Postoperative bladder care (688)

Objectives

  • To standardise the practice for management of bladder care after uncomplicated gynaecological procedures
  • To diagnose and manage postoperative voiding problems

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Background

One in 10 women in the immediate postoperative period following gynaecological surgery will have urinary retention. Indwelling catheters are associated with increased risks of urinary tract infection (UTI) and the longer they are in situ, the higher the risk of UTI.

Postoperative bladder voiding issues may be due to:

  • Pre-existing voiding problems
  • Bruising /swelling around bladder/urethra e.g. after anterior colporrhaphy
  • Over-distension of the bladder by delayed trial of voiding (TOV) can cause bladder atony
  • Physical obstruction - stress urinary incontinence procedures eg mid-urethral sling, colposuspension, autologous fascial sling (AFS)
  • Clot retention e.g. bladder injury during surgery

Removal of Catheter After Surgery

  • The planned date for catheter removal should be clearly documented in the postoperative care plan
  • All urethral catheters should be removed at 06.00 the next morning as per ERAS unless otherwise stated in the operation notes or there are clinical concerns
  • Patients who have had colposuspension (open/laparoscopic) or AFS usually have indwelling catheter for at least 48 hours
  • Women who do not have an indwelling catheter (this includes midurethral sling and bladder neck injection) should have a trial of void 4 hours after surgery
  • For the trial of void, women should be encouraged to drink normally and aim to pass urine at around 4 hrs.
  • All urogynaecological procedures, ie those for incontinence and prolapse repair, should have a bladder scan after the first two voids. The residuals should be recorded in the ‘bladder diary’ (see Appendix 1).

Trial without catheter (TWOC)

  • Measure the urine volume after each void, no later than 6 hours from catheter removal
  • Residual volume should be measured immediately after the patient passes urine
  • If uncomfortable and unable to pass urine 4 hours after catheter removal, check bladder residual by scan and follow protocol as below (Table 1).

Women undergoing AFS

  • These women are very likely to have voiding dysfunction (80%) and are taught Clean Intermittent Self Catheterisation (CISC) pre-operatively. They should be encouraged and supported to do CISC if required post-operatively. Patients who are unable to perform CISC should be discharged with an indwelling catheter and followed up by the urogynaecology nurses.

Assessment and Management of Post-void Residual

Table 1: Assessment and Management of Post-void Residual 

Volume voided

Diagnosis

Action

2 voids each >200 ml

USS residual <50% of voided volume

Normal

Nil required

Small volume (<200mL) voided

Frequency of micturition (1-2 hourly)

Likely incomplete bladder emptying

Bladder scan residual after second void. 

If voided volumes increase (>50% of residuals) and residual volume decrease, continue trial of void.

If voided volumes are not increasing and residuals ≥ voided volume see below

Unable to pass urine or residuals 

> 50% of voided volumes 4– 6 hours post operatively

Urinary retention

Inform medical staff

Perform vaginal examination to assess for haematoma/bruising

Insert indwelling catheter – short Female size 12

  • If the patient is discharged with an indwelling catheter following a midurethral sling procedure, inform the surgeon who performed the operation as early division of the tape may be required
  • Patients with voiding concerns following bladder neck injection should have CISC performed by nursing staff. If voiding fails to improve over 48 hours, offer to teach patient CISC and refer to urogynaecology nurses. Discuss with the urogynaecology team if patient is unable to perform CISC and continues to have voiding difficulties. Do not insert an indwelling catheter as this may compromise the outcome of the procedure.
  • Women who have a successful TWOC but remain as an inpatient should continue to have their bladder/voiding assessed by monitoring input/output. Ensure patient is voiding 3-4 times/day and has no sensation of incomplete bladder emptying

Guidelines for women sent home with an indwelling catheter

  • Ensure woman understands catheter care and a follow-up appointment for TWOC in the gynaecology ward is in place. She should have an emergency contact number for the ward.
  • Prophylactic antibiotics are not routinely required unless symptomatic of infection.
  • A Foley catheter size 12 with a flip-flo valve and leg bag should be used. The valve should be released every 4 hours during the day and the leg bag should be left on free drainage overnight.

First TWOC after an episode of retention

Table 2: First TWOC after an episode of retention

2 voids, each >200mL

USS residual <50% of voided volume

No further intervention

Residual volumes > 50% of voiding volumes despite trying double void technique 

Teach CISC

Contact the Urogynaecology specialist nurse team for follow up 

  • If TWOC unsuccessful after 1 week, please inform the responsible clinician

Appendix 1: POSTOPERATIVE BLADDER DIARY

Postoperative Bladder Diary (Word doc)

Contacts for further assistance

QEUH
Karen Nicolson        
Senior Charge Nurse, Urogynaecology
Karen.Nicolson@ggc.scot.nhs.uk
01412012264

PRM
Julie Graham        
Senior Charge Nurse, Gynaecology
Ward 56 
Julie.Graham@ggc.scot.nhs.uk
01412114433

RAH
Ward 32
01418879111

Editorial Information

Last reviewed: 01/06/2019

Next review date: 01/06/2024

Author(s): Veenu Tyagi.

Approved By: Gynaecology Clinical Governance Group

Document Id: 688

References
  1. Bodker B, Lose G. Postoperative urinary retention in gynaecological patients. Int Urogynecol J (2003) 14: 94–97
  2. Hakvoort R, Thijs S, Bouwmeester F, Broekman A, Ruhe I, Vernooij M, Burger M, Emanuel M, Roovers J. Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for incomplete voiding after vaginal Prolapse surgery: a multicentre randomised trial. BJOG 2011; 118:1055–1060