Neuraxial anesthesia and bladder dysfunction in the perioperative period: a systematic review

Review Article/Brief Review

Abstract

Purpose

Urinary retention requiring catheterization carries the risk of infection. Neuraxial anesthesia causes transient impairment of bladder function ranging from delayed initiation of micturition to frank urinary retention. We undertook a review of the literature to determine the elements of neuraxial anesthesia and analgesia that prolong bladder dysfunction and increase the incidence of urinary retention.

Methods

We performed a systematic search of the PubMed, MEDLINE, and EMBASE databases (from January 1980 to January 2011) to identify studies where neuraxial anesthesia and/or analgesia were employed and at least one of the following outcomes was reported: urinary retention, time to micturition, or post void residual. We included randomized controlled trials and observational studies published in the English language and we excluded case reports. The randomized trials were graded according to the Jadad score.

Principal findings

Our search yielded 94 studies, and in 16 of these studies, the authors reported time to micturition after intrathecal anesthesia of varying local anesthetics and doses. Intrathecal injections were performed in 41 of these studies, epidural anesthesia/analgesia was used in 39 studies, and five studies involved both the intrathecal and epidural routes. Meta-analysis was not possible because of the heterogeneity of interventions and reported outcomes. The duration of detrusor dysfunction after intrathecal anesthesia is correlated with local anesthetic dose and potency. The incidence of urinary retention displays a similar trend and is further increased by the presence of neuraxial opioids, particularly long-acting variants. Urinary tract infection secondary to catheterization occurred rarely.

Conclusions

Neuraxial anesthesia/analgesia results in transient detrusor dysfunction. The duration of dysfunction depends on the potency and dose of medication used; however, it does not appear to result in significant morbidity.

Anesthésie neuraxiale et dysfonction vésicale en période périopératoire: une revue systématique

Résumé

Objectif

Une rétention urinaire nécessitant un cathétérisme s’accompagne du risque d’infection. L’anesthésie neuraxiale provoque un trouble transitoire de la fonction vésicale allant du début retardé de la miction à la rétention urinaire franche. Nous avons entrepris une revue de la littérature pour déterminer les éléments de l’anesthésie et de l’analgésie neuraxiales qui prolongent la dysfonction vésicale et augmentent l’incidence de la rétention urinaire.

Méthodes

Nous avons effectué une recherche systématique dans les bases de données PubMed, MEDLINE et EMBASE (de janvier 1980 à janvier 2011) pour identifier des études dans lesquelles une anesthésie et/ou une analgésie neuraxiales ont été employées avec la description d’au moins l’un des résultats suivants: rétention urinaire, retard de miction, volume résiduel post mictionnel. Nous avons inclus les essais randomisés contrôlés et les études observationnelles publiées en anglais et avons exclu les comptes rendus de cas. Les essais randomisés ont été cotés selon le score de Jadad.

Constatations principales

Notre recherche a rassemblé 94 études et des retards de miction ont été décrits par les auteurs dans 16 de ces études, après anesthésie intrathécale avec différents anesthésiques locaux à des posologies variables. Des injections intrathécales ont été réalisées dans 41 de ces études; une anesthésie/analgésie épidurale a été utilisée dans 39 études; et les deux voies (intrathécale et épidurale) ont été utilisées dans cinq études. Une méta-analyse n’a pas été possible en raison de l’hétérogénéité des interventions et des résultats décrits. La durée des troubles dysfonctionnels du détrusor après anesthésie intrathécale est corrélée à la dose et à la puissance de l’anesthésique local. L’incidence de la rétention urinaire affiche une tendance comparable et est encore augmentée par la présence neuraxiale de morphiniques, en particulier de leurs formes à longue durée d’action. Les infections des voies urinaires après un cathétérisme ont été rares.

Conclusions

L’anesthésie/analgésie neuraxiale entraîne une dysfonction transitoire du détrusor. La durée des troubles fonctionnels dépend de la puissance et de la posologie du médicament utilisé; toutefois, cela ne semble pas se traduire par une morbidité significative.

Neuraxial anesthesia can result in significant bladder denervation in the perioperative period and can subsequently precipitate urinary retention.1 The dysfunction associated with this transient effect ranges from mild (with delayed initiation of micturition and incomplete bladder emptying) to severe (with urinary retention and bladder overdistension). When alleviated with catheterization, urinary retention can increase morbidity by introducing infection and increasing the length of hospital stay.2-5

Urinary retention is the inability to initiate micturition or to empty the bladder completely. There are no clear defining characteristics of urinary retention, such as a specific volume of urine or elapsed time postoperatively without micturition; however, in accordance with the consensus view in the contemporary literature, urinary retention would be described as an inability to initiate micturition with a bladder volume exceeding 500 mL.6 Urinary retention can be complete or partial, acute or chronic, painful or silent, obstructive or non-obstructive. “Overflow” incontinence secondary to excess intravesical pressure can occur. De novo incontinence secondary to sphincter damage, detrusor overactivity (urgency), or stress (precipitated by increased intra-abdominal pressure) developing in the perioperative period are uncommon occurrences. The long-term consequences of postoperative urinary retention (POUR) are not always immediately apparent in the perioperative period, although increased hospital length of stay and prolonged detrusor dysfunction have been documented.1,6

Neuraxial local anesthetics block the afferent and efferent limbs of the micturition reflex resulting in detrusor dysfunction and the inability to sense a full bladder, thus impairing micturition. Neuraxial opioids enhance this effect by decreasing the sensation of bladder fullness, thus increasing bladder capacity and weakening detrusor contraction through their actions at the spinal level and in the pontine micturition centre.7-9 Other previously identified perioperative and pre-existing risk factors for urinary retention include age, type of surgery, drug side effects, and benign prostatic hypertrophy, but none usually results in the transient, though dense, dysfunction caused by neuraxial anesthesia.

This study was initiated because a recent review on urinary retention did not focus specifically on urinary retention after neuraxial anesthesia and/or analgesia.1 The extensive work by Baldini et al. is a narrative review wherein they aim to give the reader a broad overview of the clinical problem.1 In the present study, we attempt to go beyond a narrative review and perform a systematic assessment of urinary outcomes, including time to micturition, incidence of catheterization, and subsequent frequency of urinary tract infection after neuraxial intervention. The primary aim of this review is to determine the incidence of urinary retention and any associated morbidity in patients following neuraxial anesthesia or analgesia and to identify risk factors prolonging impaired micturition.

Methods

A systematic search of the PubMed, MEDLINE, and EMBASE databases was performed from January 1980 to January 2011 using the medical subject heading (MeSH) words “neuraxial anesthesia” or “neuraxial analgesia” or “epidural” or “intrathecal” or “spinal”. These were combined with the MeSH terms “urinary retention” or “urinary incontinence” or “urinary catheterization” or “micturition” or “post void residual”. The search was limited to articles published in the English language and human adults. Each abstract was evaluated to identify studies where neuraxial anesthesia was utilized and urinary retention, or time to micturition, or post void residual was reported as an outcome. The references of the retrieved articles were hand searched for any relevant studies not captured in the original search. In addition to randomized controlled trials (RCTs), observational studies were also included because of the limited amount of data present in the literature.

