- Department of Neurosurgery, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI 48202, United States
Department of Neurosurgery, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI 48202, United States
DOI:10.4103/2152-7806.111088Copyright: © 2013 Alsaidi M This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Alsaidi M, Guanio J, Basheer A, Schultz L, Abdulhak M, Nerenz D, Chedid M, Seyfried D. The incidence and risk factors for postoperative urinary retention in neurosurgical patients. Surg Neurol Int 24-Apr-2013;4:61
How to cite this URL: Alsaidi M, Guanio J, Basheer A, Schultz L, Abdulhak M, Nerenz D, Chedid M, Seyfried D. The incidence and risk factors for postoperative urinary retention in neurosurgical patients. Surg Neurol Int 24-Apr-2013;4:61. Available from: http://sni.wpengine.com/surgicalint_articles/the-incidence-and-risk-factors-for-postoperative-urinary-retention-in-neurosurgical-patients/
Background:Postoperative urinary retention (POUR) is a common problem in adult neurosurgical patients. The incidence of POUR is unknown and the etiology has not been well established. POUR can lead to urogenital damage, prolonged hospital stay, higher cost, and infection. This study elucidates several risk factors that contribute to POUR in a variety of neurosurgical patients in one institution.
Methods:A total of 137 neurosurgical patients were prospectively followed up for the development of POUR, which we defined as initial postvoid residual (PVR1) >250 ml 6 hours after removal of an indwelling urinary catheter (IUC). For patients with PVR >250 ml on the third check, IUCs were reinserted and kept in for 5-7 days.
Results:Of the 137 patients, 68 (50%) were male, 41% (56/137) were 60 years or older, 86% (118/137) underwent spinal surgery, and 54% (74/137) had anesthesia over 200 minutes. Overall incidence of clinical POUR was 39.4% (54/137). Significantly higher rates of PVR1 >250 were noted in males, patients older than 60 years, and those who underwent spine surgery. When considering all patient characteristics (except selective alpha blockers), only gender, surgery time, and surgery type remained significant. In addition, PVR1 >250 was positively associated with longer length of stay. Of all patients, 24 (18%) had IUCs reinserted postoperatively or should have had one (5 refused and 2 had a third PVR). The association of IUC reinsertion with male gender was significant.
Conclusion:Male gender, time of anesthesia >200 minutes, older age, and spinal surgery are the most significant risk factors associated with POUR in neurosurgical patients.
Keywords: Indwelling urinary catheter, neurosurgery, postoperative urinary retention, risk factor
Postoperative urinary retention (POUR) is a common problem across many surgical specialties.[
The incidence of POUR has been reported in the range of 5-75% of all surgical procedures.[
The risk of POUR in neurosurgical patients has not been studied extensively. Boulis et al.[
From May 2010 to June 2011, 137 neurosurgical patients in our hospital were followed prospectively for the development of POUR. This study was approved by the Henry Ford Hospital Institutional Review Board (IRB # 6893). POUR, per hospital protocol, was defined as an initial postvoid residual (PVR1) greater than 250 ml using bladder ultrasonography (BVI 3000, Verathon) 6 hours after the removal of indwelling urinary catheters (IUCs) that were inserted during the time of surgery. Straight catheterization was performed for patients with any PVR greater than 250 ml every 6 hours. For patients with the third PVR greater than 250 ml, IUCs were reinserted. Patients were then discharged and instructed to return to the urology clinic in 5-7 days for follow-up. Subsequently, patients’ records were reviewed for age, gender, BMI, length of anesthesia, type of surgery (cervical, thoracic, lumbar, and cranial), preoperative diagnosis of DM, usage of selective alpha blockers, beta blockers, anticholinergic agents, T2 signal on cervical, and thoracic magnetic resonance imaging (MRI), NBIOIVF, and length of hospital stay. There were two patients who underwent thoraco-lumbar surgeries that were included in the thoracic group. Due to the small number of thoracic patients, cervical and thoracic patients are grouped into the cervico-thoracic group.
