MANAGEMENT OF THE BLADDER IN THE POSTOPERATIVE PERIOD FOLLOWING UNCOMPLICATED GYNAECOLOGICAL SURGERY CLINICAL GUIDELINES 1. Aim/Purpose of this Guideline All clinical staff working in the Division of women, children & sexual health to provide evidence based guidance in the management of the bladder in the postoperative period following uncomplicated gynaecological surgery 2. The Guidance Background: There is little consensus in the literature of the best management of the bladder in the immediate postoperative period following uncomplicated gynaecological surgery. Women in the immediate postoperative period following gynaecological surgery have a high incidence of urinary retention Urethral catheters are commonly used following gynaecological surgery Indwelling catheters are associated with increased risks of urinary tract infection (UTI) and the longer they are in situ, the higher the risk of UTI Guideline for removal of catheter: The planned date of removal of catheter should be clearly stated on the operation note / in the medical notes. All urethral catheters are removed at 07.00 on the scheduled day of removal, unless otherwise stated in the medical notes Attached is the voiding protocol and post op bladder diary. The amounts voided and bladder scan residual volumes should be recorded on a bladder diary and dated and signed by the nurse performing the check. This record should be at the patient s bedside at all times. While awaiting woman to empty her bladder, she should be encouraged to drink normal amount of fluids and try to empty her bladder by going to the toilet / having a bath / shower etc. Possible reasons for being unable to pass urine / empty bladder completely: 1. Bruising / swelling around bladder / urethra especially following anterior vaginal wall repair this will usually improve over 1-2 weeks Page 1 of 10
2. Overdistension of the bladder resulting in atonic bladder (acute / chronic) 3. Poor urinary flow rates prior to surgery (may have been detected on urodynamics) 4. Physical obstruction (eg midurethral sling / sutures) Suspect if unable to pass urine at all post op speak to consultant in charge 5. Clot retention suspect if a history of haematuria NOTE for complex laparoscopic surgery for severe endometriosis: Patients who fail their primary TWOC, need to be discharged with an indwelling catheter for one week and repeat TWOC on return. If they fail a second time it should be discussed with a member of the endometriosis team Guidelines for women sent home with an indwelling catheter Ensure can empty catheter bag herself and understands catheter care (instructed by nursing staff on ward) Ensure has ward number on the discharge letter to call in an emergency Ensure has follow up appointment for TWOC usually in EGU There should be no need for prophylactic antibiotics unless patient symptomatic of a urinary tract infection. Guidelines for women returning for Trial without catheter (TWOC) Ward staff to discuss the option/process of catheter removal at home on the day of TWOC to save waiting time in the hospital after catheter removal which may be up to 4 hours. Those patients who can remove catheters at home, get a bladder scan in EGU to measure residual volume in bladder following her void. Patients who cannot remove catheters at home are seen early in the morning in EGU e.g. 0900 and 0910 slots (or Gynaecology ward if EGU closed). The catheter is removed and the patient sent away with instructions to drink as normal (or at least 1 litre of water over the next few hours). She may leave the hospital and indeed is encouraged to, in order to relieve any anxiety that may be present by being in hospital The patient is advised to attempt to void when she has the desire and to return to EGU at an allotted time (usually after 6 hours and by that time, most women would have voided twice) for a scan to measure post void bladder residual volume* If she is unable to void at all / becomes anxious / distressed / is in pain, she should return to EGU earlier and follow the voiding protocol attached. If patient is sent home with an indwelling catheter following a midurethral sling procedure, inform the surgeon who performed the operation (early division of the tape may be considered) If patient voids >150ml and the post void residual is <150mls, reassure woman and Page 2 of 10
discharge (complete discharge letter) Patients with unsuccessful trial in EGU, who would be offered ISC, arrange a time / place to teach ISC and use the starter packs available in EGU / Gynaecology ward. Before patient discharged home performing CISC, ensure has follow up arranged with the Bladder & Bowel Specialist Service by written referral and sending to via Groupwise to Enquiries.ContinencePromotion@Cornwall.NHS.UK Bladder scan for post void residual check: This may be done using a specific bladder scanner (located on Gynaecology ward) or using the USS machine in EGU (use the abdominal probe, select menu and scroll down to bladder volume ) ISC Instruction The aim is to train as many of the gynaecology nurses to be able to teach CISC as possible. This is to be done in conjunction with Sharon Eustice (nurse continence consultant) using the same methods and same kit to ensure continuity If there is no one on duty who is trained to teach CISC, then contact the Bladder & Bowel Specialist Service to ask for their help via 01726 291042 (please note: the team are not able to teach CISC immediately). See flow chart below: Page 3 of 10