Studies included in the review were categorized according to modality of neuraxial anesthesia – intrathecal or epidural. Studies involving combined spinal-epidural techniques were grouped with those utilizing epidural techniques because the effects of the epidural infusion typically outlast the effects of the intrathecal component. Studies were included even if patients did not undergo surgical procedures but were volunteers for urodynamic studies. Data were abstracted using a template created independently to identify the following information: primary author with year of publication, study design, Jadad score for RCTs, number of patients, surgical class, neuraxial medication employed (local anesthetic only, local anesthetic with short- or long-acting opioid, opioid only, undefined), incidence of urinary retention, average time to first micturition, and post void residual (PVR). If reported in the source study, we also abstracted the number of patients requiring catheterization and the incidence of urinary tract infection. Where possible, we reported the statistical significance for the incidence of urinary retention between comparators.

With each neuraxial technique, studies were further subdivided into the following categories: local anesthetic only, local anesthetic with long-acting opioid, local anesthetic with short-acting opioid, and undefined.

The methodology of each RCT was graded according to the criteria published by Jadad et al.10 All RCTs were included regardless of grade, and observational studies were not graded because it became clear after the initial literature review that the level of methodological rigour and study methods were so variable that meta-analysis would not be feasible or appropriate given that there is no easily communicated standard for grading observational studies. Two of the authors (S.C., P.M.) independently performed the literature search and data extraction. Results were combined and differences were resolved through discussion amongst the three authors (S.C., P.M., I.A.).

Results

Initially, 4,465 references were retrieved, and the search yielded 3,662 abstracts when limited to the English language and human subjects. Each abstract was reviewed, but it was not utilized if it did not state clearly that urinary retention, or PVR, or time to micturition was recorded as an outcome. If the abstract did not state specifically that spinal/epidural anesthesia and/or analgesia were employed, it was not retained.

We identified 94 studies (11,162 patients) where neuraxial anesthesia or analgesia was employed and where urinary retention, time to micturition, or PVR was reported as an outcome (Figure). Meta-analysis was not performed owing to the heterogeneity of the definitions of urinary retention, if at all provided, and the significant variability in the dose, type, and use of opioids in the neuraxial medications utilized.
Figure

Flow chart of screened, excluded, and included studies

In 16 of the 94 RCTs (1,066 patients), time to return of spontaneous micturition after intrathecal anesthesia was assessed as a primary outcome (Table 2).11-26 In 41 studies (5,548 patients), urinary retention or PVR with intrathecal anesthesia was assessed (Table 3),11,13,16,17,20,22,27-65 and in 39 studies (4,938 patients), urinary retention or PVR with epidural anesthesia and/or analgesia was assessed (Table 4).28,33,35,43,48-50,54,66-100 An additional five studies involved both intrathecal and epidural techniques. There is overlap in the numbers of patients/studies reported for Tables 2, 3, and 4 because multiple outcomes and/or multiple neuraxial procedures were examined in several studies. The characteristics of the included studies are detailed in Table 1. Among the 94 studies, 54 of the included studies were RCTs, 27 were prospective observational studies, and 13 were retrospective reviews. None of the included studies designated urinary retention as a primary outcome measure. Among the 94 studies, two studies investigated spinal anesthesia in volunteers with no surgical procedure performed.15,24
Table 1

Characteristics of the 94 studies retained for analysis

 

Number (n)

Percentage (%)

Study type

 Randomized trial

54

57

 Observational study

27

29

 Retrospective review

13

14

Jadad score (for RCTs)

 5

16

30

 4

3

6

 3

25

46

 2

5

9

 1

5

9

Type of neuraxial procedure

 Spinal only

51

54

 Epidural only

39

41

 Both spinal and epidural

5

5

Urologic outcome reported*

 Urinary retention

79

84

 Time to micturition

25

28

 Post void residual

4

5

 Catheterization

64

68

 Urinary tract infection

13

14

Urologic outcome as primary outcome

 Urinary retention

0

0

 Time to micturition

16

17

 Post void residual

0

0

Urinary Retention

 Defined

43

46

 Undefined

37

39

 Not applicable

14

15

Neuraxial medication type/dose

 Reported

74

79

  Local anesthetic only

35

47

  Local anesthetic + Opioid

31

43

 Opioid only

9

10

 Not Reported

20

21

Number of subjects

 < 50

42

44

 51-100

31

35

 101-150

8

8

 151-200

7

7

 > 200

6

6

n = number of studies; RCT = randomized controlled trial; *Due to instances where multiple urologic outcomes were reported, some studies were counted more than once

Of the 55 studies (including 16 RCTs in Table 2) reporting a urologic outcome after intrathecal anesthesia, 41 specifically assessed the incidence of urinary retention, 27 assessed for rate of catheterization, 16 assessed time to micturition, six reported rates of infection, and one reported PVR. Only 25 studies defined criteria for urinary retention. The criteria ranged from quoting bladder volumes (from 150-600 mL) or time frames (from 30 min to two days) to stating that catheterization was necessary without describing indications or that urinary retention was simply as inability to void without other defining criteria (Table 3).
Table 2

Studies with time to micturition as an outcome after intrathecal local anesthetics

Intrathecal Drug Type and Author/Year

Drug Dose (mg)

Concentration

Baricity

Number of Patients

Opioid

Time (min) to Micturition Mean (SD)

Required catheterization

Total (1,066 patients)

Bupivacaine (368 patients)

 Dijkstra 200814

15

0.5%

Iso

38

-

350 (N/A)

N/A

 Ben-David 199611

15

0.5%

Hyper

15

-

428 (34)

N/A

 Ben-David 199611

10

0.33%

Hyper

15

-

241 (14)

N/A

 Kamphuis 200818

10

0.75%

Hyper

10

-

462 (61)

N/A

 Lacasse 201121

7.5

0.75%

Hyper

53

-

338 (99)

N/A

 Gupta 200316

7.5

0.5%

Hyper

20

Fent 25 μg

335 (N/A)

4/20

 Yoos 200524

7.5

0.5%

Iso

8

-

191(32)

N/A

 Ben-David 199611

7.5

0.25%

Hyper

15

-

186 (14)

N/A

 Gupta 200316

6

0.5%

Hyper

20

Fent 25 μg

268 (N/A)

3/20

 Valanne 200123

6

0.5%

Hyper

51

-

203 (N/A)

N/A

 Kuusniemi 200020

6

0.5%

Hyper

30

-

228 (60)

N/A

 Kuusniemi 200020

6

0.5%

Iso

30

-

252 (60)

N/A

 Ben-David 199611

5

0.16%

Hyper

15

-

163 (8)

N/A

 Valanne 200123

4

0.5%

Hyper

48

-

172 (N/A)

N/A

L-bupivacaine (30 patients)

 Breebaart 200313

10

0.33%

Iso

30

-

284 (57)

1/30

Ropivicaine (30 patients)

 Breebaart 200313

10

0.5%

Iso

30

-

285 (65)

1/30

Lidocaine (315 patients)

 Kamphuis 200818

100

2%

Hyper

10

Sufent 20 μg

332 (52)

N/A

 Kamphuis 200818

100

2%

Hyper

10

-

233 (31)

N/A

 Urmey 199522

80

2%

Iso

29

-

215 (73)

N/A

 Breebaart 200313

60

2%

Iso

30

-

245 (65)

0/30

 Urmey 199522

60

2%

Iso

32

-

193 (30)

