1
RN, Sc M. in Rehabilit at ion Sciences, e- m ail: 200079@sarah.br; 2 Anest hesiologist , Sc. M. Rehabilit at ion Sciences, e- m ail: 201393@sarah.br; 3 Coordinat or of t he Anest hesiology, PhD in Anest hesiology, e- m ail: 201577@sarah.br. Net work SARAH de Rehabilit at ion Hospit als
POSTOPERATI VE URI NARY RETENTI ON: EVALUATI ON OF
PATI ENTS USI NG OPI OI DS ANALGESI C
Maria do Carm o Barret t o de Carvalho Fernandes1
Verônica Vieira da Cost a2
Renat o Ângelo Saraiva3
Fer nandes MCBC, Cost a VV, Saraiva RA. Post operat iv e ur inar y r et ent ion: evaluat ion of pat ient s using opioids analgesic. Rev Lat ino- am Enfer m agem 2007 m ar ço- abr il; 15( 2) : 318- 22.
The st udy aim ed t o det erm ine t he occurrence of urinary ret ent ion in pat ient s using opioid analgesic and t o descr ibe t he m et hod used for vesical r elief. A pr ospect ive and consecut ive ser ies of 1,316 pat ient s undergoing surgery from Septem ber 1999 to April 2003 and using opioids post surgery were studied. From the 1,136 pat ient s, 594 did not use urinary cat het ers pre- surgery. From t hese 594 pat ient s, 128 ( 22% ) suffered post operat ive urinary ret ent ion. Urinary ret ent ion was significant ly relat ed t o t he use of cont inuous epidural analgesia ( p= 0.009) . About 69% of patients experiencing urinary retention post surgery returned to spontaneous m icturition following a single catheterization. The incidence found of urinary retention was sim ilar to the literature, m ore frequent in m en who received continuous epidural analgesia. The findings suggest orientation and careful nursing t eam observat ion of post operat ive m ict urit ion, em phasizing t he int erm it t ent asept ically cat het erizat ion for urinary ret ent ion in order t o prevent pot ent ial com plicat ions of t he urinary t ract .
DESCRI PTORS: incidence; ur inar y r et ent ion; ur inar y cat het er izat ion; analgesia, pat ient - cont r olled; epidur al analgesia; nur sing
RETENCI ÓN URI NARI A POST-OPERATORI A: EVALUACI ÓN DE
PACI ENTES EN TRATAMI ENTO ANALGÉSI CO CON OPI OI DES
Los obj et ivos de est e est udio fueron det erm inar la incidencia de ret ención urinaria post - operat oria en pacientes que se encontraban en uso de analgésicos opioides, así com o describir el m étodo utilizado en el vaciado vesical. Se trata de una serie prospectiva y consecutiva de 1.316 pacientes quirúrgicos, estudiados de septiem bre de 1999 a abril de 2003. De ellos, 594 pacient es no usaron cat et erism o de dem ora en el pre- operat orio. Así m ism o, 128 pacientes de este grupo presentó retención urinaria, con una incidencia del 22% (128/ 594). Hubo una asociación estadísticam ente significativa entre la ocurrencia de retención urinaria y el uso de analgesia epidural continua (p= 0,009). El 69% de los pacientes presentó una m icción espontánea luego de haber realizado apenas un cateterism o. La incidencia de retención urinaria encontrada es sem ejante a la descrita en la literatura, siendo m ás frecuente en hom bres, así com o en aquellos pacientes som etidos a analgesia epidural continua. Se sugiere una orientación y vigilancia adecuadas por el equipo de enferm ería, haciendo énfasis en el cateterism o vesical interm itente aséptico, durante el transcurso de la retención urinaria, para prevenir com plicaciones del tracto urinario.