VOIDING PROTOCOL FOLLOWING BENIGN GYNAECOLOGY OPERATION Catheter removal time should be recorded on the fluid volume chart and on the bladder diary - Encourage to drink normal amounts of mixed fluids - Women should be encouraged to try to void if haven t already at 4hours following catheter removal/after surgery. - Measure the voided volume on second void and measure residual volume by bladder ultrasound scan soon after the void. (no later than 6hours from catheter removal/postop if coming out of theatre without catheter, with a normal fluid intake) - Residual volume to be measured immediately after the patient passes urine per urethra (see Note below about Endometriosis Patients) - If uncomfortable & unable to pass urine before the 4 hrs interval, check residual by scan and follow protocol as below On 2 nd void, voided more than 150 ml with residual between 150 and 400 ml Void more than 150 mls with residual less than 150mls x once Void less than 150 ml with residual more than 400 ml x 2 nd void Rpt void and residual check every 2 hrs Insert Foley catheter No 12 with Flip flo valve and leave in situ No futher checks needed, unless unless the woman feels she is unable to completely void subsequently At discharge: - Foley s catheter in situ with flip flo valve for daytime and leg bag for night - Flip flo valve to be released every 4 hrs during day and leg bag on free drainage during night - Book trial without catheter in emergency gynaecology unit (EGU) in 5-7 days - Ward staff to discuss with the patient the option and process of catheter removal at home (if possible) on the day of TWOC prior to coming to EGU. - If TWOC is unsuccessful again in EGU, arrangements to be made for the patient to learn intermittent self catheterisation (ISC) * NOTE for complex laparoscopic surgery for severe endometriosis: Patients who have more than 150mls in the bladder at their first TWOC, need to be discharged with an indwelling catheter for one week and repeat TWOC on return. Do Not follow the algorithm above for these patients. If they fail TWOC a week later (more than 150mls) it should be discussed with a member of the endometriosis team Page 4 of 10
POSTOPERATIVE BLADDER DIARY Name: Hospital Number: Date: Time Volume of urine passed per urethra Residual urine by bladder scan Volume of urine drained via catheter Name of nurse Instructions 1. Use this chart in conjunction with the flow-chart for voiding protocol for Urogynaecology patients) 2. Insert time in column one for each event 3. If a catheter is inserted please document the time of insertion and time of measurement of urinary volume drained (usually 20 minutes or until catheter stops draining) 4. If there are any concerns regarding management contact the operating surgeon/ on call via the switchboard. Page 5 of 10
3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Audit the compliance to guideline and the voiding protocol Miss Farah Lone, Consultant O&G Ad hoc monitoring of guidance as part of routine audit activity Biannual review presented at the Audit and Governance meeting Audit and Governance meeting Audit and Governance meeting Required changes to practice will be identified and actioned within 3 months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 6 of 10
Appendix 1. Governance Information Document Title Management of the Bladder in the postoperative period following uncomplicated gynaecological surgery Date Issued/Approved: 11/04/2017 Date Valid From: 08/06/2017 Date Valid To: 08/06/2020 Directorate / Department responsible (author/owner): Miss Farah Lone Consultant O&G Contact details: 01872 252685 Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: All clinical staff working in the Division of women, children & sexual health to provide evidence based guidance in the management of the bladder in the postoperative period following uncomplicated benign gynaecological surgery Post operative, Voiding, Gynaecology, Bladder care RCHT PCH CFT KCCG Medical Director Date revised: 11/04/2017 This document replaces (exact title of previous version): Management of the Bladder in the postoperative period following uncomplicated gynaecological surgery Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Obstetric & Gynaecology Directorate meeting Medical Director Not Required {Original Copy Signed} Internet & Intranet Intranet Only Page 7 of 10
Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Clinical / Gynaecology Governance Team can advise Reference and Associated documents No Version Control Table Date Versi on No Summary of Changes Changes Made by (Name and Job Title) 13 Jun 14 V1.0 Initial Issue 11/04/2017 V1.1 Minor changes Lee Azancot Data Administrator Farah Lone Consultant All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 8 of 10
Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Voiding Protocol Following Benign Gynaecology Operation Directorate and service area: Is this a new or existing Policy? Gynaecology Existing Name of individual completing Telephone: assessment: Miss Farah Lone 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* As above 01872 252685 All clinical staff working in the Division of women, children & sexual health to provide evidence based guidance in the management of the bladder in the postoperative period following uncomplicated gynaecological surgery 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? As above See section 3 All obs & benign gynae patients No b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Page 9 of 10
Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No x 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment 1. Miss Farah Lone 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 10 of 10