Postoperative urinary retention is a common complication after major orthopedic procedures of the lower limb.1 The incidence of urinary retention in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty ranges from 7% to 84%.2–4 This wide range could be explained by different definitions used for urinary retention as well as different policies for bladder management. In the literature, urinary retention has been defined as the inability to void spontaneously after surgery or bladder volume exceeding 400 to 600 mL immediately after surgery or 6 to 8 hours after surgery, determined with or without ultrasound.2–5 Catheterization may be indicated, depending on the policy used for bladder management.
Three main policies are described for managing bladder voiding: (1) patients can be catheterized (indwelling) preoperatively, perioperatively, or directly postoperatively; (2) voiding can be managed with intermittent catheterization for which bladder volume is controlled every 6 to 8 hours until spontaneous voiding occurs; (3) patients can be catheterized as indicated only, based on previous reports of postoperative bladder management, using indwelling or intermittent catheterization.
Currently, there is no clear policy for postoperative bladder management for men undergoing THA. There is a growing consensus for the use of an indwelling catheter only as indicated, thereby reducing foreign body insertion.6 Unnecessary catheterization may lead to urinary tract infection, which is believed to increase the risk of implant infection as a result of hematogenous spread.7 However, a direct association between implant infection and urinary tract infection has not been proven.7–11 The use of intermittent catheterization was found to have an additive effect on the cumulative risk of urinary tract infection.4 Iorio et al8 studied the risk of infection in patients who received an indwelling catheter preoperatively and those who were catheterized (indwelling) only if symptoms of urinary retention developed. No difference between groups was noted in the occurrence of urinary tract infection if the catheter was removed within 24 to 48 hours after insertion.
It is important to avoid urinary retention because late diagnosis may lead to over-distention and atony of the bladder, causing permanent damage of urinary function with postvoiding residual volume.6 For hospitalized patients in general and for patients undergoing a broad range of orthopedic surgical procedures, several risk factors for urinary retention have been identified. These include advanced age, hypertension, diabetes mellitus, urinary flow obstruction, a history of genitourinary intervention, failure to void preoperatively, anesthesia time greater than 2 hours, patient-controlled anesthesia, male sex, and the use of epidural anesthesia.2,5,12–16 Several studies evaluated the predictive value of urinary retention with preoperative urologic symptom analysis, but no major correlations were found.5,15,16
Risk factors for urinary retention in specific patient groups, such as men undergoing unilateral THA, are not clearly identified, are poorly described, and are mainly based on small patient groups.5 The primary goals of this study were to describe the incidence of postoperative urinary retention and to analyze potential risk factors in men undergoing THA with a protocol of catheterization as indicated. In addition, the study considered the recurrence rate of urinary retention and the incidence of urinary tract infection.
Materials and Methods
A total of 409 primary THA procedures were performed in men between January 2010 and October 2012. Patient files were retrospectively reviewed for eligibility. The only exclusion criterion was catheterization preoperatively, perioperatively, or immediately postoperatively because of severe urologic conditions, such as urostoma, incontinence, or malignancy under treatment. After application of the exclusion criterion, 376 THA procedures (in 347 men) were included in this study. Urinary retention was defined as inability to void after surgery during admission with placement of a single or indwelling catheter. Urinary tract infection was defined as a positive urine culture result (>107 bacterial colonies of microorganism forming per liter) with antibiotic treatment.