DESCRI PTORES: incidencia; r et ención ur inar ia; cat et er ism o ur inar io; analgesia cont r olada por el pacient e; analgesia epidur al; enfer m er ía
RETENÇÃO URI NÁRI A PÓS-OPERATÓRI A: AVALI AÇÃO DE
PACI ENTES EM USO DE ANALGESI A COM OPI ÓI DES
Os objetivos deste estudo foram determ inar a incidência de retenção urinária pós-operatória em pacientes que estavam em uso de analgesia com opióides e descrever o m étodo utilizado para esvaziam ento vesical. Trata-se de um a série prospectiva e conTrata-secutiva de 1.316 pacientes cirúrgicos de 9/ 1999 a 4/ 2003. Dos 1.316 pacientes, 594 não usaram cateterism o de dem ora no pré-operatório. Desses, 128 pacientes apresentaram retenção urinária, com incidência de 22% (128/ 594). Houve associação estatisticam ente significativa entre a ocorrência de retenção urinária e uso da analgesia peridural cont ínua ( p= 0,009) . Cerca de 69% dos pacient es apresent aram m icção espontânea após a realização de apenas um cateterism o. A incidência de retenção urinária encontrada é sem elhante à literatura, sendo m ais freqüente em hom ens e naqueles subm etidos à analgesia peridural contínua. Sugere-se orient ação e vigilância adequada pela equipe de enferm agem , com ênfase no cat et erism o vesical int erm it ent e assépt ico, na ocorrência de ret enção urinária para prevenção de com plicações do t rat o urinário.
DESCRI TORES: incidência; retenção urinária; cateterism o urinário; analgesia controlada pelo paciente; analgesia epidur al; enfer m agem
I NTRODUCTI ON
T
he t reat m ent of post operat ive pain is st ill a ser iou s ch allen g e in cu r r en t m ed icin e, d esp it e t h eint ense effor t s m ade for it s effect iv e cont r ol.
Effect iv e post oper at iv e pain cont r ol depends
on an indiv idualized pr escr ipt ion and on fact or s lik e
t h e p a t i e n t ’ s e m o t i o n a l a s p e c t s , p h y s i o l o g i c a l
alt er at ions due t o t he sur gical pr ocedur e, t echniques
an d r esou r ces av ailable at t h e ser v ice( 1 ). Mor eov er,
t h e ex t en sion , sit e an d du r at ion of t h e su r ger y can
influence t he int ensit y of t he post oper at iv e pain.
Now ad ay s, sev er al t ech n iq u es ar e u sed t o
t r e a t p o s t o p e r a t i v e p a i n( 2 - 3 ). Pa t i e n t - c o n t r o l l e d
an alg esia, w it h op ioid s, is on e of t h e m ost r ecen t
p r o c e d u r e s a n d h a s b e e n f r e q u e n t l y s t u d i e d i n
post oper at iv e pain r esear ch( 2 , 4 - 5 ).
Alt hough t he use of opioids in post oper at iv e
an algesia is con sider ed safe, t h e adv er se effect s of
t his class of analgesia can coexist wit h pain relief and
com p r ise: r esp ir at or y d ep r ession , sed at ion , n au sea
a n d v o m i t i n g , i t c h i n g , c o n s t i p a t i o n a n d u r i n a r y
r et ent ion( 2- 3).
Urinary ret ent ion has been report ed relat ively
f r e q u e n t l y i n s t u d i e s a b o u t t h e s u b j e c t( 6 - 9 ). I n
in t er n at ion al m ed ical lit er at u r e, r ep or t s of sev er al
st udies affir m t hat t he incidence of ur inar y r et ent ion
can vary from 3 t o 40%( 2,5- 11). I n Brazil, t here are few
s t u d i e s a b o u t t h e t h e m e , e s p e c i a l l y i n v o l v i n g
or t hopedic sur ger ies( 3,12- 13).
Th e e t i o l o g y o f p o s t o p e r a t i v e u r i n a r y
r et en t ion is r elat ed t o t h e u se of an t ich olin er gic or
analgesic drugs, t ype of surgery, int ravenous t herapy,
p a t i e n t ’ s p o s i t i o n a n d l o s s o f p r i v a c y d u r i n g
ur inat ion( 10). A r ecent st udy per for m ed in a t ot al hip
a r t h r o p l a s t y c o n c l u d e d t h a t t h e m a l e g e n d e r,
a d v a n ce d a g e a n d t h e u se o f p a t i e n t - co n t r o l l e d
analgesia ar e fact or s t hat incr ease t he pr obabilit y of
u r i n a r y r e t e n t i o n( 7 ). I n t h e p h y si o l o g y o f u r i n a r y
r et en t ion , op ioid s in cr ease t h e t on u s an d r an g e of
con t r act ion s of t h e u r in ar y sp h in ct er, b u t d im in ish
co n t r a ct i o n s o f t h e u r et h r a , m a k i n g sp o n t a n eo u s
ur inat ion difficult( 8).
A l t h o u g h s o m e p a t i e n t s d o n o t p r e s e n t
sy m pt om s, t her e ar e fr equent clinical m anifest at ions
t h at in clu de: in capacit y t o u r in at e, abdom in al pain ,
ab d om in al d ist en sion , p alp ab le b lad d er, j act it at ion ,
u r i n a r y u r g e n c y, r i g o r, s h i v e r, d i a p h o r e s i s a n d
h eadach e( 6 ).
