A number of female patients, aged 60 and older, have been found to have urinary retention during the recovery period following total hip replacement or hip fracture. (Whether the retention preceded or followed the hip fracture is unknown.) Those found to have a UTI were treated with oral antibiotics for one week. Many failed voiding trials following catheter removal and required replacement. What are the treatment options for these patients? Please address the role of tamsulosin (Flomax) in women, phenazopyridine (Pyridium), and other treatments that could be tried prior to urologic referral.
—Thomas Doolin, PA, Slingerlands, N.Y.
The best approach to postoperative urinary retention is prevention. The risk of retention is greater in patients with neuropathy or neurologic damage, those who suffer chronic constipation or impaction, and those taking anticholinergic medications. Increase in risk is also dependent on the type of surgery (especially bladder or anorectal procedures). Use of anesthesia (particularly for long durations) and opioid pain medications will also increase risk. Strategies to reduce risk include providing adequate hydration before and during surgery, early mobilization, and use of toilet or commode rather than the unnatural position required by bedpan use. In patients who develop retention in the early postoperative period (the first day or two), an indwelling catheter can be placed for 12-24 hours. Thereafter, straight, i.e., in-and-out, catheterization is recommended along with mobility. Bedpans use should be discouraged. All aggravating medications should be avoided, including opiates, antispasmodics (including phenazopyridine [Pyridium]), antiparkinsonian meds, and antipsychotics. Calcium channel blockers may also perpetuate retention in patients on narcotic pain medications. There has been some anecdotal use of Flomax in men, but success is limited to those with documented benign prostatic hyperplasia prior to surgery. Use of Flomax in women has not been studied. If a patient fails to respond to the above measures, a urology consult should be sought before unproven methods are attempted.
—Claire Babcock O’Connell, MPH, PA-C (113-9)