A study of incidence of post-operative urinary retention following spinal anaesthesia

 

Jassa Ram Thakur^1*, Vijay Kumar Sauhta², Tsering Yougyal³, Dara Singh⁴, Kartic Syal⁵

 

Abstract              Background: Urinary retention is one of the most common problems contributing to surgical procedures. Proper management of patients pre operatively and intraoperatively can reduce the incidence of POUR. Aim and objective: To study the incidence of post operative urinary retention following spinal anaesthesia. Methodology: Present study was an observational study conducted on 100 patients of ASA1 and ASA2 aged 20-60 years of either sex posted for lower limb /lower abdominal surgery under spinal anaesthesia. All patients were closely followed for 24 hours post operatively for voiding and were graded into various voiding difficulty grades. Data was analysed with appropriate statistical tests.  Results and discussion: Mean age of the patients was 49.3± 3.1 years. Male to female ratio was 4:1. Incidence of post operative urinary retention was 40%. Increasing age was significantly associated with higher incidence of POUR. (p<0.05).Males show higher incidence of difficulty in voiding urine than females but the difference was not statistically significant (p>0.05).

Key Word: urinary retention following, spinal anaesthesia.

 

INTRODUCTION

Subarachnoid (spinal) block is a safe and effective alternative to general anaesthesia when the surgical site is located on the lower extremities, perineum (e.g., surgery on the genitalia or anus) and lower abdominal wall (e.g., inguinal herniorrhaphy). Because of the technical challenges of readily identifying the epidural space and the toxicity associated with the large doses of local anaesthetics needed for epidural anaesthesia, spinal anaesthesia was the dominant form of neuraxial anaesthesia well into the 20th century.¹ There are certain post- operative problems related to spinal anaesthesia which can increase patient’s morbidity and distress. One of the most common post-operative complaints is post-operative urinary retention (POUR) has been defined as the inability to void despite a full bladder. This is related to many factors and multiple variants can have variable influence on incidence and severity of urinary problems and even post-operative urinary retention (POUR). Spinal anaesthesia influences the urination by blocking all afferent nerve fibres, rendering the patient unable to feel bladder distension of urinary urgency. In spinal anaesthesia, detrusor muscle strength and the ability to void restarts with return of sacral sensation to pinprick. Even a single episode of bladder over distension can result in significant morbidity. Overfilling of bladder can stretch and damage the detrusor muscle, leading to atony of the bladder wall, so recovery of micturition may not occur when the bladder is emptied. On other hand, the excessive use of an indwelling catheter can lead to UTI, urethral stricture and prolonged hospital stay. Short-term prophylactic catheterization is recommended in patients with obstructive symptoms. Type of surgery (higher incidence in lower abdominal surgeries), anaesthesia (general vs. regional), age of patient (higher incidence with increasing age) and sex (males>females) have influence on incidence and severity of POUR.^2,3 In a Medline-based search study by Jenson et al. (2002) ⁴ the incidence of POUR following inguinal herniorrhaphies performed under local anaesthesia, regional anaesthesia and general anaesthesia were 0.37%, 2.4% and 3.0%, respectively. The investigators concluded that the type of anaesthesia significantly influenced the risk of POUR and spinal anaesthesia significantly influenced the risk of POUR. Urinary retention is one of the most common problems contributing to surgical procedures. Recent studies have shown the benefits of α-adrenergic blockers in preventing post-operative urinary retention (POUR). Present study was conducted to find out the incidence of post operative urinary retention following spinal anaesthesia in lower limb or lower abdomen surgeries.

Aim and objective: To study the incidence of post operative urinary retention following spinal anaesthesia.

 

MATERIAL AND METHODS

Present study was an observational study conducted at Indira Gandhi Medical College and associated hospitals Shimla. Study population was 100 patients of ASA1 and ASA2 aged 20-60 years of either sex posted for lower limb /lower abdominal surgery under spinal anaesthesia.

Inclusion Criteria: 1. Patients posted for lower limb / lower abdominal surgery under spinal anaesthesia 2. Patients willing to participate in the study.

Exclusion criteria: 1. Patients with urinary tract disease 2. Catherised patients. 3. Patients with warfarin 4. Patients with sitting systolic blood pressure in the upper extremity of less than 100 mmHg at the time of eligibility screening 5. Patients with Intra operative IV fluid more than 1500 ml 6. Patients with intraoperative blood loss more than 750 ml.

Study was approved by ethical committee of the institute. A valid written consent was taken after explaining study to them.

