1. Postoperative urinary retention
Dr Tahereh Forooghifar
Fellowship of pelvic floor
disorders

2. POSTOPERATIVE URINARY RETENTION
(POUR):
Impaired voiding after a procedure
despite a full bladder that results in
an elevated postvoid residual.

3. International Continence Society
International Urogynecological
Association:
Abnormally slow and/or incomplete
micturition.

4. Incidence General surgical population: 4 to 13 percent
General surgical population:
4 to 13 percent
Cesarean with epidural anesthesia :
23 to 28 percent
Pelvic surgery range :
2 to 43 percent

5. RISK FACTORS Age over 50 years (double) Concurrent neurologic disease
Administration >750 mL of
intravenous fluid

6. RISK FACTORSR Duration of surgery >2 hours
Intraoperative anticholinergic(atropine)
Use of regional anesthesia
Incontinence surgery and radical pelvic
surgery.

7. Women with these risk factors
are counseled about the
increased risk of POUR and
clean intermitten catheterization.

8. CLINICAL PRESENTATION
Slow urine stream
Straining to void
Incomplete bladder emptying
Suprapubic pressure or pain
Need to immediately re-void
Position-dependent micturition

9. CAUSES OF POUR Bladder (Detrusor) dysfunction Urethral obstruction
Failure of pelvic floor relaxation

10. Abnormal bladder function
Preexisting voiding dysfunction
Anesthetic agents 
Nerve injury secondary to surgery
Cystotomy
Bladder overdistention injury 
Postoperative agents used for analgesia

11. Nerve injury after surgery
Parasympathetic and sympathetic:
pelvic and hypogastric plexus

12. Cystotomy Differentiation cystotomy from urinary retention:
Irrigating the bladder with 75 mL to 100 mL
of sterile saline through a catheter then
attempting to withdraw the same amount
of fluid.
Cystography or Cystoscopy

13. Bladder overdistention injury
 Acute prolonged bladder overdistention is defined as
≥120 percent of a normal bladder capacity for ≥24 hours.
Wall ischemia :
30 minutes during
acute overdistention.

14. Urethral obstruction
Mechanical
Failure of pelvic floor relaxation

15. Mechanical Self-limited obstruction Sling obstruction
Urethral foreign body
Pelvic organ prolapse
Urethral injury 
Constipation

16. Mechanical (urethral)
Sling obstruction 
Midurethral sling or
Bladder neck (fascial slings and retropubic
suspensions)
Treatment:
Surgical lysis of sling
We do not perform urethral dilation :
increase risk of urethral mesh erosion

17. Sling obstruction 
Transobturator midurethral slings< Retropubic midurethral slings< Burch urethropexy< Fascial slings TOT< TVT< BURCH<FASCIAL SLING

18. Mechanical Urethral foreign body: Excessive sling tension
Postop transurethral dilation
Cystoscopy and Urethroscopy :
Direct visualization of the
eroded sling or suture

19. Diagnosis U/A, U/C POST VOIDING RESIDUAL VOLUME VOIDING TRIAL
CYSTOSCOPY
URODYNAMIC STUDY
(rarely requires)

20. PVR There is no standardized PVR 50 mL to 100 mL normal
>200 mL abnormal
Between 100 mL and 200 mL
requires clinical correlation

21. Voiding trials Retrograde or spontaneous
To confirm adequate voiding and
minimal PVR in patients with
symptoms or risk factors for
POUR

22. VOIDING TRIALS Retrograde method : More predictive for continued
catheterization
Preferred by patients
Greater ease of use
Fewer catheterizations
Took less time

23. Spontaneous voiding trial
Removing the catheter
Voiding until she has a strong
urge or four hours have passed.
The voided volume is measured
PVR : straight catheterization or
ultrasound within 15 minutes of
the completed void.

24. Voiding trial Success is defined: PVR = 100 mL or less or
Void two-thirds or greaterof the
total bladder volume
Two voiding trials

25. Retrograde voiding trial
The bladder is retrograde filled
through the catheter with 300 mL of sterile saline or
the patient says she is at maximum capacity (whichever
occurs first).