All patients followed uniform preoperative food and liquid restriction from 12:00 PM on the evening before surgery until after surgery. In general, for spinal anesthesia, 15 to 30 mg bupivacaine 0.5%, based on weight, was used; for general anesthesia, a combination of propofol, fentanyl, and atracurium or mivacurium was used. Epidural anesthesia was not used. All patients received 2.0 g cefazolin intravenously at induction. All procedures were performed by or under the supervision of an experienced orthopedic surgeon. A standard posterolateral approach was used and cemented as cementless prostheses were implanted. Generally, on the first day after surgery, patients started walking under the guidance of a physiotherapist twice a day, and this was continued until hospital discharge. Postoperative pain control with multimodal analgesia was not standardized. Depending on the level of pain experienced, analgesics were administered as patient-controlled analgesia intravenously (morphine sulfate 50 mg in 50 mL sodium chloride 0.9%), intramuscularly (morphine), or orally (oxycodone, tramadol). Pain was recorded with the visual analog scale as no pain, bearable pain, pain, or severe pain (score 0–3). In the first hours after surgery, patients were expected to urinate in a urinal while lying down. If a patient did not void, the nursing staff on the postanesthesia care unit or orthopedic ward performed ultrasound of the bladder (bladder scan) 6 to 8 hours after surgery and then every 2 hours. Single catheterization (removal of the catheter after the bladder is emptied) was performed if retention exceeded 300 mL. Then 6 to 8 hours after catheter removal the patient was evaluated for spontaneous voiding. If retention exceeded 500 mL or if single catheterization was performed but retention recurred, an indwelling (Foley) catheter was placed and was removed the next day.
Potential risk factors analyzed were age, body mass index, American Society of Anesthesiologists physical status (Class I–III), comorbidities (hypertension, diabetes mellitus, prostate pathology, urethral strictures, history of urinary retention), smoking, type of anesthesia, postoperative morphine administration or patient-controlled anesthesia, average pain during the first 24 hours after surgery, and length of surgery (Table 1). Patients with and without urinary retention were compared with Pearson’s chi-square test or, if appropriate, Fisher’s exact test for categorical variables. Student’s t test was used for continuous variable analysis. To determine whether system or patient factors were associated with the dependent variable urinary retention, binary logistic regression analysis was performed with SPSS version 21.0 software (SPSS, Chicago, Illinois). Adjusted odds ratios were calculated for categorical variables. P≤.05 was considered statistically significant.
Patient Characteristics and Potential Risk Factors for Postoperative Urinary Retention (n=376)
The perioperative and postoperative course of bladder voiding was analyzed for all 376 THA procedures. Patient characteristics and potential risk factors are shown in Table 1. Mean patient age was 68 years (range, 31–93 years), with mean body mass index of 27 kg/m2 (range, 16–45 kg/m2). General anesthesia was used in 234 men, and 140 men received spinal anesthesia. Patients were admitted for an average duration of 4.2 days.
After THA, 150 men (39.9%) had urinary retention. Single catheterization was performed in 14 patients, and 136 patients received an indwelling catheter. Among these 150 men, urinary retention recurred in 10 (6.7%) after removal of the catheter, and all patients were recatheterized (indwelling). Of these 10 patients, 7 had undergone single catheterization at first, accounting for 50% of all patients undergoing primary single catheterization. The other 3 patients received a second indwelling catheter, accounting for 1% of all patients with indwelling catheters. Distribution of the amount of retention is shown in Table 2. Unfortunately, in 25 men, bladder volume could not be obtained from patient files. Urinary retention was diagnosed an average of 8.4 hours after surgery, with a mean bladder volume of 603 mL (range, 330–1100 mL; SD, 170 mL). In addition, after 8.4 hours, 77 men (22%) had bladder volume of 700 mL or greater. Urinary tract infection occurred in 2 of the 150 patients with urinary retention (1.3%) who had a catheter inserted and in none of the patients without urinary retention. No patients had acute prosthetic infection.
Bladder Volume in Patients Diagnosed With Primary Urinary Retention (n=125)
A significant difference between patients who had urinary retention and those who did not was seen in postoperative morphine intake (P=.014), type of anesthesia (P=.010), and age 70 years or older (P=.011) (Table 1). The other potential risk factors could not be confirmed. Multivariate data analysis showed significant effects on the incidence of urinary retention, expressed in adjusted odds ratios, for the use of spinal anesthesia compared with general anesthesia, postoperative use of patient-controlled anesthesia vs morphine and tramadol/acetaminophen, and age 70 years or older (Table 3). Because of missing values, 282 THA procedures were available for this analysis. With every additional risk factor, the risk of urinary retention increased, with an odds ratio of 1.91 (95% confidence interval, 1.40–2.61). When the variable postoperative analgesic intake was removed from the original multivariate analysis, 374 patients were available for analysis, resulting in an odds ratio of 1.59 (95% confidence interval, 1.04–2.43) for age 70 years and older and 1.81 (95% confidence interval, 1.17–2.79) for spinal anesthesia.