Patients under the study were thoroughly assessed preoperatively regarding detailed history, physical examination and all necessary investigations. Patient were catherised. Vital parameters like pulse, blood pressure both systolic and diastolic, respiratory rate, oxygen saturation were measured. After keeping complete resuscitation and anaesthesia instruments ready, spinal anaesthesia was given. Painting and drepping was done with aseptic precautions. Depending on the requirement of spinal blockade level inj Bupivacaine (heaavy) was administered at level L3-L4 with spinal needle. Intraoperatively patients were monitored for vital parameters like pulse, BP, respiratory rate and oxygen saturation etc.

All patients were closely followed for 24 hours post operatively for voiding and were graded into various voiding difficulty grades as given:

Grade 0: Spontaneous voiding without difficulty.

Grade 1: Voiding with difficulty.

Grade 2: Intermittent single evacuation of bladder.

Grade 3: Intermittent repeated evacuation of bladder

Grade 4: Continuous catheterization.

Data was collected with pre tested questionnaire. Data included demographic data, clinical history and clinical examination. Intraoperative hemodynamic of the patient, level of blockade and details of post operative urinary retention were noted.

Data was entered in the excel sheet. Data was analysed with appropriate statistical tests.

 

RESULTS

In our study we studied 100 patients undergoing spinal anaesthesia. Mean age of the patients was 49.3± 3.1 years. Majority of the patients were from the age group of 50-60 years (32%) followed by 30-39 years (30%). Patients in the age group of 20-29 years and 40-49 years were 21% and 17% respectively. In our study, 80% of the patients were male and 20 % patients were female. Male to female ratio was 4:1. Out of total 100 patients 59 patients underwent lower limb surgeries and 41 patients underwent lower abdomen surgeries. Table 2 shows voiding difficulty in patients after spinal anaesthesia. Majority of the patients had spontaneous Voiding without difficulty G0 (60%). Voiding with difficulty (G1) was observed in 17% patients. Intermittent single evacuation of bladder (G2) was seen in 7% patients. Intermittent repeated evacuation of bladder (G3) was observed in 8% patients. Continuous catherization was seen in 8% patients. Thus in our study incidence of post operative urinary retention was 40%. Table 3 shows Voiding difficulty in patients according to age group. In age group of 20-29 years, out of total 21 patients had no voiding difficulty. None of the patient had voiding difficulty. In age group of 30-39 years 25 (83.33%) patients had no urinary retention and 16.67% patients had Grade 1 difficulty in voiding urine. In age group of 40-49 years, out of total 17 patients majority 12(70.59%) had no urinary retention 4 patients (23.53%) had grade 1 difficulty in voiding urine and 1 patient (5.88%) had grade 2 difficulty in voiding urine. In the age group of 50-60 years, only 2 patients were not having difficulty in urine voiding remaining 30 patients had difficulty in passing urine. Grade 1 difficulty was seen in 8(25%) patients and grade 2 difficulty was seen in 6(18.75%). Grade 3 and grade 4 difficulty was observed in 25% patients each. Thus we can conclude that as the age increases there is increase in voiding difficulty of the patients post operatively. Significant increase in the voiding difficulty in patients with increase in age was observed (p<0.05). Table 4 shows Voiding difficulty in patients according to sex. Out of total 100 patients 80 were male and 20 were female. Among male majority 47(58.75%)were not having any difficulty in voiding urine. 14 patients had grade 1 voiding difficulty and 4 patients had grade 2 voiding difficulty. In females 65% females did not have any difficulty in voiding urine after spinal anaesthesia. Males show higher difficulty in voiding urine than females but the difference was not statistically significant (p>0.05).

 

Table 1: Distribution of patients undergoing spinal anaesthesia according to age group

 

Figure 1: Distribution of patients undergoing spinal anaesthesia according to sex

 

Table 2: Voiding difficulty in patients after spinal anaesthesia

 

Table 3: Voiding difficulty in patients according to age group

 

