Cases & Commentaries

Urinary Retention Dilemma

Commentary By Angela C. Joseph, RN, MSN, CURN

The Case

Following an elective thyroidectomy, a
56-year-old man with a history of benign prostatic hypertrophy
(BPH) and urinary hesitancy returned to the med-surg unit for
monitoring calcium balance (the thyroid is adjacent to the
parathyroid glands, which control the body's calcium balance).
After returning, the patient began complaining of problems with
urination, lower abdominal discomfort, and frequently voiding very
small amounts of urine. The nurse administered terazosin (an alpha
blocking agent for urinary obstruction), first the 2 mg initially
ordered by the physician; the dose was later increased to 10 mg by
the surgeon (the patient's pre-surgical dose). The total urine
output during the 24 hours following surgery was only 1200 cc
(which seemed low in light of the amount of intravenous hydration),
and it came in frequent, small amounts.

During this time, the patient became increasingly
uncomfortable and restless. During morning rounds, the surgeon
learned of the patient's continued difficulty voiding and ordered
urinary catheterization. The nurse catheterized the patient and
obtained 900 cc of urine (normal post-void residual volume is a few
hundred cc). The patient experienced immediate relief. The catheter
was then removed, and the patient was discharged a few hours
later.

After arriving home, the patient again became
increasingly uncomfortable and unable to void more than a small
amount. He called his urologist and was seen that afternoon. The
urologist placed a Foley catheter that yielded 800 cc urine. The
patient again experienced immediate relief. This time, the catheter
was left in for a week to allow the bladder to regain tone. During
this extended time with an indwelling catheter, the patient took
antibiotics to prevent a urinary tract infection.

The Commentary

Several issues arise when reviewing this case.
First, should patients have a urinary catheter in place during
surgery and postoperatively? There is not a single easy answer to
this question, since the decision hinges on a variety of physician,
hospital, and surgical factors. Although providers are often
reluctant to place catheters in an effort to minimize patient
discomfort and the risk of infection, short-term use of a catheter
may, at times, actually facilitate patient comfort and infection
control. For example, a large cross-sectional, prospective study
evaluated 2618 French men with BPH and acute urinary retention. Of
these patients, 71.6% developed spontaneous, acute urinary
retention and 28.0% developed acute urinary retention
postoperatively. Patients were treated with a trial without
catheters (with or without an alpha blocker) versus surgery for
their BPH. The results of the study favored catheterization over
the surgical approach. Based on these results, most institutions
now favor short-term use of catheterization (3 days or less), then
trial without a catheter after an episode of urinary retention. The
additional use of an alpha blocker prior to catheter removal
improved outcomes.(1)

Second, if indwelling catheters are not used,
what other options are available for patients like this one to
ensure bladder emptying? This patient had known BPH, with symptoms
of hesitancy (enlarged prostate preventing the bladder neck from
funneling and allowing urine to flow), frequency, small voided
volumes, and abdominal discomfort. This scenario should have
alerted the staff that the patient had a "failure to empty problem"
(2),
with a significant risk for urinary retention, especially since he
was not taking his alpha blocker. Having the patient "time void"
(void at predetermined intervals such as every 3–4 hours,
even when he had no urge to do so) would have provided the staff
important information about the patient's voiding function and risk
for postoperative urinary retention. Although the predictive
utility of a trial of time voiding needs further study (3), it
makes sense that prevention of overdistention of the bladder will
help prevent failure of the detrusor muscle by allowing the bladder
to decompress on a timed basis. To evaluate the effectiveness of
the patient's ability to void, the use of a bladder volume
instrument (BVI) (a portable, non-invasive instrument that allows
ultrasonic measurement of post-void residual) would have provided
additional objective evidence of the patient's ability to empty the
bladder with each void.(4)
Strict intake and output measurements, including BVI readings after
voiding and a bladder diary, provide objective documentation and
significant insight into the patient's voiding problem. If residual
volumes are small in comparison to the volume voided (eg, voided
volume of 500 cc with a post-void residual of 50 cc), then no
further intervention would be necessary. If post-void residual
volumes are large (eg, voided volume 150 cc and 500 cc retained),
then further intervention, such as double voiding and clean
intermittent catheterization, would be indicated.

