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.