N/A

 Ben-David 200012

50

1%

Hypo

55

-

200 (102)

N/A

 Urmey 199522

40

2%

Iso

29

-

159 (36)

N/A

 Kawamata 200319

30

3%

Hyper

32

-

260 (N/A)

N/A

 Kawamata 200319

30

1%

Hyper

33

-

200 (N/A)

N/A

 Ben-David 200012

20

1%

Hypo

55

Fent 25 μg

188 (87)

N/A

Prilocaine (36 patients)

 Hendriks 200917

50

2%

Iso

36

-

227 (45)

2/36

Articaine (165 patients)

 Kallio 200626

100

4%

Hyper

30

-

279 (N/A)

N/A

 Dijkstra 200814

100

5%

Hyper

39

-

257 (N/A)

N/A

 Kallio 200626

84

4%

Hyper

30

-

271 (N/A)

N/A

 Kallio 200626

60

4%

Hyper

30

-

249 (N/A)

N/A

 Hendriks 200917

36

2%

Iso

36

-

184 (39)

1/36

2-Chloroprocaine (114 patients)

 Casati 200625

50

2%

Iso

15

-

203 (N/A)

N/A

 Lacasse 201121

40

2%

Iso

53

-

271 (87)

N/A

 Yoos 200524

40

2%

Iso

8

-

113 (14)

N/A

 Casati 200625

40

2%

Iso

15

-

198 (N/A)

N/A

 Casati 200625

30

2%

Iso

15

-

182 (N/A)

N/A

 Gonter 200515

30

1.5%

Hyper

8

-

103 (12)

N/A

Procaine (8 patients)

 Gonter 200515

80

4%

Hyper

8

-

156 (23)

N/A

Fent = fentanyl; Hyper = hyperbaric; Hypo = hypobaric; Iso = isobaric; N/A = not available; SD = standard deviation; Sufent = sufentanil

Table 3

Intrathecal anesthesia studies

Author/Year

Study Design

Jadad Score

N

Surgical Class

Intrathecal Drug/Dose

Incidence of Retention (%)

PVR (mL)

Catheterization (%)

Infection (%)

Comments

Total 5,548 patients

Local anesthetic only (4,662 patients)

Tetracaine

 Carpiniello 198830

OBS

N/A

77

ORTHO

Tetracaine dose N/A

34/77 (44.1)

N/A

34/77 (44.1)

8/77 (10.4)

Retention defined as requiring catheterization

 Ryan 198454

REV

N/A

25

GEN

1. Lidocaine dose N/A (n = 4)

1. 0/4 (0)

N/A

1. 0/4 (0)

N/A

Retention defined as requiring catheterization

2. Tetracaine dose N/A (n = 21)

2. 6/21 (28.6)

2. 6/21 (28.6)

*See Table 4 – long-acting spinal/epidural 16/53

Bupivacaine

 Ben-David 199611

RCT

3

60

ORTHO

Hyperbaric Bupivacaine 0.5%

 

N/A

N/A

N/A

Retention not defined

1. 15 mg (n = 15)

1. 0/15 (0)

2. 10 mg + 1 mL NS (n = 15)

2. 0/15 (0)

3. 7.5 mg + 1.5 mL NS (n = 15)

3. 0/15 (0)

4. 5 mg + 2 mL NS (n = 15)

4. 0/15 (0)

 Farag 200535

RCT

1

22

ORTHO

Bupivacaine 15 mg

0/22 (0)

N/A

0/22 (0)

N/A

Retention not defined

Compared with epidural ropivacaine

 Moreno-Egea 200047

OBS

N/A

41

GEN

Hyperbaric Bupivacaine 0.5%

1/41 (2.4)

N/A

N/A

N/A

Retention not defined

13 mg

 Jellish 199637

RCT

3

61

ORTHO

Hyperbaric Bupivacaine 0.75% 11 mg

9/61 (14.8)

N/A

9/61 (14.8)

N/A

Retention defined as requiring catheterization, volume/time not specified

 Anannamcharoen 200827

RCT

3

67

GEN

Hyperbaric Bupivacaine 0.5% 7.5-10 mg (n = 33)

10/33 (30.3)

N/A

10/33 (30.3)

N/A

Retention not defined

In favour of local infiltration for incidence of retention and requirement for catheterization (P = 0.03)

 Casati 200431

RCT

3

120

ORTHO

Hyperbaric Bupivacaine 0.5%

8 mg (n = 40)

3/40 (7.5)

N/A

N/A

N/A

Significant difference in retention (P = 0.03) compared with TIVA or combined FEM/SCI

Significant difference in time to micturition (P < 0.0005) spinal vs other groups (260 vs 145-180 min)

 Fanelli 200034

RCT

3

94

ORTHO

Hyperbaric Bupivacaine 0.5%

8 mg

0/94 (0)

N/A

N/A

N/A

Retention defined as the inability to initiate micturition within 6 hr

 Luger 200844

OBS

N/A

45

ORTHO

Hyperbaric Bupivacaine 0.5%

6-7.5 mg

14/45 (31.1)

N/A

14/45 (31.1)

N/A

Retention defined as bladder volume > 500 mL by US or inability to void 4 hr after intrathecal injection

 Esmaoglu 200432

RCT

1

70

ORTHO

Hyperbaric Bupivacaine 0.5% 7.5 mg (n = 25)

3/35 (8.6)

N/A

3/35 (8.6)

N/A

Retention defined as inability to initiate micturition – time not indicated

Hypobaric Bupivacaine 0.18% 7.5 mg (n = 25)

0/35 (0)

 

0/35 (0)

 Kaya 200438

RCT

3

50

ORTHO

Hyperbaric Bupivacaine 0.5% 7.5 mg (n = 25)

0/25 (0)

N/A

N/A

N/A

Retention not defined

Hypobaric Bupivacaine 0.18% 7.5 mg (n = 25)

0/25 (0)

 Borghi 200329

RCT

5

90

ORTHO

Hyperbaric Bupivacaine 0.5%

 

N/A

 

N/A

Retention not defined

1. 4 mg (n = 30)

1. 0/30 (0)

 

1. 0/30 (0)

2. 6 mg (n = 30)

2. 0/30 (0)

 

2. 0/30 (0)

3. 8 mg (n = 30)

3. 0/30 (0)

 

3. 0/30 (0)

 Sungurtekin 200358

RCT

3

60

GEN

Hyperbaric Bupivacaine 0.5% 7.5 mg (n = 30)

2/30 (6.7)

N/A

N/A

N/A

Retention not defined

Compared to local infiltration, no difference

 Voelckel 200962

RCT

3

40

ORTHO

Hyperbaric Bupivacaine 0.5%

5 mg

13/20 (65.0)

N/A

9/20 (45.0)

N/A

Retention defined as bladder volume > 500 mL by US and inability to initiate micturition

 Faas 200233

REV

N/A

113

GEN

1. Lidocaine 5% dose N/A (n = 77)

*7/113 (6.2)

N/A

*7/113 (6.2)

N/A

Retention defined as requiring catheterization

2. Bupivacaine 0.75% dose N/A (n = 19)

No criteria for catheterization defined

3. Procaine 10% dose N/A (n = 16)

*Results were reported as combined totals and not differentiated between drug/dose