For many years, clean intermittent
self-catheterization (CISC) has been used to facilitate bladder
emptying.(5,6)
It is affordable (particularly when catheters are cleaned and
reused) and easy for the patient to learn. The threat of urinary
retention and having to wait hours in the emergency room in
excruciating pain is also eliminated. If this patient was unable to
adequately empty his bladder, then he could have been placed on a
regimen of CISC every 4 hours after voiding. As voluntary voided
volumes increased, catheterizations could be systematically
decreased. This would have allowed the patient safe evacuation of
his bladder without having an indwelling catheter and concomitant
antibiotics to prevent urinary tract infection. CISC prevents the
continuous presence of a foreign body in the bladder (indwelling
urethral catheter) that will rapidly develop a biofilm that can
lead to infection. It also discourages the growth of opportunistic
bacterial colonies in the bladder that may invade the detrusor
muscle, cause a "symptomatic" urinary tract infection, and require
antibiotic use.

A systematic review of the Cochrane Database for
short-term indwelling urethral catheter use during hospitalization
found that intermittent catheterization, as opposed to indwelling
catheterization, was a better choice for patients with urinary
retention. Patients with indwelling catheters had higher
bacteriuria than patients with intermittent catheterization (RR
2.9; 95% CI 1.44–5.84); however, intermittent catheterization
was more costly.(8)

As part of nursing education, nurses are taught
to catheterize patients.(9) In
my experience working in a rehabilitation area, many of my patients
with neurogenic bladders utilize CISC exclusively to empty their
bladders. Morbidity is low unless patients fail to follow
established techniques of cleansing/storing catheters and
equipment.(6) If
patients are unable to self-catheterize because of an enlarged,
obstructive prostate, then an indwelling catheter can always be
inserted by the urologist until further treatment interventions
(such as medications or surgery) can be considered.

For the case at hand, the patient was placed on a
medication (terazosin) that can take days to relax the bladder neck
and relieve obstruction. Thus, the decision to discharge the
patient without a catheter or plans for self-catheterization after
terazosin was begun was an error, since the
reoccurrence of painful obstruction was predictable. Intermittent
catheterization would have relieved bladder distention and allowed
time for the medication to relax the bladder neck while preventing
the need for an indwelling urethral catheter and antibiotics that
may cause side effects.(10)

However the clinical situation was managed, the
case also illustrates problems in nurse-physician communication
surrounding the issue of urinary catheterization. In my experience,
such communication can be facilitated by using a simple protocol to
assist nurses and other providers in caring for these patients.
With the advent of computerized patient records, instructing and
educating nurses and other health care providers with a keystroke
is now possible.(11)
For patients with history of BPH and difficulty voiding, "pop up"
clinical reminders can be configured and made available prior to
writing orders and as part of the postoperative, daily, or
discharge notes. If computerized patient records are not available,
this information can be part of written protocols and procedures. A
sample protocol is shown in the Table.

In conclusion, this patient should have been
monitored for voiding with post-void residuals after surgery since
he had a known BPH problem. His terazosin should have been
restarted postoperatively. If the patient was unable to empty at
least three-quarters of his bladder volume, then CISC should have
been recommended and taught prior to discharge. If the patient
refused to do CISC or was incapable of doing it independently, then
an indwelling catheter should have been placed for 3 days, after
which time the catheter should have been removed and a voiding
trial performed. If the patient failed the voiding trial, then CISC
could be resumed until a mutually agreed upon treatment management
could be determined. This would have allowed the patient every
opportunity to enjoy the return of his bladder function without the
risk of overdistention due to outlet obstruction and pain due to
inability to void. The use of antibiotics, with their accompanying
risk of possible side effects, could have been avoided. Since there
are no guidelines to assist health care providers with decision
making in regard to BPH patients, institutions need to incorporate
agreed upon standards for acceptable voided volumes and post-void
residuals for this patient population.

Take-Home Points

  • Prior to discharge, surgical patients
    need to be able to empty their bladders "adequately." Demonstration
    of the patient's ability to void, as well as documentation of that
    ability, should be part of best practice. If patients are unable to
    void adequately, then CISC or short-term indwelling catheter, with
    or without an alpha blocker, needs to be considered.
  • A "pre-determined plan of care" will
    provide a standard of care for all BPH patients, facilitate
    communication, avoid confusion, and prevent inappropriate care.
    Policies for acceptable voided volumes and post-void residual
    amounts are dependent on the physician and institution.
  • Patients should have a follow-up
    appointment with MD within 1 week postoperatively and a 24-hour
    advice number to call for problems that arise during that
    week.