Multivariate Regression Analysis of Risk Factors for Urinary Retention
During the inclusion period of this study, 29 patients underwent staged bilateral THA. Factors including length of surgery, type of anesthesia, and postoperative use of analgesics during admission were comparable between the first and second THA procedures. Of these 58 THA procedures, 25 (43.1%) resulted in urinary retention. In this group of 25 patients, 8 (28%) had urinary retention after both THA procedures.
Postoperative urinary retention is a common complication after major orthopedic procedures of the lower limb. Risk factors for urinary retention in specific patient groups, such as men receiving unilateral THA, are not clearly identified, are poorly described, and are mainly based on small patient groups. Catheterizing all men preoperatively will lead to an increase in health care costs. Therefore, it is necessary to identify patients who are at risk for urinary retention. The incidence of urinary retention in men undergoing primary unilateral THA in this study was 39.9%. Of potential risk factors for urinary retention, age 70 years and older, spinal anesthesia, and postoperative use of patient-controlled anesthesia were identified as significant risk factors. The use of morphine could not be confirmed as a risk factor; however, the odds ratio was 2.03, with a 95% confidence interval of 0.99 to 4.16. Other patient-related factors, such as comorbidities, American Society of Anesthesiologists physical status (Class I–III), and body mass index, were not associated with an increased risk of urinary retention.
In a study by Griesdale et al13 of men and women who underwent total knee arthroplasty and THA, male sex and THA were identified as significant risk factors for urinary retention. A prospective cohort study by Sarasin et al16 that included men and women undergoing lower limb arthroplasty under spinal anesthesia found that male sex and age 70 years and older were significant risk factors for urinary retention. Other risk factors in the literature included the use of spinal anesthesia, the use of morphine, and a history of urinary retention.17 Several studies identified a history of benign prostatic hypertrophy as a significant risk factor for urinary retention, although this finding was not confirmed in this study.5 Controversy exists over several comorbidities that are believed to be potential risk factors, such as diabetes mellitus and hypertension. Because most studies, including the current study, did not identify these comorbidities as significant risk factors, it is not likely that preoperative catheterization of these patients will reduce the incidence of urinary retention.18,19
Several studies of preoperative voiding quality showed increased risk of urinary retention in patients who were unable to pass urine into a bottle while lying in bed (“bottle test”), who had urinary peak flow rates indicative of obstruction, and who had a history of bladder outflow problems.5,15 However, these tools for determining risk seem very time-consuming. Other risk factors that were identified in the literature and were not analyzed in this study included perioperative intravenous fluid administration and failure to void preoperatively.4 These factors also contribute to exceeding bladder volume.
Prompt detection of urinary retention is important to prevent exceeding bladder volume. As in this study, other investigators established a goal of spontaneous voiding within 6 to 8 hours after surgery.2,4,13,20 In the current study population, the first bladder scan was performed after an average of 8 hours. However, at this time, 22% of patients already had bladder volume of 700 mL or more. Mean bladder volume in the current study was 603 mL (range, 330–1100 mL), which is relatively high. Only 2 other studies reported mean bladder volume before catheterization, and these values were 565 mL (range, 50–1400 mL) and 838 mL (range, 400–1275 mL).20,21 These findings indicate that early tracing of urinary retention is important. Therefore, ultrasound should be obtained 6 to 8 hours after the start of anesthesia instead of 6 to 8 hours after the end of surgery to prevent exceeding volume and long-term bladder atony.
