627 Postgrad Med J: first published as 10.1136/pgmj.33.386.627 on 1 December 1957. Downloaded from

POST-OPERATIVE RETENTION OF URINE By BERNARD H. HAND, F.R.C.S. D3pt. of Surgical Studies, Middlesex Hospital

Introduction Treatment Post-operative retention of urine is a common Prevention surgical complication, and it is essential to have a While it is not possible to eliminate the con- clear understanding of the factors involved in its dition, unquestionably much can be done to production and the principles of its management, reduce its incidence in all types of case. The if further complications and mortality are to be following measures are therefore stressed: prevented. i. A few words of encouragement are useful, The object of this article is not only to describe particularly to those patients who report that the methods of prevention and relief of urinary they could not pass water after a previous retention but to point out when they are indicated. operation. Protected by copyright. The post-operative treatment of cases who have 2. As many patients experience difficulty in undergone surgery to the bladder, prostate and passing water while in bed, it gives them great urethra will not be considered. confidence post-operatively if they practice this before the operation, and there is no reason why Diagnosis this should not be advised as a routine in all While in most cases the diagnosis of retention routine cases. of urine presents no problem, a word of warning 3. It is important that all patients go to the is needed, however, in two types of case. operating theatre with an empty bladder. While First, in the immediate post-operative period it it may be necessary for technical reasons, in is usual for less urine to be secreted, the degree addition it allows a longer period of time to of oliguria being proportional to the severity of the elapse before the bladder is full again, during operation, and sometimes anuria may occur from which the patient is able to recover his faculties renal damage. Either of those conditions would and become aware of the situation before over- account for the patient's failure to pass water. It distention develops. This is clearly a nursing is therefore necessary to palpate the abdomen and problem and its importance and rationale should http://pmj.bmj.com/ confirm the presence of a distended bladder be stressed upon the nursing staff. before assuming that urinary retention has 4. The more distended the bladder becomes occurred. If no urine has been passed within the more difficult it is to micturate; patients 24 hours of operation and the bladder is not should therefore be asked to try and pass water palpable it is necessary to pass a catheter to as soon after operation as practical. Again, this determine the quantity and character of what is a nursing problem and some routine should be little urine has been secreted. adopted whereby the house surgeon is informed on October 2, 2021 by guest. Secondly, elderly and middle-aged male patients if a patient has not been successful within some even with retention of urine may make no com- stipulated time. plaint because they are passing water and have 5. During the course of taking a full history, little or no pain-they may even complain of and performing a full clinical examination, it is frequency of micturition. However, the volume important to assess the patient's ability to mic- of urine being passed is only 1-3 ounces at a time turate, particularly in middle-aged and elderly and palpation of the abdomen will reveal a dis- males. It may be that the degree of prostatic tended bladder. This is a comparable situation obstruction which already exists is such that to the patient who is passing frequent small loose post-operative retention is almost inevitable. motions when in fact the rectum is obstructed by Further, patients are sometimes admitted for a mass of hard impacted faeces. surgery, particularly in an emergency, with chronic 628 POSTGRADUATE MEDICAL JOURNAL December 1957 Postgrad Med J: first published as 10.1136/pgmj.33.386.627 on 1 December 1957. Downloaded from urinary retention from obstruction, in addition to pre-operatively and none is induced by surgery. the primary condition. In these cases careful Here psychological and postural factors are consideration has to be given to decide which responsible and treatment presents little difficulty. condition takes priority. In reaching this decision The solution to the problem should not be the following factors must be taken into account: simply to pass a catheter. While little harm will (a) The age and general condition of the patient, result, if properly carried out, in this group and in particular his