Nonparametric methods such as Wilcoxon two sample tests, Kruskal–Wallis test, and Spearman's correlation coefficients were used to assess the associations between PVR1 and demographic, medical, and surgical information. These methods were used instead of standard parametric methods because of the wide distribution of values for PVR1 which ranged from 0 to 1000. Regression methods using stepwise procedures were utilized to determine which combination of factors were most associated with PVR1 for all patients, males only and females only. Chi-square tests were done to assess the relationship between patient characteristics and IUCs for the categorical variables and Wilcoxon nonparametric two sample tests for the continuous variables (PVR1 and NBIOIVF). In addition, sensitivity, specificity, and positive and negative predictive values for IUC reinsertion based on specific cutpoints of PVR1 were computed. The testing alpha level was set at 0.05. All statistical analyses were done using SAS (Cary, NC, USA) version 9.2.
Of the 137 patients, 68 (50%) were male and the mean age was 57.5 years (SD = 14, range 26-95 years). The remainder of the patient characteristics is shown in
When considering all patient characteristics (except selective alpha blockers), the three variables that remained significant in the multivariable regression analysis were gender, duration of anesthesia, and surgery type (spine vs cranial) [
Of all patients, 24 (18%) had IUCs reinserted postoperatively or should have had one (5 refused and 2 had a third PVR). The association of IUC reinsertion with gender was significant, with males having higher rates of reinsertion than females (28% vs 7%, P = 0.001). A trend was seen with patients older than 60 compared with younger patients having higher reinsertion rates (25% vs 12%, P = 0.055), and longer duration of anesthesia (>200 minutes) vs shorter (≤200 minutes) being associated with higher reinsertion rates (23% vs 11%, P = 0.069). Surgery location, DM, beta blockers, BMI, and anticholinergic agents were not significantly associated with IUC reinsertion [
96% of the patients with IUC reinsertion had a PVR1 greater than 250 ml, while 73% of the patients without a IUC reinsertion had a PVR1 less than 250 ml. Of the patients with a PVR1 over 250 ml, 42% had IUC reinsertion (positive predictive values [PPV]) and of the patients with a PVR1 <250 ml, only 1% had IUC reinsertion (negative predictive values [NPV]). However, a cutpoint of 800 ml for PVR1 had a 86% NPV and 100% PPV [
POUR: Gender, age
POUR is common among different neurosurgical patients and may be a major source of pain, infection, and increased cost. Although Boulis et al.[
POUR: Type of surgery
Rectal procedures are associated with high rates of POUR, and many believe this is due to damage of the autonomic nerve, which sometimes occurs during total mesorectal excision.[
POUR: Anesthesia type and duration
Although all of our patients underwent general anesthesia, evidence suggests that techniques and length of anesthesia correlate well with increased incidence of POUR. Sedative agents effect the cortical micturition center leading to suppression of detrusor contraction and the micturition reflex.[
POUR: Diabetes mellitus, net balance of intraoperative IV Fluid
DM has been implicated in the impairment of bladder sensation, capacity, and decreased contractility, which would lead to higher incidence of POUR.[
POUR: Home medication of anticholinergic agents, beta blockers, and selective alpha blocker agents
Urinary retention is a known common side effect of anticholinergic agents. Such agents lead to impaired bladder contractility by working on the cholinergic receptors in the detrusor smooth muscle fibers. Although we failed to show a significant difference among our patients who were on home anticholinergic agents, the use of such agents intraoperatively has been hypothesized to increase the incidence of POUR.[
POUR: Indwelling urinary catheter reinsertion
IUCs have been associated with increased risk of infection. Higher mortality rate has been shown in hospitalized patients with indwelling bladder catheters who developed UTI.[
Clinically, those patients with a very high PVR1 had much higher incidence of IUC insertion. Although IUCs have been associated with increased morbidity and mortality, in patients with a high PVR1 (>800 ml), early reinsertion of the IUC may not be unreasonable to avoid the dreadful consequences of distended bladder and potential renal failure, as well as to facilitate aggressive mobilization for a few days. Such early mobilization is paramount to reduce DVT and pulmonary embolism (PE) and, potentially, POUR.
POUR: Length of stay
Boulis et al.[
POUR is prevalent among neurosurgical patients, especially in males, those older than 60 years of age, and those with spinal pathologies. It may lead to high rates of infection, complication, cost, and longer hospital stay. Therefore, more studies are needed to understand the exact pathophysiology, risk factors, and potential point of intervention that would lead to the decreased incidence of POUR.
The authors would like to thank Sue MacPhee-Gray for editorial assistance and Kelly Tundo for help with the IRB application.
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