with both Additional Reading implanted rat. Neurourology and regional and local anesthesia. Ameri- Rawal, N., Mollefors, K., Axelsson K., Urodynamics, 19(1), 87-99. can Journal of Surgery, 148(3), 313- Lingårdh, G., & Widman, B. (1983). Meyboom, R.H., Brodie-Meijer, C.C., 316. An experimental study of urody- Diemont, W.L., & van Puijenbroek, Singh, S.K., Agarwal, M.M., Batra, Y.K., namic effects of epidural morphine E.P. (1999). Bladder dysfunction Kishore, A.V.K., & Mandal, A.K. and of naloxone reversal. Anesthesia during the use of tramadol. (2008). Effect of lumbar epidural Analgesia, 62(7), 641-647. Pharmacoepidemiology and Drug administration of tramadol on lower Scoma, J.A. (1975). Catheterization in Safety, Suppl. 1, S63-S64. urinary tract function. Neurourology anorectal surgery. Archives of Mulroy, M.F., Salinas, F.R., Larkin, K.L., & Polissar, N.L. (2002). Ambulatory and Urodynamics, 27, 65-70. Surgery, 110(12), 1506. surgery patients may be discharged before voiding after short-acting spinal and epidural anesthesia. Anesthesiology, 97(2), 315-319. Olsen, S.W., & Nielsen, J. (2007). A study into postoperative urine retention in Need CNE? the recovery ward. British Journal of Anaesthetic & Recovery Nursing, Visit www.suna.org 8(4), 91-95.

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