ability to survive two anaes- simpler measures should be tried first and are thetics and two operations; the opinion of the frequently successful. anaesthetist should be sought on this point. (i) Simple Measures. A short talk with the (b) The cause and degree of obstruction and its patient, explaining that nothing has been done rate of progression are more important than the operatively to interfere with his ability to mic- size of the prostate as felt on rectal examination. turate, will help to reassure him. It is valuable (c) The nature and urgency of the proposed to point out that overstraining will not help, and operation must be taken into account. Clearly that initiation of micturition is achieved by in the case of a strangulated hernia, or emergency relaxation of the perineal musculature. Patients gastrectomy, no delay is possible. are sometimes assisted by putting screens round (d) If time permits a full investigation by means the bed, placing a hot-water bottle on the hypo- of bacteriological examination of the urine, blood gastrium, using a warmed bedpan or urinal, urea, intravenous pyelogram should be carried turning on taps and sitting over the edge of the out, to show the state of renal function and the bed. If the patient's general condition and the degree of chronic retention. Cystoscopy should operative procedure permits, he should be stood be avoided owing to the danger of inducing out of bed, supported if necessary by a nurse or retention, infection or haemorrhage, unless the house surgeon, preferably of male sex. A small surgeon is prepared to proceed immediately to enema and removal of a rectal tube inserted at remove the obstruction. operation are sometimes helpful. In an agitatedProtected by copyright. In the' light of 'the information obtained, the patient a small dose of morphia may be given. following alternatives are possible: (2) Carbachol. If the above measures fail Car- (i) The primary condition is treated, risking the bachol (carbamyl choline chloride) may be em- development of urinary retention. ployed. To be effective 0.25 mg. should be (ii) The obstruction is dealt with in the first given subcutaneously or intramuscularly, and this instance and after a suitable interval the primary dose may be repeated half an hour later. If this condition is treated. is not successful no more should be given. Since (iii) Where it is not essential to treat the primary Carbachol acts on most smooth muscle, some condition at all, advise against surgery of any kind. surgeons do not permit its use in cases where a For instance, an elderly man with symptoms of gastro-intestinal anastomosis has been performed, urinary obstruction should have an uncomplicated in case a violent wave of peristalsis is produced inguinal hernia controlled by a truss, rather than and the anastomosis damaged. It is contra- risk the possibility of two operations. indicated in cardiac and shocked cases since it 6. In certain operations experience has shown may cause a fall in blood pressure with peripheral that even without any degree of pre-operative vasodilation. Some patients appear hypersensi- http://pmj.bmj.com/ urinary obstruction, post-operative retention of tive and may sweat, feel nauseated and faint. urine is extremely likely. In these cases it is Atropine may be used as an antidote. While usual for a self-retaining urethral catheter to be Carbachol requires to be given parenterally for inserted before, or immediately after, operation acute retention, should the bladder be hypotonic and left in place for several days. Thus it has after retention is relieved, oral Carbachol 2 mg. become a routine after anterior perineal repairs, three times a day does help to improve the for stress Wertheim's operations incontinence, bladder tone. on October 2, 2021 by guest. hysterectomy and abdomino-perineal resection of (3) Urethral Catheterization. If simple man- the rectum. oeuvres and injection of Carbachol have failed catheterization should now be performed. This Treatment of the Established Condition must be carried out with the utmost gentleness For purposes of description it is deemed ad- and scrupulous aseptic technique. There is much visable to divide the cases into three groups, to be said in favour of performing this in the defining each group and considering its manage- operating theatre, but clearly in a busy general ment separately. hospital this may be impractical-but a mask and rubber gloves should be worn. Scrubbing up Group i should be performed after the external genitals In these patients no organic obstruction exists have been swabbed. A soft rubber catheter Decemtber 1957 HAND: Post-operative Retention of Urine 629 Postgrad Med J: first