Angela C. Joseph, RN, MSN, CURN
Clinical Nurse Specialist
VA San Diego Heathcare System

References

1. Desgranchamps F, DeLa Taille A, Doublet JS,
for the RetenFrance Study Group. The management of acute urinary
retention in France: a cross-sectional survey in 2618 men with
benign prostatic hyperplasia. BJU Int. 2006;97:727-733.
[go to PubMed]

2. Barrett DM, Wein AJ. Voiding dysfunction:
diagnosis, classification and management. In: Gillenwater JY,
Grayhack JT, Howard SS, Duckett JW, eds. Adult and Pediatric
Urology. 2nd ed. St. Louis, MO: Mosby Year Book;
1991:1001-1099.

3. Ostaszkiewicz J, Roe B, Johnston L. Effects of
timed voiding for the management of urinary incontinence in adults:
systematic review. J Adv Nurs. 2005;52:420-431.
[go to PubMed]

4. Moselhi M, Morgan M. Use of a portable bladder
scanner to reduce the incidence of bladder catheterisation prior to
laparoscopy. BJOG. 2001;108:423-424.
[go to PubMed]

5. Lapides J, Diokno AC, Silber SJ, Lowe BS.
Clean, intermittent self-catheterization in the treatment of
urinary tract disease. J Urol. 1972;107:458-461.
[go to PubMed]

6. Madersbacher H, Wyndaele JJ, Igawa Y, et al.
Conservative management in neuropathic urinary incontinence. In:
Abrams P, Cardozo L, Khoury S, Wein A, eds. International
Consultation on Continence. 2nd ed. Plymouth, United Kingdom:
Plymbridge Distributors Ltd.; 2002.

7. Niel-Weise BS, van den Broek PJ. Antibiotic
policies for short-term catheter bladder drainage in adults.
Cochrane Database Syst Rev. July 20, 2005:CD005428.
[go to PubMed]

8. Niel-Weise BS, van den Broek PJ. Urinary
catheter policies for short-term drainage in adults. Cochrane
Database Syst Rev. July 20, 2005:CD004203.
[go to PubMed]

9. Ribby KJ. Decreasing urinary tract infections
through staff development, outcomes, and nursing process. J Nurs
Care Qual. 2006;21:272-276.
[go to PubMed]

10. Trautner BW, Darouiche RO. Role of biofilm in
catheter-associated urinary tract infection. Am J Infect Control.
2004;32:177-183.
[go to PubMed]

11. Darmer MR, Ankersen L, Nielsen BG, Landberger
G, Lippert E, Egerod I. Nursing documentation audit—the
effect of a VIPS implementation programme in Denmark. J Clin Nurs.
2006;15:525-534.
[go to PubMed]

Table

Protocol for patients with known BPH.

  • Time
    void patients by the clock every 4 hours
    postprocedure, measure, record.

  • Check
    bladder volume instrument (BVI) after void, measure, record.

  • Document
    with intake and output as part of the medical record.

  • Contact
    MD for order for straight catheterization if urine output is less than
    25% of total volume as determined by the post-void BVI measurement.
    Always have patient try to void first. Males will empty better
    standing since standing straightens the curve in urethra and lessens
    resistance.

  • With
    order for clean intermittent self-catheterization (CISC), teach
    patient how to catheterize prior to discharge and provide supplies for
    use at home.

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  • Time void patients by the clock every 4 hours postprocedure,
    measure, record.
  • Check bladder volume instrument (BVI) after void, measure,
    record.
  • Document with intake and output as part of the medical
    record.
  • Contact MD for order for straight catheterization if urine
    output is less than 25% of total volume as determined by the
    post-void BVI measurement. Always have patient try to void first.
    Males will empty better standing since standing straightens the
    curve in urethra and lessens resistance.
  • With order for clean intermittent self-catheterization (CISC),
    teach patient how to catheterize prior to discharge and provide
    supplies for use at home.