26. Retrograde voiding trial
Void of 200 mL or greater is
considered successful
(two- thirds of instilled volume)
Two voiding trials

27. Fail (voiding trial) Physical exam: Self-limited obstruction :
(CIC) until the obstructing
process resolves

28. Fail (voiding trial) Physical exam: No evidence of obstruction:
Discharg with CIC or indwelling
catheter
Short interval (days) follow-up in the
office
Retrograde voiding trial

29. Persistent voiding dysfunction
Pelvic muscle tone
Prolapse
Incision of midurethral sling

30. Pelvic muscle tone (passive)
Place one or two digits of your right hand
8 cm into the vagina.
Press firmly on the muscles of right and left
pelvic floor
Start from muscle attachment to the pubic
bone at 12 o’clock and rotate to the
coccyx.
Assess for excessive/imbalanced muscle
tone and pain at each pressure point.

32. Pelvic muscle tone (contraction)
Placing your left hand lateral to
the patient’s right knee
Asking her to abduct her knee
into the palm of our left hand
Asymmetric muscle tone or pain
(pelvic floor muscle therapy)

33. Prolapse Digital vaginal exam with the
patient in the standing position.
Anterior or apical prolapse can
cause bladder neck or urethral
obstruction.
If prolapse is found
pessary

34. Incision of midurethral sling
  Absence of prolapse:
Over-tight incontinence sling:
Midline incision of sling
Success rates : 86 to 100%

36. The optimal time to perform the
sling transection is unclear.
Synthetic sling lysis one to three
weeks post op.
Fascial sling lysis one to two
months following initial surgery.

37. Urodynamic testing No obstruction on exam The patient’s symptoms are
inconsistent with the medical
and surgical history

38. Postoperative urodynamics
Bladder contractility
Urethral tone
Urethral obstruction

39. Detrusor hypocontractility
Radical pelvic surgery
Urodynamics does not change the
treatment plan
CIC until the patient can adequately
void (>6 to 8 months)
Radical hysterectomy
Symptoms may never
resolve

40. Complications of untreated retention
Overdistention injury (CIC)
Detrusor overactivity
Overactive voiding symptoms

41. If the need for catheterization continues, CIC rather than an indwelling urethral or suprapubic catheter is suggested (Grade 2C)

42. Clean intermittent catheterization
CIC rather than an indwelling urethral or suprapubic catheter
Required four to six times a day and
possibly once overnight
Reusable catheters can be used for
up to four weeks

43. CIC CIC frequency is inadequate: Indwelling catheter (choice to avoid
overdistention)
Lower urinary complication rates
 Systemic antimicrobial agents are
not used

44. Clean intermittent catheterization
Catheterization continues:
PVRs are less than one
third of the voided volume and
total bladder volumes are not
causing overdistention.

46. POSTPARTUM URINARY RETENTION

47. Postpartum urinary retention
OVERT PUR
COVERT PUR

48. OVERT PUR Absence of micturition within six
hours of vaginal delivery or
removal of indwelling catheter
after cesarean delivery.

49. COVERT PUR PVR > 150 mL No symptom No urge to void
Overflow incontinence

50. Incidence
0.7–4% of deliveries

51. Ethiology
Injury to the pudendal nerve
during labour..

52. Risk Factors Epidural anesthesia Primiparity
Instrument assisted delivery
Episiotomy
Prolonged labour
Perineal trauma

53. Management 4hrs post birth has the woman passed urin No 2 hrly check
Adequate hydration
Fluid balanc chart
Measure first passage urin (250)

54. Management Adequate analgesic Ambulation Perineal exam :
Swollen or painful :
Catheter

55. Management U/A-U/C (mid stream) UTI(Antibiotic therapy) Constipation
Avoid and treatment

56. Treatment of overt PUR Intermittent catheterization
Routine use of antibiotics is not
necessary
Pharmacological therapies are not
effective.

57. Clean intermittent catheterization
Every four to six hours or
urge to void, but unable
CIC
Patient is able to void a small
volume, then self-catheterization (PVR)
Discontinue CIC
PVR <150 mL and
no longer significat symptoms

59. Trial without catheter (TWOC)
Catheter is removed (two or three days)
Fill bladder slowly by drinking fluid
(a glass liquid every minutes)
Trial to pass urine spontaneously
Unable to pass urine
New catheter or
CIC

60. Persistence voiding dysfunction
postpartum
Neurological examination
(pudendal)
Intermittent catheterisation
Urodynamic study