published as 10.1136/pgmj.33.386.627 on 1 December 1957. Downloaded from size i6-i8 (French) of the Jacques or Harris treatment of the primary disease. The distinction type, well lubricated with sterile jelly or liquid between these groups can be made by a con- paraffin, is used. Some advise that a local anaes- sideration of the past history of urinary symptoms thetic, such as I: I,500 nupercaine, should be and the height of the bladder above the pubis. used. While not essential it has the advantage Obviously these two types are not absolutely that, after instillation, the patient may micturate clear-cut entities, but when faced with borderline spontaneously. The catheter should not be cases it is important to decide from the beginning touched with the hand but held with sterile which line to adopt so that suprapubic catheteriza- gauze. Subsequently, the patient should be en- tion or cystotomy do not require to be carried out couraged to drink freely, if his operation permits, after several urethral catheterizations have failed and attempt to pass water at frequent intervals to establish micturition. thereafter. With the above technique in this In the first type conservative measures should group it should not be necessary to prescribe any certainly be attempted as they are sometimes chemotherapy. successful. Some advise that Carbachol should be administered; but since it is unlikely to be Group 2 successful and theoretically could cause rupture No organic obstruction exists pre-operatively, of a diseased bladder, its use is perhaps unwise. but the operation leads to its development. One of the following measures should now be Usually the obstruction is of a temporary nature adopted: and resolves within a few days, being due to (a) Urethral catheterization. traumatic oedema or damage to the pelvic auto- (b) Perineal urethrostomy. nomic nerves. Here treatment only occasionally (c) Suprapubic aspiration. presents a problem. Many of this group fall into (d) Suprapubic catheterization. the category in which an indwelling catheter is (e) Suprapubic cystotomy. employed since difficulty is anticipated. If not, In the other type, with acute on chronic reten- Protected by copyright. then the procedures mentioned under group i tion, if simple measures have failed, urethral should be followed, and if a catheter is passed it catheterization and suprapubic aspiration should may be advisable to leave it in situ for a few days not be employed since they are unlikely to succeed draining the bladder intermittently rather than in establishing micturition where the obstruction continuously to allow recovery of tone. The was so well developed pre-operatively. Either catheter can be removed when abdominal dis- suprapubic catheterization or cystotomy are there- tension has been relieved, or if the patient passes fore required with slow decompression of the urine round the catheter or becomes aware of bladder over a period of 24 hours. bladder distension. (a) Urethral Catheterization. In cases where the pre-operative obstruction is not marked, Group 3 urethral catheterization may be successful in Some degree of obstruction exists pre-opera- establishing spontaneous micturition. If per- tively which is rendered complete by a combina- formed, the aseptic and gentle technique is par- tion of the factors at play in groups i and z. ticularly important in these cases since infection

This group frequently poses difficult problems in is more likely to occur and in association with http://pmj.bmj.com/ management and increases the morbidity and obstruction will be persistent until the source of mortality of surgery. The conditions which are obstruction is removed. A soft rubber catheter concerned here are bladder-neck obstruction from may easily fail to pass the obstruction and rather benign hypertrophy, carcinoma, fibrous or cal- than pass two catheters a bicoude gum elastic culus disease of the prostate, urethral stricture, catheter or Tiemann's rubber catheter, which and finally neurological diseases such as tabes has a solid curved tip, should be employed in the dorsalis and disseminated sclerosis. first instance. The danger of urethral catheteriza- tion in these cases is that, however gently per- on October 2, 2021 by guest. i. Bladder-neck Obstruction formed, the superadded trauma is likely to in- In this condition there are two types of case crease the oedema and mitigate against the patient to be considered, the first developing acute reten- passing water of his own accord later. A further tion where no previous chronic retention existed danger, with a vascular prostate, is haemorrhage pre-operatively, and the second where acute and conversion of the case