I nt er m it t ent asept ic cat het er izat ion has been
in d icat ed as a t r eat m en t of ch oice in t h is k in d of
clinical int er cur r ence( 14- 15), aim ing t o r educe t he r isk
of m echanical and infect ious com plicat ions, pain and
d i s c o m f o r t( 6 ). H o w e v e r, t h e u s e o f i n t e r m i t t e n t
c a t h e t e r i z a t i o n o r d e l a y i n t h e o c c u r r e n c e o f
post oper at iv e ur inar y r et ent ion has been quest ioned,
especially in t he nur sing ar ea. I ncidence st udies ar e
t he epidem iological m et hod used t o v er ify t he act ual
occu r r en ce of u r in ar y r et en t ion an d t h e p er f or m ed
t r eat m ent . I n v iew of t hese inquir ies, w e car r ied out
t his st udy, wit h a view t o det erm ining t he incidence of
post oper at iv e ur inar y r et ent ion in pat ient s w ho w er e
using opioids as analgesia, w hich t hey cont r olled v ia
t h e v e n o u s r o u t e ( PCA) , o r co n t i n u o u s e p i d u r a l
analgesia, and descr ibe t he m et hod used for bladder
o u t l et , b ef o r e t h e f i r st sp o n t a n eo u s u r i n a t i o n , i n
pat ient s w ho pr esent ed ur inar y r et ent ion.
METHODS
A t ot al of 1216 pat ient s, children and adult s,
who underwent ort hopedic, t horacic and neurosurgical
surgeries in t he period from Sept em ber 18t h, 1999 t o
Ap r il 2 8t h, 2 0 0 3 w er e ev alu at ed p r osp ect iv ely an d
consecut ively. The st udy was evaluat ed and approved
by t he Et hics Com m it t ee of t he Hospit al SARAH.
All pat ient s using pat ient - cont rolled analgesia
( PCA) or cont inuous analgesia w er e follow ed by t he
a n e s t h e s i o l o g y t e a m , c o m p o s e d o f 1 5
anest hesiologist s and a nurse, unt il t he suspension of
t he analgesia was det erm ined by t he anest hesiologist s
dur ing t he pr e- anest het ic consult at ion.
During t he post operat ive period, pat ient s who
p r esen t ed d i f f i cu l t y t o u r i n at e w er e st i m u l at ed t o
p e r f o r m i t i n a s p o n t a n e o u s w a y t h r o u g h n o n
a g g r e s s i v e m e t h o d s , s u c h a s t h e u s e o f w a r m
c o m p r e s s e s o n t h e a b d o m e n , s i t p o s i t i o n o r i n
or t h ost at ism w h en p ossib le, u se of r u n n in g w at er
sound and pr om ot ion of pr iv acy in t he bat hr oom or
on t he bed. I n cases of failure t o perform spont aneous
u r in at ion aft er su ch m easu r es, besides t h e r efer r ed
pr esen ce of abdom in al pain an d bladder dist en t ion ,
t he pat ient s w er e subm it t ed t o t he inv asiv e m et hod
t hr ough asept ic cat het er izat ion. These pat ient s w er e
e v a l u a t e d a n d f o l l o w e d . Th e t y p e o f b l a d d e r
ca t h et er i za t i o n a n d i t s f r eq u en cy b ef o r e t h e f i r st
An ev alu at ion pr ot ocol w as u sed, f illed ou t
b y t h e n u r se of t h e an est h esiolog y t eam , w it h t h e
following variables: gender, age, t ype of surgery, ASA
( Am er ican Societ y of An est h esiolog y ) classif icat ion
of physical st at e; analgesia and opioid used, adverse
effect s, nursing conduct in t he t ype of cat het erizat ion
per f or m ed ( in t er m it t en t or in dw ellin g) . I n addit ion ,
t he pat ient ’s sat isfact ion wit h t he adopt ed t herapeut ic
a n a l g e si c sch e m e w a s v e r i f i e d t h r o u g h a cl o se d
q u est ion , w h ich all p ar t icip an t s v er b ally ag r eed t o
an sw er.