A known limitation of retrospective studies is an incomplete database. In this study, only 282 of the 376 patients could be included in the multivariate analysis. Because the main missing variable in the current database was postoperative use of analgesics, an additional multivariate regression analysis was performed only for age and type of anesthesia. No major differences in odds ratios were observed compared with the original analysis. Another limitation was that information on perioperative and postoperative fluid balance indicating intravenous fluid infusion, although mostly standardized, was not recorded. The amount of fluid intake and output could have affected the incidence and time of onset of urinary retention. A strength of this study was that, compared with other studies, the population was very homogeneous because it included only men undergoing primary unilateral THA. At the authors’ institution, only men can be used as study subjects because all women undergoing THA receive an indwelling catheter preoperatively. This practice is standard because flexion of the hips is not allowed until the first day after surgery as part of the postsurgical protocol, and this requirement is insurmountable among women while urinating.
In this study, the incidence of urinary retention for men undergoing primary THA was 39.9%. Identified risk factors were age 70 years or older, spinal anesthesia, and postoperative use of patient-controlled anesthesia. In these patients, preoperative indwelling catheterization or more meticulous postoperative monitoring is advised. In general, a bladder scan should be performed within 6 to 8 hours after the start of anesthesia instead of 6 to 8 hours after surgery to prevent exceeding bladder volume.
- Kemp D, Tabaka N. Postoperative urinary retention: Part II. A retrospective study. J Post Anesth Nurs. 1990; 5(6):397–400.
- Oishi CS, Williams VJ, Hanson PB, Schneider JE, Colwell CW Jr, Walker RH. Perioperative bladder management after primary total hip arthroplasty. J Arthroplasty. 1995; 10(6):732–736. doi:10.1016/S0883-5403(05)80067-1 [CrossRef]
- Lampe HI, Sneller ZW, Rijnberg WJ. Urination problems following total hip arthroplasty: insertion or not of an indwelling catheter [in Dutch]?Ned Tijdschr Geneeskd. 1992; 136(17):827–831.
- Michelson JD, Lotke PA, Steinberg ME. Urinary-bladder management after total joint-replacement surgery. N Engl J Med. 1988; 319(6):321–326. doi:10.1056/NEJM198808113190601 [CrossRef]
- Redfern TR, Machin DG, Parsons KF, Owen R. Urinary retention in men after total hip arthroplasty. J Bone Joint Surg Am. 1986; 68(9):1435–1438.
- Balderi T, Carli F. Urinary retention after total hip and knee arthroplasty. Minerva Anestesiol. 2010; 76(2):120–130.
- Wroblewski BM, del Sel HJ. Urethral instrumentation and deep sepsis in total hip replacement. Clin Orthop Relat Res. 1980; 146:209–212.
- Iorio R, Whang W, Healy WL, Patch DA, Najibi S, Appleby D. The utility of bladder catheterization in total hip arthroplasty. Clin Orthop Relat Res. 2005; (432):148–152. doi:10.1097/01.blo.0000149823.57513.00 [CrossRef]
- Fitzgerald HR, Nolan DR, Ilstrup DM, Van Scoy RE, Washington JA, Coventry MB. Deep wound sepsis following total hip arthroplasty. J Bone Joint Surg Am. 1977; 59:847–855.
- Glynn MK, Sheehan JM. The significance of asymptomatic bacteriuria in patients undergoing hip or knee arthroplasty. Clin Orthop Relat Res. 1984; 185:151–154.
- Ainscow DAP, Denham RA. Risk of haematogenous infection in total joint replacement. J Bone Joint Surg Br. 1984; 66:580–582.
- Williams A, Price N, Willett K. Epidural anaesthesia and urinary dysfunction: the risks in total hip replacement. J R Soc Med. 1995; 88(12):699–701.
- Griesdale DE, Neufeld J, Dhillon D, et al. Risk factors for urinary retention after hip or knee replacement: a cohort study. Can J Anaesth. 2011; 58(12):1097–1104. doi:10.1007/s12630-011-9595-2 [CrossRef]
- Wynd CA, Wallace M, Smith KM. Factors influencing postoperative urinary retention following orthopaedic surgical procedures. Orthop Nurs. 1996; 15(1):43–50. doi:10.1097/00006416-199601000-00009 [CrossRef]
- Waterhouse N, Beaumont AR, Murray K, Staniforth P, Stone MH. Urinary retention after total hip replacement: a prospective study. J Bone Joint Surg Br. 1987; 69(1):64–66.