from one of urinary retention is superimposed on a pre-existing retention to one of clot retention with all its chronic retention. The latter should be detected hazards. After catheterization it is inadvisable to in the pre-operative phase of a routine case and leave the catheter in situ as this increases the the cause treated primarily-but in an emergency, chance of oedema and infection; also a limit must even if detected it would take second place to the be put on the number of.times it may be repeated, 630 POSTGRADUATE MEDICAL JOURNAL Deacember 1957 Postgrad Med J: first published as 10.1136/pgmj.33.386.627 on 1 December 1957. Downloaded from depending upon the circumstances. If catheteriza- methods have failed in acute retention and all tion has proved successful a short course of cases where an acute retention is superimposed on chemotherapy or Haustus hexamine compositus is a chronic one. It involves the blind introduction advisable. The latter renders the urine acid, under local anaesthesia of a modified Malecot reduces infection, and by its mildly irritant effect catheter (No. I6-I8 French) stretched over an often assists micturition. introducer which has a cutting terminal end. (b) Perineal Urethrostomy. Namely, the insertion The catheter is fixed on the stretch and is held in of a self-retaining catheter via the perineal position distally by a hinged arm, which is con- urethra, has been advised in certain cases of trolled proximally. The orifice made in the urinary retention by Sandrey (I949), and may be bladder is smaller than the unstretched catheter employed in the post-operative period. Although and the tract oblique, thereby reducing the danger it spares the anterior urethra, ascending infection of leakage and permitting rapid closure when the is not prevented and the method has not been obstruction has been removed. Space does not generally accepted. permit a full description of the technique and (c) Suprapubic Aspiration. This method, al- readers are referred to the original descriptions by though not in common use, has definite advantages Riches; however, a few points are stressed. It over urethral catheterization. First, as nothing should always be performed in the operating passes through the urethra, infection is less likely theatre with the table tilted into a slight Tren- to occur; secondly, the oedema of the bladder delenburg position. The catheter should only neck is not increased by the trauma of the pro- be inserted blindly if the dome of the bladder cedure, and the patient is therefore more likely to can be definitely felt. If not, then surface of the pass water spontaneously afterwards; thirdly, bladder should be exposed through a small in- prostatic haemorrhage does not occur; fourthly, cision and insertion performed under direct vision. it is a simple procedure requiring no special The site of insertion should be midway between surgical instruments or experience; and lastly, if the pubic symphysis and the top of the bladder,Protected by copyright. it fails it does not interfere with any subsequent but never higher than midway between the pubic treatment. While it is not suggested that this symphysis and the umbilicus. The catheter and method should be used in all cases where urethral introducer should be well lubricated. An incision catheterization is indicated, it has a real place about i in. long is made in the anterior abdominal particularly in the older age groups. It has been wall and the linea alba. After insertion it is vital employed with success on numerous occasions on to fix the catheter and shield firmly to the abdo- this unit. minal wall, since, should it come out within the It can be performed quite easily in the patient's first seven days it may be difficult or impossible bed with its foot on blocks. The technique to replace it, particularly if not attempted imme- employed is as follows: After shaving the pubic diately. hair and painting the skin with iodine, the skin The disadvantage of the method is that it and abdominal wall above the pubis are infiltrated requires two special instruments and a knowledge with local anaesthetic. A sterile narrow lumbar of the technique which may not be available in puncture needle with a syringe attached is inserted an emergency. It is under these circumstances just above the pubic symphysis in a backward and that suprapubic cystotomy is indicated. http://pmj.bmj.com/ slightly downwardl direction until the bladder is (e) Suprapubic Cystotomy. The technique is as reached. By aspirating as much as possible the follows: A local or general anaesthetic may be bladder can be al-nost completely emptied. The employed, with the patient in a slight Trendelen- disadvantages