Table 4: Voiding difficulty in patients according to sex

DISCUSSION

In our study we studied 100 patients undergoing spinal anaesthesia. Mean age of the patients was 49.3± 3.1 years. Majority of the patients were from the age group of 50-60 years (32%) followed by 30-39 years (30%). In our study, 80% of the patients were male and 20 % patients were female. Male to female ratio was 4:1. In our study, Majority of the patients had spontaneous Voiding without difficulty G0 (60%). Voiding with difficulty (G1) was observed in 17% patients. Intermittent single evacuation of bladder (G2) was seen in 7% patients. Intermittent repeated evacuation of bladder (G3) was observed in 8% patients. Continuous catherization was seen in 8% patients. Thus in our study incidence of post operative urinary retention was 40%. In our study we found that as the age increases there is increase in voiding difficulty of urine in the patients post operatively. Significant increase in the voiding difficulty in patients with increase in age was observed in our study (p<0.05). In a study conducted by Lee and colleagues (2007)67 it was demonstrated that post operative urinary retention increases with age and the risk increases by 2.4 to 2.6 time in patients over 50 years of age is due to progressive neuronal degeneration leading to bladder dysfunction.^5,6 In a study undertaken by Hollma et al., 376 men undergoing hip arthroplasty were assessed for post operative urinary retention (defined in their study as inability to void after surgery for which single or indwelling catheter is required) it was demonstrated that that increasing age was an independent risk factor for POUR. ⁷ This is similar to finding in our study where we found that incidence of grade 3 and grade 4 voiding problems, that is need for frequent evacuations and / or persistant catheterization was most prevalent in patients having age more than 50 years, where as it was negligible in younger patients. In our study, when comparison of different age groups was done in relation to requirement of catheterization for voiding difficulty, it was found that, none of the subjects in 20-29 and 30-39 years required catheterization. While in age group of 40-49 years catheterization rate was 5.8% and in the age group of 50- 60 years it was 68.7%. Among male majority 47(58.75%)were not having any difficulty in voiding urine. 14 patients had grade 1 voiding difficulty and 4 patients had grade 2 voiding difficulty. In females 65% females did not have any difficulty in voiding urine after spinal anaesthesia. Males show higher incidence of difficulty in voiding urine than females but the difference was not statistically significant (p>0.05). In a study conducted by Tammela et al. (1986) ⁸ , it was found that higher incidence of post operative urinary retention has been reported in males as compared to women. ^5,8,9 The difference thus found has already been found probably due to gender specific pathologies such as benign prostatic hypertrophy in males.^10,11 Possible reasons for sex related differences in urinary tract anatomy and physiology between male and female. Male urethra is longerand more tortuous than female urethra. There is also a presence of prostate in male which may enlarge in benign prostatic hypertrophy, thus obstructing to flow of urine. All these factors contribute in increased resistance for urinary flow leading to higher incidence in males.

 

CONCLUSION

In our study we found that incidence of POUR was more in age >50 years and male sex with incidence of 40%.

 

REFERENCES

1. Corning JL. Spinal anesthesia and local medications of the cord. N Y Med J. 1885. 42:483.
2. Tammela T, Kontturi M, Lukkarinen O. Postoperative urinary retention. I. Incidence and predisposing factors. Scand J Urol Nephrol 1986;20:197–201.
3. Pertek JP, Haberer JP. Effects of anaesthesia on postoperative micturition and urinary retention [French]. Ann Fr Anesth Reanim 1995;14:340–351.
4. Jensen P, Mikkelsen T, Kehlet H. Postherniorrhaphy urinary retention--effect of local, regional, and general anesthesia: a review. Reg Anesth Pain Med 2002;27:612–
5. Yoshimura N, Chancellor MB: Physiology and pharmacology of the bladder and urethra, Campbell-Walsh Urology, 9th edition. Edited by Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. Philadelphia, Elsevier, 2006,.pp 1922-79.
6. Keita H, Diouf E, Tubach F, Brouwer T, Dahmani S, Mantz J, Desmonts JM: Predictive factors of early postoperative urinary retention in the postanesthesia care unit. Anesth Analg 2005; 101:592–6Keita, H Diouf, E Tubach, F Brouwer, T Dahmani, S Mantz, J Desmonts, JM.
7. Gallo, Susan; Dupand, Jacqueline; Pshon, Nicole orthopaedic Nursing: March-April 2008 – volume 27 –Issue 2 –P41-115.
8. Tammela T, Kontturi M, Lukkarinen O: Postoperative urinary retention. II. Micturition problems after the first catheterization. Scand J Urol Nephrol 1986; 20:257–60Tammela, T Kontturi, M Lukkarinen, O.investigation before and after operative in a consecutive series. AnnSurg 1980; 191:8.
9. Coombes GM, Millard RJ: The accuracy of portable ultrasound scanning the measurement of residual urine volume. J Urol 1994; 152:2083–5.
10. Petros JG, Rimm EB, Robillard RJ, Argy O: Factors influencing postoperative urinary retention in patients undergoing elective inguinal herniorrhaphy. Am J Surg 1991; 161:431–3.

Petros JG, Mallen JK, Howe K, Rimm EB, Robillard RJ: Patient-controlled analgesia a postoperative urinary retention after open appendectomy. Surg Gynecol Obstet 1993; 177:172–5.

Policy for Articles with Open Access
Authors who publish with MedPulse International Journal of Anesthesiology (Print ISSN:2579-0900) (Online ISSN: 2636-4654) agree to the following terms:
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Authors are permitted and encouraged to post links to their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.