4. Tetracaine 1% dose N/A (n = 1)

 Mulroy 200249

RCT

3

110

AMB

1. Procaine 85 mg (n = 67)

1. 0/67 (0)

N/A

3/201* (1.5)

N/A

Retention defined as bladder volume > 400 mL by US and unable to initiate micturition in PACU

2. Lidocaine 60 mg (n = 28)

2. 0/28 (0)

3. Bupivacaine 6 mg (n = 15)

3. 0/15 (0)

* Study did not differentiate between 110 undergoing spinal and 91 undergoing epidural block

 Kuusniemi 200020

RCT

3

60

ORTHO

1. Isobaric Bupivacaine 0.5%

1. 0/30 (0)

N/A

N/A

N/A

Retention not defined

2. 6 mg (n = 30)

2. 0/30 (0)

3. Hyperbaric Bupivacaine 0.5% 6 mg (n = 30)

 

 Keita 200539

OBS

N/A

42

GEN

Bupivacaine 0.5% dose N/A

7/42 (16.7)

N/A

7/42 (16.7)

N/A

Retention defined as bladder volume > 600 mL and unable to initiate micturition

ORTHO

URO

 Lamonerie 200441

OBS

N/A

19

ORTHO

Bupivacaine 0.5% dose N/A

11/19 (57.9)

N/A

11/19 (57.9)

N/A

Retention defined as bladder volume

GEN

> 500 mL and inability to micturate after 30 min

 Pavlin 199850

OBS

N/A

84

AMB

1. Bupivacaine dose N/A (n = 54)

1. 16/107* (15.0)

N/A

N/A

N/A

Retention defined as inability to void

2. Lidocaine dose N/A (n = 31)

*No differentiation between types of local anesthetic and spinal vs epidural

 Petros 199052

REV

N/A

111

GEN

1. Bupivacaine 0.5% dose N/A (n = 58)

1. 26/59 (44.1)

N/A

1. 26/59 (44.1)

N/A

Retention defined as catheterization volume > 400 mL

2. Lidocaine 5% dose N/A (n = 52)

2. 10/52 (19.2)

 

2. 10/52 (19.2)

Catheterization when bladder palpable with patient urge

 Schmittner 201056

RCT

1

201

GEN

Hyperbaric Bupivacaine 0.5%

5 mg (n = 101)

N/A

N/A

N/A

N/A

No difference between spinal vs TIVA. Time to micturition:

Spinal – 237 min, TIVA – 230 min

Prilocaine

 Kreutziger 201040

OBS

N/A

86

ORTHO

Prilocaine 2% 60 mg

20/86 (23.3)

123

20/86 (23.3)

0/86 (0)

Retention defined as bladder volume > 600 mL and inability to initiate micturition

 Hendriks 200917

RCT

4

72

ORTHO

1. Prilocaine 2% 50 mg (n = 36)

N/A

N/A

1. 3/36 (8.3)

N/A

In favour of Articaine (P < 0.001)

2. Articaine 2% 50 mg (n = 36)

2. 1/36 (2.8)

Criteria for catheterization not defined

Lidocaine

 Breebaart 200313

RCT

5

90

ORTHO

1. Isobaric Lidocaine 2% 60 mg (n = 30)

1. 0/30 (0)

N/A

1. 0/30 (0)

N/A

Retention defined as bladder volume > 500 mL and unable to void, sensation but unable to initiate micturition, or PVR of > 300 mL

2. Isobaric L-bupivacaine 0.33% 10 mg (n = 30)

2. 1/30 (3.3)

 

2. 1/30 (3.3)

3. Isobaric Ropi 0.5% 10 mg (n = 30)

3. 1/30 (3.3)

 

3. 1/30 (3.3)

 Urmey 199760

RCT

5

40

ORTHO

Isobaric Lidocaine 2% 60 mg (n = 40)

0/40 (0)

N/A

0/40

N/A

Retention defined as inability to void

*RCT between different needle aperture directions

 Urmey 199522

RCT

3

90

ORTHO

Isobaric Lidocaine 2%

 

N/A

N/A

N/A

Retention defined as inability to void prior to discharge

1. 40 mg (n = 29)

1. 0/29 (0)

2. 60 mg (n = 32)

2. 0/32 (0)

3. 80 mg (n = 29)

3. 0/29 (0)

 Toyonaga 200659

REV

N/A

2011

GEN

Lidocaine 3% dose N/A

336/2,011 (16.7)

N/A

336/ 2,011 (16.7)

N/A

Retention defined as inability to void and requiring catheterization > 24 hr postoperatively

1,442 received epidural eptazocine

 Petros 199153

REV

N/A

145

GEN

Lidocaine 5% dose N/A

12/145 (13.8)

N/A

12/145 (13.8)

N/A

Retention defined as catheterization volume > 400 mL Catheterization when bladder palpable with patient urge

 Linares-Gil 200942

OBS

N/A

406

GEN (n = 219)

3% Hyperbaric Lidocaine 0.9 mg·kg−1

N/A

N/A

0/406 (0)

N/A

Criteria for catheterization not indicated

ORTHO (n = 187)

Mepivacaine

 Pawlowski 200051

RCT

5

60

ORTHO

1. Isobaric Mepiv 1.5% 60 mg (n = 29)

0/29 (0)

N/A

N/A

N/A

Retention not defined

2. Isobaric Mepiv 2% 80 mg (n = 31)

0/31 (0)

Local anesthetic with long-acting opioid (85 patients)

Zacharoulis 200964

OBS

N/A

45

GEN

Hyperbaric Bupivacaine 0.5% 15 mg, morphine 250 μg, fent 20 μg

16/45 (35.6)

N/A

16/45 (35.6)

1/16 (6.3)

Retention not defined

Mahan 199345

REV

N/A

40

ORTHO

Hyperbaric Tetracaine 5-8 mg + morphine 0.2-0.4 mg (n = 40)

10/40 (25.0)

N/A

10/40 (25.0)

N/A

Retention defined as volume 400-600 mL and inability to void despite urge, distended bladder, unable to void after bethanecol, and requiring catheterization

Local anesthetic with short-acting opioid (381 patients)

McLain 200546

OBS

N/A

200

ORTHO

Isobaric Bupivacaine 0.5%

16/200 (8.0)

N/A

N/A

N/A

Retention not defined

No difference compared with general anesthesia

15 mg, fent 2 μg, epi 200 μg

Song 200057

RCT

3

25

GEN

Hyperbaric Bupivacaine 0.75% 9-11.25 mg + fent 25 μg

5/25 (20.0)

N/A

N/A

N/A

Retention not defined

van Veen 200861

RCT

3

100

GEN

Hyperbaric Bupivacaine 0.5%, sufent dose N/A (n = 49)

13/49 (75.5)

N/A

13/49 (26.5)

0/13 (0)

Local infiltration vs intrathecal

Bladder volume assessed by US 3 hr postoperatively

Volume to define retention N/A

Gupta 200316

RCT

5

40

GEN

Fent 25 μg with Hyperbaric Bupivacaine 0.5% 6 mg (n = 20)

3/20 (15.0)

N/A

3/20 (15.0)

N/A

Retention defined as bladder volume > 500 mL and unable to void requiring catheterization

Hyperbaric Bupivacaine 0.5% 7.5 mg (n = 20)

4/20 (20.0)

 

4/20 (20.0)

