Post-Operative Retention

Sandra Whytock RN MSN GNC(C) NCA

Clinical Nurse Specialist, Elder Care Program
Providence Health Care
February 2006

Retention: Agenda
Prediction
Prevention
Detection
Management
.. but first

Foley Catheters: Consequences

Polymicrobial bacteriuria (universal by 30
days)
Febrile episodes (1 per 100 patient days)
Nephrolithiasis,
Bladder stones
Chronic renal inflammation
Pyelonephritis
Reduced Mobility

Indications for Foley Catheter

Short term decompression of acute
retention
When retention cant be managed
surgically or medically
When wounds need to kept clean
Comfort in terminal illness
Patient insistence despite knowing
risks

NORMAL
BLADDER
FUNCTION

Bladder Function:
Conditions for emptying
The bladder must contract effectively
Urethra must relax and must permit
unobstructed flow
The bladder & urethra must be
coordinated

Retention: the Danger

If low bladder wall compliance or outlet
obstruction, urine flow from ureters is
impeded
Risk of hydronephrosis and/or reflux from
bladder into ureters
Possible effect on upper urinary tract:
Kidney damage
Infection from mixing urine from ureters with
higher level of bacteria with urine from
bladder)

Possible UTI d/t stasis of urine in bladder

Retention:
A predictable problem
Who is at risk?

Causes of Retention
Neuropathy or Neurological damage
Constipation & fecal impaction
Anticholinergic Medication

Antispasmotics
Antiparkinsonian agents
Antipsychotics - especially the older ones
Tricyclic antidepressants

Calcium channel blockers and narcotics

may precipitate retention when administered

with another anticholinergic

More Causes of Retention

Diuresis with sudden bladder over
distention (diuretics, alcohol toxicity,
hyperglycemia)
Vit B12 deficiency

What about Surgery: Factors

Contributing to Risk of Retention?
Bladder procedures, anorectal
procedures
Anaesthetics
Anicholinergic medications
Opiates
Peri-operative fluid volume
Constipation/reduced mobility

Patients at Risk for Retention

Neurological disease (MS, Parkinsons,
chronic alcohol, diabetic neuropathy)
Trauma: spinal cord injury, pelvic #,
Bladder outlet obstruction (BPH, prostate
cancer, uterine/bladder prolapse,
impaction)
Iatrogenesis (medications, anaesthetics,
radiation, large volume replacement)
Elderly (detrusor hyperactivity with
impaired contractility)

Can Retention be Prevented?

Not always but
Often by avoiding transient causes:
Prevent or resolve constipation
Prevent or resolve bladder infection
Patient is up. Mobility helps
Toilet or commode are best
Upright, avoid bedpan
Adequate intake (minimum 1500 mL)
Void in response to urge not request
Discontinue anticholinergic meds if possible ASAP (e.g.
loxapine). Can take as much as 2 3 weeks to recover
from effects.

Detecting Retention:
Doing a Post Void Residual
Who should have a PVR?
Anyone who:

has difficulty voiding or inability to void

is incontinent
has recently had a catheter removed
has repeated urinary tract infections
has unexplained agitation
has unexplained distention

Some Normals You Will Need

to Know
Normal
Bladder capacity:
400 600 mL
Desire to void at
250 300 mL
300 400 mL per
void
Residual < 50 mL
1/3 voided volume at
night
No straining,
hesitation, pain or
post-void dribble

With changes of Aging

Bladder capacity 250
300 mL
Same or less
Total volume voided
per void decreases
Residual < 100 mL
Up to 2/3 voided
volume after 2000
No straining, pain, or
post-void dribble

Method for Measuring PVR

In & Out Catheterization or Bladder Scanner
Procedure:

Have patient void in as close as possible to

ideal position. Toilet or commode;
Measure the void.
Measure residual no later than 15 to 30 minutes
post void
Note: Bladder will empty best following natural
urge rather than when asked to void; ideally
first void in the morning

Interpreting PVR Results

< 50 mL normal at most ages
< 100 mL normal for elderly
Between 50 and 199 mL use clinical
judgement to determine impact on
individual (e.g frequent UTIs)
> 200 mL inadequate emptying report to
physician/refer to urologist if continues
> 400 mL requires In and Out catheter

You Have Discovered Retention.

Now What?
Get and order for In and Out catheter for residual > 400
mL & PRN (for discomfort)
Avoid Foley if possible because far more likely to cause
infection than I & O
Look for & manage transient causes:
Delirium (medications)
Constipation, impaction
Anticholinergic medications
Infection
Restricted mobility
Consider putting Foley in for 7 days to decompress the
bladder and/or until the patient mobile/until transient
causes removed
Then do trial of voiding
May try medications especially for men

Removal of Foley: Voiding Trials

Before taking Foley out ensure ideal conditions
for voiding
No constipation !!!!
No bladder infection
Patient is up. Mobility helps
Toilet or commode are best
Upright, avoid bedpan
Adequate intake (minimum 1500 mL)
Void in response to urge not request
Discontinue anticholinergic meds if possible (e.g.
loxapine). Sometimes need as much as 2 3 weeks to
recover from effects.

In and Out Catheterization for

Trial of voiding
Purpose:
To retrain bladder/restore bladder
capacity after Foley
To prevent reflux or hydronephrosis
J kidney damage
Goal:
To maintain total bladder volume (void
plus residual) less than 500 mL

Schedules for In and Out

Catheterization for Trial or for
Retention
Start with scan q.i.d. Do in and out for residual
volumes > 400 mL (or as physician orders)
When residuals consistently between 200 &
300 mL reduce cath to BID
When PVR under 200 mL - daily cath. usually
at hs
When consistently between 100 & 200 mL
check once per week
As long as bladder has less than 200 mL at
least once per day risk of infection is lowered

Schedule Needs Revision If:

Patient is uncomfortable (feeling of
bladder fullness between caths)
Patient leaks urine between In & Out
caths.
Patient has bladder spasms
Void plus residual is > 500 mL . Use chart
to determine time of day and add an extra
cath.
Spread out intake over day

Documentation
Chart void time
Void amount
Residual measurement time
Residual amount
Catherization time
Catheterization amount
NB times and volumes are all important

Post-Op Retention Retention

Is Predictable expect it
Is Preventable avoid transient
contributors
Is detectable In and out cath. or
bladder scanner. Follow procedure
Can be managed in a timely and
evidence-based way follow protocol.
Include prevention