POSTOPERATIVE URINARY RETENTION IN ABDOMINAL SURGERY. Marta Alves Servicio de Urología

Transcription

1 POSTOPERATIVE URINARY RETENTION IN ABDOMINAL SURGERY Marta Alves Servicio de Urología

2 Introduction Incidence Mechanism of micturition Risk factors Prevention Diagnosis Complications/Adverse effects associated with POUR Clinical management Conclusions

3 POUR has been defined as the inability to void in the presence of a full bladder. Slow urine stream Straining to void A feeling of incomplete bladder emptying Suprapubic pressure or pain [1]

4 Incidences General surgery 3.8% Anorectal surgery 1-52% Hernia repair %

5 Mechanism of micturition

6 Preoperative risk factors Age ( 2.4 times in patients over 50) [1] Gender (4.7% compare to women 2.9%) [1] Benign prostate hyperplasia Type of surgery Previous pelvic surgery Neurological diseases

7 Intraoperative risk factors Large amount of IV >750ml (anorectal and hernia repair surgery 2.3 times more) [2] Duration of surgery [3] Anesthetic and analgesia agents

8 Spinal anesthesia Act on neurons segments S2- S4 Contraction of detrusor abolished in 2-5 min and recovery depends on sensory block Spinal analgesia Decrease the parasympathetic effects Impaired coordination between detrusor and internal urethral sphincter Use of long-acting local anesthetics is related to a higher incidence of POUR [4] The onset and the duration depends on the TYPE and DOSE of opiod

9 Epidural anesthesia Epidural analgesia Similar to intrathecal anesthetic Incidence of POUR with epidural anesthetics for inguinal herniorrhaphy is lower than with spinal anesthesia Site of insertion: lumbar epidural>thoracic epidural Not dose-dependence [5]

10 Postoperative risk factors Bladder volume at the arrival in PACU> 270ml [6] Excessive liquid intake Higher incidence of POUR in continuos epidural infusion compared with PCA Constipation Mobilization

11 Prevention Identify patients at risk(type of surgeries, medical history ) Fluid restriction in anorectal surgery and inguinal hernia repair Appropiate anesthesia and analgesia strategy Fluid restriction in the postoperative period Avoid constipation and encourage an early mobilization Prescription of daily drugs of patients

12 Diagnosis

13 Complications and adverse effects Autonomic response Infection Bladder overdistension Incidence of 44% >500ml diagnose and treated 1-2h Further investigation

14 Clinical management 1. Alpha receptors antagonists Removal within 4-5 days (Tamsulosine 0.4mg) [7] 2. Ciprofloxacin 500mg

15

16 Conclusions Multifactorial Anesthesi a Surgery Patient Identification of risk factors Proper anamnesis and exploration Ultrasound if doubts Removing avoidable causes

17 References 1. Tammela T, Kontturi M, Lukkarinen O. Postoperative Urinary Retention: I.Incidence and Predisposing Factors. Scandinavian Journal of Urology and Nephrology. 1986;20(3): Petros J, Rimer E, Robillard R, Argy O. Factors Influencing Postoperative Urinary Retention in Patients Undergoing Elective Inguinal Herniorrhaphy. Survey of Anesthesiology. 1991;35(4): Pavlin D, Pavlin E, Gunn H, Taraday J, Koerschgen M. Voiding in Patients Managed With or Without Ultrasound Monitoring of Bladder Volume After Outpatient Surgery. Anesthesia & Analgesia. 1999;89(1): Kamphuis E, Ionescu T, Kuipers P, de Gier J, van Venrooij G, Boon T. Recovery of Storage and Emptying Functions of the Urinary Bladder after Spinal Anesthesia with Lidocaine and with Bupivacaine in Men. Anesthesiology. 1998;88(2): Rawal N, Millefors K, Axelsson K, Lingerdh G, Widman B. An Experimental Study of Urodynamic Effects of Epidural Morphine and of Naloxone Reversal. Anesthesia & Analgesia. 1983;62(7): Predictive Factors of Early Postoperative Urinary Retention in the Postanesthesia Care Unit. Survey of Anesthesiology. 2005;49(6): Cataldo P, Senagore A. Does alpha sympathetic blockade prevent urinary retention following anorectal surgery?. Diseases of the Colon & Rectum. 1991;34(12): Baldini G, Bagry H, Aprikian A, Carli F. Postoperative Urinary Retention. Anesthesiology. 2009;110(5):