No significant difference between groups

Mulroy 200048

RCT

3

16

ORTHO

Procaine 75 mg + fent 20 μg

0/16 (0)

N/A

N/A

N/A

Retention defined as inability to void

Undefined (420 patients)

Lingaraj 200743

REV

N/A

23

ORTHO

N/A

0/23 (0)

N/A

N/A

N/A

Retention not defined

Sarasin 200655

OBS

N/A

182

ORTHO

N/A

94/182 (51.6)

N/A

94/ 182 (51.6)

N/A

Retention defined as bladder volume > 500 mL by US

Bodker 200328

OBS

N/A

16

GYN

N/A

1/16 (6.3)

N/A

1/16 (6.3)

0/16

Retention defined as postoperative bladder volume by US exceeding preoperative volume and unable to initiate micturition

Zaheer 199865

REV

N/A

78

GEN

N/A

28/78 (35.9)

N/A

28/78 (35.9)

N/A

Retention defined as requiring catheterization within 24 hr

Fleischer 199436

OBS

N/A

28

GEN

N/A

9/28 (32.1)

N/A

N/A

N/A

Retention not defined

Young 198763

REV

N/A

93

GEN

N/A

17/93 (18.2)

N/A

N/A

6/93 (6.5)

Retention not defined

AMB = ambulatory; fent = fentanyl; epi = epinephrine; GEN = general surgery; FEM/SCI = femoral/sciatic; GYN = gynecology; morph = morphine; N = number in group; n = number in study; N/A = not applicable or not indicated in study; NS = normal saline; OBS = observational study; ORTHO = orthopedic; PACU = postanesthesia care unit; PVR = post void residual; RCT = randomized controlled trial; REV = retrospective review; ropi = ropivacaine; sufent = sufentanil; TIVA = total intravenous anesthetic; URO = urology; US = ultrasound

Forty-two of the 44 studies reporting a urologic outcome after epidural analgesia specifically assessed the incidence of urinary retention. Similarly, only 26 studies defined criteria for urinary retention, but these criteria were as varied as those in the studies reporting intrathecal anesthesia. Thirty-one studies reported catheterization rates, seven reported infection rates, and only one reported PVR.

Local anesthetic type and dose

The incidence of POUR appears correlated with the specific intrathecal local anesthetic utilized. The studies reporting incidence rates of > 20% were those utilizing either tetracaine or bupivacaine, while those employing procaine or lidocaine reported incidence rates < 20% (Table 3). The studies utilizing epidural analgesia are difficult to assess in this respect because of the highly variable durations of infusion (Table 4).
Table 4

- Epidural anesthesia or analgesia studies

Author/Year

Study Design

Jadad Score

N

Surgical Class

Epidural Drug/Dose

Incidence of Retention (%)

PVR (mL)

Catheterization (%)

Infection (%)

Comments

Total 4,938 patients

Local Anesthetic only (672 patients)

Bupivacaine

 Matthews 198986

OBS

N/A

9

THOR

Bupivacaine 0.25% 5 mL·hr−1

6/9 (66.7)

N/A

6/9 (66.7)

N/A

Retention defined as requiring catheterization

Criteria for catheterization not defined

 Singelyn 200595

RCT

3

15

ORTHO

Bupivacaine 0.125% 10 mL·hr−1

6/15 (40.0)

N/A

N/A

N/A

Retention defined as requiring catheterization

 Lanz 198284

RCT

5

117

ORTHO

1 Mepivacaine 2% (n = 72)

2 Bupivacaine 0.5% (n = 45)

19/117 (16.2)

N/A

19/117 (16.2)

N/A

Retention defined as requiring catheterization

Criteria for catheterization not defined

 Ryan 198454

REV

N/A

81

GEN

1 Bupivacaine, dose N/A (n = 32)

2 Lidocaine, dose N/A (n = 21)

3 Mepivacaine, dose N/A (n = 12)

4 2-Chloroprocaine, dose N/A (n = 14)

5 Prilocaine, dose N/A (n = 2)

10/81 (12.3)

N/A

9/81 (11.1)

N/A

Retention defined as requiring catheterization

Unclear as to which local anesthetic resulted in retention

Criteria for catheterization not defined

Ropivacaine

 Farag 200535

RCT

1

16

ORTHO

Ropivacaine 1% 15 mL

0/16 (0)

N/A

N/A

N/A

Retention not defined

Compared with intrathecal bupivacaine

 Ladak 200983

OBS

N/A

5

THOR

Ropivacaine 0.2%

0/5 (0)

N/A

N/A

N/A

Thoracic epidural

Retention defined as US bladder volume > 600 mL or by inability to void

 Evron 200675

RCT

5

100

OB

Ropivacaine 0.2% 5 mL·hr−1, PCEA 5 mL

1/100 (1.0)

N/A

1/100 (1.0)

10/100 (10.0)

Retention defined as bladder volume > 300 mL by US

Numbers reported are postpartum after epidural removal

33% of patients catheterized during labour

Criteria for catheterization not defined

 Turner 199697

RCT

2

115

ORTHO

Ropivacaine 0.2%

6 mL·hr−1 (n = 22)

8 mL·hr−1 (n = 23)

10 mL·hr−1 (n = 23)

12 mL·hr−1 (n = 24)

14 mL·hr−1 (n = 23)

2/22 (9.1)

1/22 (4.7)

2/22 (9.1)

5/24 (20.8)

7/24 (29.2)

N/A

N/A

N/A

Retention not defined

Prilocaine

 Gurel 198678

OBS

N/A

35

GEN

Prilocaine 2% 400 mg (n = 35)

11/35 (31.4)

N/A

6/35 (17.1)

N/A

Retention defined as being unable to void within 12 hr of epidural

 Reiz 198092

RCT

3

18

ORTHO

Prilocaine 2% + epi 5 μg·mL−1 (n = 18)

0/18 (0)

N/A

N/A

N/A

Retention not defined

Lidocaine

 Faas 200233

REV

N/A

31

GEN

Lidocaine 2% + epi, dose N/A

2-Chloroprocaine 3%, dose N/A

1/31 (3.2)

N/A

1/31 (3.2)

N/A

Retention defined as requiring catheterization

Criteria for catheterization not defined

 Mulroy 200249

RCT

3

91

AMB

2-Chloroprocaine 2% – 21 mL (n = 43)

Lidocaine 2% – 19 mL (n = 48)

0/91 (0)

N/A

0/91 (0)

N/A

See Table 1 for comments

Criteria for catheterization not defined

 Pavlin 199850

OBS

N/A

23

AMB

Lidocaine, dose N/A

16/107* (15.0)

N/A

N/A

N/A

Retention defined as inability to void

*No differentiation between types of local anesthetic and spinal vs epidural

2-Chloroprocaine

 Mulroy 200048

RCT

3

16

ORTHO

2-Chloroprocaine 3% 450 mg

0/16 (0)

N/A

0/16 (0)

N/A

Retention defined as inability to void

Criteria for catheterization not defined

Local anesthetic with long-acting opioid (555 patients)

Bupivacaine

Evron 198576

OBS

N/A

80

OB

Bupivacaine 0.5% 20 mL

1. Morphine 4 mg (n = 40)

2. Methadone 4 mg (n = 40)

20/40 (50.0)

1/40 (2.5)

N/A

1. 23/40 (57.5)