are that it can only be performed burg position a short median sub-umbilical in- at the most thre& times; if attempted more fre- cision is made, passing between the recti muscles. quently extravasation of urine into the cave of The peritoneum is identified and retracted up- Retzius is liable to occur, and further, it is dan- wards and the dome of the bladder identified, two gerous to attempt it if a scar is present in the stay sutures are inserted and either a Morson's on October 2, 2021 by guest. lower abdominal wall, in case loops of intestine or Kidd's bladder trocar and canula inserted into are adherent to it; under surface. the bladder. A self-retaining catheter of a (d) Suprapubic Catheterization. Essentially this Malecot or De Pezzer type is inserted, taking care is a method of suprapubic cystotomy and the not to spill urine into the wound, and tied in technique advised is that described by Riches with catgut. The wound is closed in layers with (I943). It was originally designed for the treat- a drain in the cave of Retzius in case of urinary ment of paraplegics, but soon became applied to leakage. cases of prostatic obstruction. It is indicated in all cases where the alternative Emergency Prostatectomy is suprapubic cystotomy, namely, where the above In recent years emergency prostatectomy has December 1957 HAND: Post-operative Retention of Urine 631 Postgrad Med J: first published as 10.1136/pgmj.33.386.627 on 1 December 1957. Downloaded from found a definite place in the treatment of urinary pass several of the same type, leaving them all in retention due to benign prostatic enlargement, in the urethra-and one can usually be pass ed cases where renal function is considered adequate through the stricture (faggot method). The oth ers and infection is either absent or minimal. It is are then removed and a gradual dilatation p er- too early for it to have found a place in cases formed by attaching larger sizes in turn. The where the retention has presented as a post- bladder is then emptied. Under these circum - operative manifestation. However, the time may stances dilatation should only be carried out far come when such a place is found provided the enough to permit micturition, full treatment being above criteria are fulfilled, the general condition postponed till later in the post-operative period. of the patient permits it and the two operative Occasionally general anaesthesia is required to fields do not transgress one another. achieve the dilatation. In either case it is ad- visable to prescribe a short course of chemo- 2. Urethral Stricture therapy. Any patient with a severe stricture - of the urethra is likely to report this pre-operatively, so 3. The Neurological Bladder we need only consider a passable stricture which has become further narrowed by oedema. Simple Should a tabetic or a patient with disseminated measures should be tried first, and while Car- sclerosis develop post-operative retention, the bachol is unlikely to do harm it is unlikely to be advice of a neurologist should be obtained before successful and is best avoided in these cases. any suprapubic drainage is instituted; since closure Dilatation of the structure is therefore required. of the fistula may never be possible and the This can be performed under local anaesthesia patient is left with a permanent suprapubic tube. with full aseptic precautions. A filiform gum Urethral catheterization is therefore indicated in elastic or plastic bougie is passed to the face of the first instance. the stricture. It should possess a thread at the Protected by copyright. proximal end to allow follow-through bougies of BIBLIOGRAPHY a larger size to be attached. One bougie RICHES, E. W. (I1943), Lancet, ii, IZ28. may not RICHES, E. W. (I950), Brit. Surg. Prac., 7, I58. negotiate the orifice and it is then necessary to SANDREY, J. G. (I949), Postgrad. med. JV., 25, 71.

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THE MODERN VIEW OF ANAESTHESIA CHLORPROMAZINE AND ALLIED http://pmj.bmj.com/ G. S. W. Organe, M.D., D.A., F.F.A.R.C.S. SUBSTANCES THE PRODUCTION OF John Beard, M.D., D.A., F.F.A.R.C.S., UNCONSCIOUSNESS D.C.H. B. G. B. Lucas, D.A., F.F.A.R.C.S. CONTROLLED HYPOTHERMIA ANALGESIA E. J. Delorme, M.D., F.R.C.S.(C.) J. B. Wyman, M.B.E., D.A., F.F.A.R.C.S. MANAGEMENT OF THE APNOEIC MUSCLE RELAXATION IN SURGERY PATIENT Angus Smith, F.F.A.R.C.S. Ronald Woolmer, D.A., F.F.A.R.C.S. on October 2, 2021 by guest. CONTROL OF THE BLOOD PRESSURE THE USE OF ANTIDOTES IN AND CONTROLLED HYPOTENSION ANAESTHESIA C. F. Scurr, M.V.O., D.A., F.F.A.R.C.S. B. A. Sellick, D.A., F.F.A.R.C.S. Published by THE FELLOWSHIP OF POSTGRADUATE MEDICINE 60, Portland Place, London, W.1