- Sarasin SM, Walton MJ, Singh HP, Clark DI. Can a urinary tract symptom score predict the development of postoperative urinary retention in patients undergoing lower limb arthroplasty under spinal anaesthesia? A prospective study. Ann R Coll Surg Engl. 2006; 88(4):394–398. doi:10.1308/003588406X106531 [CrossRef]
- Kumar P, Mannan K, Chowdhury AM, Kong KC, Pati J. Urinary retention and the role of indwelling catheterization following total knee arthroplasty. Int Braz J Urol. 2006; 32(1):31–34. doi:10.1590/S1677-55382006000100005 [CrossRef]
- Balderi T, Mistraletti G, D’Angelo E, Carli F. Incidence of postoperative urinary retention (POUR) after joint arthroplasty and management using ultrasound-guided bladder catheterization. Minerva Anestesiol. 2011; 77(11):1050–1057.
- Izard JP, Sowery RD, Jaeger MT, Siemens DR. Parameters affecting urologic complications after major joint replacement surgery. Can J Urol. 2006; 13(3):3158–3163.
- Knight RM, Pellegrini VD Jr, . Bladder management after total joint arthroplasty. J Arthroplasty. 1996; 11(8):882–888. doi:10.1016/S0883-5403(96)80127-6 [CrossRef]
- Miller AG, McKenzie J, Greenky M, et al. Spinal anesthesia: should everyone receive a urinary catheter? A randomized, prospective study of patients undergoing total hip arthroplasty. J Bone Joint Surg Am. 2013: 95(16):1498–1503. doi:10.2106/JBJS.K.01671 [CrossRef]
Patient Characteristics and Potential Risk Factors for Postoperative Urinary Retention (n=376)
|Variablea||No Urinary Retentionb||Urinary Retentionc||P|
|Age, mean±SD, y||67.0±9.89||68.6±12.89||NS|
|Body mass index, mean±SD, kg/m2||27.3±3.63||27.6±4.39||NS|
|Length of surgery, mean±SD, h||1.8±0.50||1.71±0.40||NS|
|Length of hospital stay, mean±SD, d||4.6±3.70||4.00±2.91||NS|
|Pain score first 24 hours, mean±SDd||1.06±0.71||1.20±0.85||NS|
|American Society of Anesthesiologists physical status (Class I–III), No.|
| Class I||51 (23%)||35 (23%)||NS|
| Class II||153 (68%)||100 (67%)|
| Class III||19 (8%)||15 (10%)|
|Benign prostatic hypertrophy/prostate carcinoma||32 (14%)||25 (17%)||NS|
| Hypertension||90 (40%)||59 (39%)||NS|
| Diabetes mellitus type 2||26 (12%)||24 (16%)||NS|
| History of urinary retention||2 (1%)||2 (1%)||NS|
|Smoking, No.||44 (20%)||24 (16%)||NS|
|Age ≥70 y, No.||89 (39%)||79 (53%)||.011|
|Postoperative urinary tract infection, No.||0 (0%)||2 (1%)||NS|
|First voiding spontaneously, No.||226 (100%)||9 (6%)||NS|
| General||154 (69%)||80 (53%)||.003|
| Spinal||70 (31%)||70 (47%)|
|Postoperative analgesics, No.|
| Paracetamol, tramadol||40 (18%)||13 (9%)||.020|
| Morphine, subcutaneous||102 (45%)||63 (42%)|
| Patient-controlled analgesia||32 (14%)||33 (22%)|
| Data missing||52 (23%)||41 (27%)|
Bladder Volume in Patients Diagnosed With Primary Urinary Retention (n=125)a
|Maximum Bladder Volume, mL||No.|
Multivariate Regression Analysis of Risk Factors for Urinary Retention
|Variable||Adjusted OR (95% CI)|
|Age ≥70 y||1.77 (1.06–2.95)|
|Spinal anesthesia||1.79 (1.07–2.99)|
|Morphine, subcutaneous||2.03 (0.99–4.16)|
|Patient-controlled analgesia||4.10 (1.79–9.40)|