2. 1/40 (2.5)

1. 4/40 (10.0)

2. 0/40 (0)

Retention not defined

Criteria for catheterization not defined

 Lanz 198284

RCT

5

57

ORTHO

1 Mepivacaine 2% + morph 0.1 mg·kg−1 (n = 35)

2. Bupivacaine 0.5% + morph 0.1 mg·kg−1 (n = 22)

22/57 (38.6)

N/A

22/57 (38.6)

N/A

Retention defined as requiring catheterization

Criteria for catheterization not defined

 Bigler 198970

RCT

3

10

GEN

Bupivacaine 0.5% + morph 20 μg·mL−1, 5 mL·hr−1

1/10 (10.0)

N/A

1/10 (10.0)

N/A

Retention defined as requiring catheterization

Criteria for catheterization not defined

 Basse 200069

OBS

N/A

98

GEN

Bupivacaine 0.25% + morph 50 μg, 4 mL·hr−1

9/98 (9.2)

N/A

9/98 (9.2)

4/98 (4.1)

Retention defined as requiring re-insertion of catheter after trial of void on postoperative day 2

 Ladak 200983

OBS

N/A

44

THOR

Bupivacaine 0.1% + hydromorph 15 μg·mL−1

5/44 (11.4)

N/A

N/A

N/A

Thoracic epidural

Retention defined as US bladder volume > 600 mL or by inability to void

 Gedney 199877

RCT

3

160

ORTHO

Bupivacaine 0.0625%  + 

1. Diamorph 50 μg·mL−1

2. Morph 50 μg·mL−1

3. Fent 2 μg·mL−1

4. Meth 100 μg·mL−1

5. Pethidine 1 mg·mL−1

Bupivacaine 0.125%  + 

6. Diamorph 50 μg·mL−1

7. Morph 50 μg·mL−1

8. Fent 2 μg·mL−1

9. Meth 100 μg·mL−1

10. Pethidine 1 mg·mL−1

16 patients per group 6-8 mL·hr−1 x 48 hr

52/98 (53.1)

N/A

52/98 (53.1)

N/A

Retention defined as requiring catheterization

62 patients catheterized preoperatively and maintained throughout epidural infusion not included in calculation

Criteria for catheterization not defined

Ropivacaine

 Kim 200682

RCT

5

30

GEN

Ropivacaine 0.2% + morph 36 μg·mL−1 5 mL·hr−1, PCEA 0.5 mL

13/30 (43.3)

N/A

1/30 (3.3)

N/A

Retention defined as serious major problems according to scale described by Vercauteren98

Prilocaine

 Gurel 198678

OBS

N/A

44

GEN

Prilocaine 2% 400 mg + morph 3 mg (n = 44)

35/44 (79.5)

N/A

12/44 (27.3)

N/A

Retention defined as being unable to void within 12 hr of epidural

 Reiz 198092

RCT

3

15

ORTHO

Prilocaine 2% + epi 5 μg·mL−1 + postoperative Morphine (mean 3.6 mg)

2/15 (13.3)

N/A

N/A

N/A

Retention not defined

Lidocaine

 Capdevila 199972

RCT

2

17

ORTHO

Lidocaine 1% + morph 30 μg·mL−1 + clonidine 2 μg·mL−1, 0.1 mL·kg−1

9/17 (52.9)

N/A

9/17 (52.9)

N/A

Retention defined as inability to void despite urge

Local anesthetic with short-acting opioid (1,579 patients)

Bupivacaine

 Oloffson 199788

RCT

3

1,000

OB

Bupivacaine 0.25% + sufent 5 μg·mL−1 (n = 500), 6 mL bolus

Bupivacaine 0.125% + sufent 10 μg (n = 500) 6 mL bolus

17/500 (3.4)

10/500 (2.0)

N/A

17/500 (3.4)

10/500 (2.0)

N/A

Retention defined as inability to void with bladder volume > 500 mL

 Turker 200396

RCT

2

30

ORTHO

Bupivacaine 0.125% + fent 2 μg·mL−1, 10 mL·hr−1

7/30 (23.3)

N/A

N/A

N/A

Retention not defined

 Singelyn 199894

OBS

N/A

64

ORTHO

Bupivacaine 0.125% + sufent 0.1 μg·mL−1 + clonidine 1 μg·mL−1, 5-7 mL·hr−1, PCEA 2.5 mL

21/64 (32.8)

N/A

N/A

N/A

Retention not defined

 Vercauteren 199898

RCT

5

60

ORTHO

Sufent 0.1 μg·mL−1 epidural 3 mL·hr−1, PCEA 3 mL

1. Bupivacaine 0.12% (n = 20)

2. Bupivacaine 0.06% (n = 20)

3. No Bupivacaine (n = 20)

8/20 (40.0)

2/20 (10.0)

3/20 (15.0)

N/A

8/20 (40.0)

2/20 (10.0)

3/20 (15.0)

N/A

Retention defined as requiring catheterization

Catheterization performed with

1. Incontinence

2. Inability to urinate > 18 hr postoperatively or 6 hr from previous void

3. Severe urge, but cannot initiate

4. Inability to void > 200 mL

 Wuethrich 2010100

OBS

N/A

13

URO

Bupivacaine 0.1% + fent 2 μg·mL−1 + epi

2 μg·mL−1 – 8 mL·hr−1, PCEA 5 mL

N/A

425

13/13 (100.0)

0/13 (0)

Thoracic epidural

PVR returned to normal after epidural discontinued

 Chu 200674

RCT

1

60

ORTHO

Bupivacaine 0.1% + fent 2 μg·mL−1, rate N/A

8/30 (26.7)

N/A

N/A

N/A

Retention not defined

 Carli 200273

RCT

2

32

GEN

Bupivacaine 0.1% + fent 2 μg·mL−1, 8-15 mL·hr−1

2/32 (6.3)

N/A

2/32 (6.3)

0/32

Retention defined as requiring catheterization for inability to void

 Paulsen 200189

RCT

2

23

GEN

Bupivacaine 0.1% + fent 5 μg·mL−1, 8-10 mL·hr−1

3/23 (13.4)

N/A

3/23 (13.4)

3/23

Retention not defined

Criteria for catheterization not defined

 Senagore 200393

RCT

3

18

GEN

Bupivacaine 0.1% + fent 20 μg·mL−1, 4-6 mL·hr−1

1/18 (5.6)

N/A

N/A

N/A

Retention not defined

Ropivacaine

 Niemi 200287

RCT

5

12

GEN

Ropivacaine 0.1% + fent 2 μg·mL−1 + epi

2 μg·mL−1

4/12 (33.3)

N/A

4/12 (33.3)

N/A

Retention not defined

Indication for catheterization not defined

 Liang 201085

OBS

N/A

60

OB

Ropivacaine 0.067% + fent 2.5 μg·mL−1 – 5 mL·hr−1, PCEA 4 mL

9/60 (15.0)

N/A

4/60 (6.7)

N/A

Retention defined as PVR > 150 mL or bladder volume > 500 mL by US and unable to void

 Evron 200675

RCT

5

98

OB

Ropivacaine 0.2% + fent 2 μg·mL−1 – 5 mL·hr−1, PCEA 5 mL

4/98 (4.1)

N/A

4/98 (4.1)

7/98 (7.1)

Retention defined as bladder volume > 300 mL by US

Numbers reported are postpartum after epidural removal

33% of patients in each group catheterized during labour

Criteria for catheterization not defined

 Kim 200682

RCT

5

30

GEN

Ropivacaine 0.2% + sufent 0.9 μg·mL−1

5 mL·hr−1, PCEA 0.5 mL

0/30 (0)

N/A

0/30 (0)

N/A

Retention defined as serious major problems according to scale described by Vercauteren87

 Borghi 200471

RCT

1

48

ORTHO

Ropivacaine 0.2% + sufent 0.25 μg·mL−1

4 mL·hr−1, PCEA 5 mL

N/A

N/A

29/48 (60.4)

N/A

Indication for catheterization not defined

Lidocaine

 Kau 200381

RCT

3

31

GEN

Lidocaine 30 mg + fent 20 μg

0/31 (0)

N/A

0/31 (0)

N/A

Retention not defined

Criteria for catheterization not defined

Opioid only (1,552 patients)

Morphine

 Petersen 198290

OBS

N/A

32

GEN

Morphine 25.9-32.3 mg

14/32 (44.8)

N/A

14/32 (44.8)

N/A

Retention defined as sensation of requiring voiding but unable to initiate

 Husted 198580

OBS

N/A

12

GYN

Morphine 4 mg q 20 min, mean 27.9 mg

2/12 (16.7)

N/A

N/A

N/A

Retention not defined

 Viscusi 200599

RCT

5

183

ORTHO

Extended release morphine

15 mg (n = 47)

20 mg (n = 45)

25 mg (n = 43)

1/136 (0.7)

N/A

N/A

N/A

Retention not defined

 Reiz 198091

REV

N/A

1,200

N/A

Morphine 2 mg

181/1,200 (15.1)

N/A

N/A

N/A

Retention not defined

 Liang 201085

OBS

N/A

60

OB

Morphine 1.5 mg (n = 60)

20/60 (33.3)

N/A

13/60 (21.7)

N/A

Retention defined as PVR > 150 mL or bladder volume > 500 mL by US and unable to void

 Gustaffson 198279

RCT

3

10

ORTHO

Morphine 0.05 mg·kg−1

2/10 (20.0)

N/A

2/10 (20.0)

N/A

Retention defined as requiring catheterization

Criteria for catheterization not defined

Fentanyl

 Baron 199667

RCT

5

34

THOR

Infusion 0.5 μg·kg−1·hr−1

Fent 5 μg·mL−1(n = 16)

Fent 5 μg·mL−1 + epi 3.3 μg·mL−1 (n = 18)

8/16 (50.0)

10/18 (55.6)

N/A

8/16 (50.0)

10/18 (55.6)

N/A

Retention defined as requiring catheterization

Criteria for catheterization not defined

Ahuja 198566

OBS

N/A

21

GEN

Fent 0.5-1 μg·kg−1·hr−1

0/21 (0)

N/A

0/21 (0)

0/21

Retention not defined

Criteria for catheterization not defined

THOR

Undefined (580 patients)

 Barretto 200768

OBS

N/A

487

ORTHO

THOR

N/A

115/487 (23.6)

N/A

115/487 (23.6)

N/A

Retention defined as inability to void spontaneously

 Lingaraj 200743

REV

N/A

26

ORTHO

N/A

6/26 (23.1)

N/A

6/26 (23.1)

N/A

Retention defined as unable to void spontaneously and requiring catheterization

Criteria for catheterization not defined

 Bodker 200328

OBS

N/A

67

GYN

N/A

9/67 (13.4)

N/A

9/67 (13.4)

0/67 (0)

Retention defined as bladder volume by US exceeding pre-op bladder capacity estimate and inability to void

AMB = ambulatory, Diamorph = diamorphine, epi = epinephrine, Fent = fentanyl, GEN = general surgery, GYN = gynecology, hydromorph = hydromorphone; Meth = methadone, morph = morphine, n = number in group, N = number in study, N/A = not applicable or not indicated in study, OB = obstetric, OBS = observational study, ORTHO = orthopedic surgery, PCEA = patient controlled epidural analgesia, PVR = post void residual, RCT = randomized controlled trial, REV = retrospective review, Sufent = sufentanil, THOR = thoracic surgery, URO = urology, US = ultrasound

The 16 RCTs that specifically examined time to return of spontaneous micturition after intrathecal anesthesia as a primary outcome assessed several local anesthetics in differing concentrations, densities, and doses (Table 2). The time to first micturition varied from 103 min15 (2-chloroprocaine) to 462 min (bupivacaine).18 We did not perform a linear regression analysis of the micturition time based on dose because we considered that the varying densities and concentrations utilized would confound the results. Seeing as widely varying doses, concentrations, and densities were utilized even within groups, we did not combine the results of each local anesthetic.

Time to spontaneous micturition correlates with the potency of the local anesthetic administered intrathecally, and it correlates with dose for each specific local anesthetic. Kamphuis et al. showed this with filling cystometric studies comparing bupivacaine with lidocaine.18 The longer lasting and more potent bupivacaine was associated with longer detrusor dysfunction (462 min) compared with lidocaine (233 min). This difference becomes more apparent when varying doses of the same medication (concentration and density) are compared within studies. Ben-David et al., Urmey et al., Kallio et al., and Casati et al. showed this with bupivacaine, lidocaine, articaine, and 2-chloroprocaine, respectively.11,22,25,26 The longest times to spontaneous micturition after intrathecal anesthesia with each of bupivacaine, lidocaine, articaine, and 2-chloroprocaine were 462 min, 260 min, 279 min, and 271 min, respectively.18,19,21,26

Neuraxial opioids

The effects of intrathecal or epidural opioids on bladder function are similar to those of local anesthetics in that the potency and dose of the opioid appears to predict the duration of bladder dysfunction. Morphine in conjunction with intrathecal anesthesia was utilized in only two studies, both non-randomized, and the reported incidence rates of urinary retention were 36% and 25%, respectively.45,64 In contrast, studies in which either intrathecal fentanyl or sufentanil was utilized reported lower incidence rates ranging from 0 to 25%.12,16,18,46,48,57,61 Kamphuis et al. showed that the addition of sufentanil 20 μg prolonged the detrusor dysfunction associated with intrathecal lidocaine 100 mg from 233 to 332 min.18

A similar pattern occurred with neuraxial opioids and epidural analgesia, though the pattern is less distinct (Table 4). Ten studies utilizing long-acting opioids reported incidence rates of 9.2-79.5% (only three studies showed rates < 40%). In 15 studies on short-acting opioids, the rate of urinary retention ranged from 0% to 40%.

Comparison with other anesthetic modalities

Only five studies made comparisons with other anesthetic modalities. Schmittner et al. compared intrathecal with general anesthesia and found no difference in time to micturition.56 Casati et al. also found no difference between intrathecal, general, or peripheral nerve block anesthesia in terms of time to micturition.25 Sungurtekin et al. found no difference between intrathecal anesthesia and local infiltration, while van Veen et al., Young et al., and Anannamchareon et al. reported significantly higher rates of urinary retention with intrathecal anesthesia compared with local infiltration.27,58,61,63

Urinary tract infection

Thirteen of the 94 studies included in this review reported the incidence of urinary tract infection associated with catheterization.28,30,40,61,63,64,66,69,73,75,76,89,100 Six of these reported no infections while seven studies reported rates of < 10%.

Discussion

Our review of the literature identified several themes with respect to the effects of neuraxial anesthesia and analgesia on POUR and other urinary outcomes. First, the potency/dose of local anesthetic and the presence of opioids affect detrusor dysfunction and the time to return of spontaneous micturition. This time period lasts as long as 462 min (bupivacaine) or is as short as 103 min (2-chloroprocaine). With long-acting epidural opioids, the reported incidence of urinary retention is as high as 79.5%. Second, whether detrusor dysfunction specifically results in POUR is unclear, but the incidence of POUR, at least after single-dose intrathecal anesthesia, is low, and complications, such as urinary tract infections, are even less frequent. Complications (urinary tract infection) associated with POUR after epidural analgesia also surface infrequently. However, there are inherent limitations to our analysis. Few of the included studies are randomized trials that compare general with neuraxial anesthesia and include urinary retention as a primary outcome. Furthermore, we included all RCTs regardless of Jadad score and did not grade observational studies to highlight the inadequacy of the current evidence with methodologically sound studies assessing this clinical issue. Indeed, the heterogeneity of definitions and anesthetic management further hampers any ability to offer more quantitative analysis.

Our conclusions must be viewed cautiously owing to several factors, including the aforementioned varying definitions used by the included studies to define urinary retention and the significant heterogeneity in local anesthetic type/dose and opioid doses. Several studies, though implicating intrathecal anesthesia as a risk factor for urinary retention, neither discuss a comparative anesthetic modality nor provide the dose/type of local anesthetic utilized.28,30,33,36,41,43,52-55

Results of studies assessing the urodynamic effects of both intrathecal local anesthetics and opioids tend to concur with our data. Kamphuis et al. performed filling cystometric studies in 30 male patients to estimate detrusor pressure and flow rates.18 The studies were performed both prior to and following intrathecal anesthesia with hyperbaric lidocaine (100 mg) with or without sufentanil (20 μg) or with hyperbaric bupivacaine (10 mg). Patients’ bladders were filled at a constant rate of 50 mL∙min−1 when supine, and filling was stopped when a strong desire to void was felt (the cystometric capacity ~ 500 mL). The urge to void disappeared within 60 sec of the start of injection of intrathecal anesthetic. The recovery of the ability to void normally (using only detrusor muscle, generating intravesical pressures of 40-50 cm H2O) did not occur until the block regressed to the S3 segment. Importantly, the mean duration of detrusor block was significantly longer than somatic motor blockade; 233 min vs 144 min, respectively, for plain lidocaine; 332 min vs 124 min, respectively, for lidocaine with sufentanil; and 462 min vs 233 min, respectively, for hyperbaric bupivacaine.

Kuipers et al. studied the dose effect behaviour of isolated intrathecal opiates (sufentanil or morphine) on detrusor function in 40 healthy male volunteers randomized to receive sufentanil (10 or 20 μg) or morphine (0.1 or 0.3 mg).9 Urodynamic data, including flow rates, bladder pressures, and post void residuals, were recorded hourly. Typically, administration of opiates resulted in dose-dependent decreases in urinary flow rate, increased voiding time, increased post void residual, and diminished urge sensation. Bladder function reverted to normal within 24 hr in all those receiving sufentanil and morphine 0.1 mg. Two participants receiving the higher morphine dose (0.3 mg) did not have full recovery of bladder function within the 24-hr study period. The lower dose of sufentanil (10 μg) resulted in diminished urge (itself a subjective sensation) in six of ten subjects vs nine of ten when the larger dose was used.

The above urodynamic data show the mechanism of detrusor dysfunction, and our data suggest that it is drug and dose related. It is unclear when detrusor dysfunction becomes POUR, although, regardless of the definitions used by source studies, POUR occurred more frequently with high potency local anesthetics, higher doses, and opioids.

There are other purported risk factors for POUR that were not addressed in this review, including the volume of intraoperative fluid administered, type of surgery, and age. Keita et al. prospectively studied 313 adult patients (mean age 46 yr; range 16-88 yr) scheduled for general (86.5%) or neuraxial (13.5%) anesthesia and showed that the volume of intraoperative fluid administration (≥ 750 mL odds ratio [OR] = 2.3), age (≥ 50 yr OR = 2.4), and bladder volume on entry to the postanesthesia care unit (≥ 270 mL OR = 4.8) were independent risk factors for the development of POUR.39 Joelsson-Alm et al. observed that orthopedic surgical patients were 6.87 times (95% confidence interval [CI] 1.76 to 26.79) more likely to develop bladder distension.101 Other studies have implicated colorectal surgery and obstetric status as risk factors. The odds ratio for POUR after colorectal surgery and epidural analgesia was reported to be as great as 4.3 (95% CI 1.2 to 15.9).5 Weiniger et al. showed that intrapartum women receiving epidural analgesia during labour had greater post void residuals independent of fluid volume administered when compared with controls not receiving epidural anesthesia (median 240 mL vs 45 mL, respectively) with no significant difference on postpartum days one or two.102 In addition, advanced age appears to be a risk factor for urinary retention as males > 70 yr having spinal anesthesia for lower limb joint replacement are at higher risk of developing retention than females or those < 69 yr irrespective of anesthetic modality.55,103

Conclusion

Our review of the literature suggests that the duration of detrusor dysfunction caused by neuraxial anesthesia and analgesia is related to the dose/potency of local anesthetic and the use of long-acting neuraxial opioids. This may influence the incidence of POUR. Unfortunately, the defining criteria in the literature are so heterogeneous when present that an accurate estimate of the incidence and subsequent complications is extremely difficult to determine.

There are several limitations to our review. First, only two of the RCTs included in this review specifically compared general with neuraxial anesthesia and the respective incidence of POUR as a primary outcome, inherently resulting in underpowered results. The observational studies included frequently lacked a comparator group. Second, the definitions of POUR were widely variable such that POUR in one study may not be considered POUR in another. Details regarding individual cases were not provided, preventing any ability to rate outcomes according to standardized criteria.

From the available literature, short-acting neuraxial blockade is safe in both inpatient and ambulatory anesthesia given the short duration of detrusor dysfunction with a minimal incidence of POUR and subsequent catheterization/infection. However, clinicians should select agents carefully to strike a balance between duration of somatic blockade and the risk of POUR. We suggest that clinicians remain cognizant of this issue and scan patients at higher risk of urinary retention with catheterization at a bladder volume of 500 mL (~cystometric capacity) given that there is a lack of knowledge regarding the subclinical implications of an episode of retention that “spontaneously” resolves.

Moving forward, standard definitions for urinary retention and indications for catheterization should be developed in conjunction with urologists so that relevant clinical trials comparing anesthetic modalities and incorporating urological endpoints produce data that can be easily used by all clinicians to assess and manage this clinical problem.

Notes

Acknowledgement

The authors sincerely thank Professor Stephen Halpern for his suggestions and input.

Disclosures

The authors have no conflicts of interests to declare and they did not receive financial support for this work.

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Copyright information

© Canadian Anesthesiologists' Society 2012

Authors and Affiliations

  1. 1.Department of Anesthesia, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
  2. 2.Department of Anaesthesia and Intensive Care Medicine, Cork University HospitalUniversity College CorkCorkIreland

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