The dat a w er e com piled and analyzed in Epi I n f o v er si o n 6 . 0 4 . Th e p ar am et r i c v ar i ab l es w er e ex p r essed b y m ean s an d st an d ar d d ev iat ion s. Th e
cat egor ical v ar iables w er e ex pr essed in per cent ages
a n d a n a l y ze d b y t h e e x a ct Ch i - sq u a r e t e st . Fo r
st at ist ical significance, w e consider ed p£ 0.05.
RESULTS
Fr om t h e 1 3 1 6 pat ien t s ev alu at ed, 5 9 4 did
n o t u s e t h e i n d w e l l i n g v e s i c a l c a t h e t e r i n t h e
t ransoperat ive period. From t hese pat ient s, 128 ( 22% )
p r e se n t e d u r i n a r y r e t e n t i o n , 1 2 6 o f w h o m w e r e
subm it t ed t o ort hopedic surgeries and t wo t o t horacic
su r g er i es, w h o n eed ed i n t er m i t t en t o r i n d w el l i n g
v esical cat het er s t o r eliev e sy m pt om s ( Figur e 1)
Reg ar d in g t h e an aly sis of t h e p r e- su r g ical
phy sical st at e, ev aluat ed by t he ASA cr it er ia, it w as
ver ified t hat 49% w er e classified as physical st at e I I
( ASA) ; 4 8 % as ASA I and 3 % as phy sical st at e I I I
( ASA) .
Regarding t he anest hesia, around 75% of t he
p at ien t s r eceiv ed com b in ed an est h esia ( g en er al +
e p i d u r a l b l o ck a g e ) , f o l l o w e d b y 2 1 % o f r e g i o n a l
block age and 4% of gener al anest hesia.
Regar din g t h e t y pes of su r gical pr ocedu r es
per for m ed, 126 ( 98% ) w er e or t hopedic and t w o ( 2% )
t h o r a c i c . Th e r e w e r e n o c a s e s o f p o s t o p e r a t i v e
u r i n a r y r e t e n t i o n i n p a t i e n t s s u b m i t t e d t o
n e u r o s u r g e r y , b e c a u s e a l l w e r e s u b m i t t e d t o
i n d w e l l i n g c a t h e t e r i z a t i o n i n t h e t r a n s o p e r a t i v e
p e r i o d . T h e o r t h o p e d i c s u r g e r i e s w i t h h i g h e r
occu r r en ce of u r in ar y r et en t ion w er e, in decr easin g
o r d e r : t o t a l a r t h r o p l a s t y o f t h e h i p a n d t o t a l
ar t h r op last y of t h e k n ee, t r ip le ar t h r od esis of t h e
f oot , low er lim b am pu t at ion , low er lim b ost eot om y
an d t u m or r esect ion , am on g ot h er s.
Regar din g t h e post oper at iv e an algesia u sed
in pat ient s who present ed urinary ret ent ion, 115 ( 24% )
pat ien t s r eceiv ed con t in u ou s epidu r al an algesia an d
13 ( 12% ) pat ient - cont r olled v enous analgesia ( PCA) .
Th e r e w a s a st a t i st i ca l l y si g n i f i ca n ce a sso ci a t i o n
bet w een t he occur r ence of ur inar y r et ent ion and t he
u se of con t in u ou s epidu r al an algesia, t h at is, t h er e
w as higher fr equency of ur inar y r et ent ion in pat ient s
who received cont inuous epidural analgesia ( p= 0,009)
( Table 1) .
Table 1 - Dist ribut ion of pat ient s who present ed urinary
r et ent ion accor ding t o t he analgesic t echnique used.
Brasília - DF, 2003 0QTGVGPVKQP 4GVGPVKQP
Figur e 1 - Fr equency dist r ibut ion of ur inar y r et ent ion
am ong t he 594 pat ient s not cat het erized in t he pre or
t ransoperat ive per iod. Brasília - DF, 2003
Fr om t h ose pat ien t s w h o pr esen t ed u r in ar y
r et ent ion, w e v er ified t hat 79 ( 62% ) w er e m en and
4 9 ( 3 8 % ) w o m e n , w i t h s t a t i s t i c a l s i g n i f i c a n c e
( p= 0 . 0 4 ) .
Th e m ean age of t h e pat ien t s w it h u r in ar y
r et en t ion w as 3 2 . 4 ± 1 8 . 2 y ear s, w it h a m in im u m
age of 6 years old and a m axim um of 80 years old.
* p= 0.009 : significant associat ion bet w een t he analgesic t echnique of analgesia and t he occurrence of urinary ret ent ion
* * num ber of individuals; % : proport ion t o t he line t ot al
I n order t o alleviat e t he sym pt om s, 79 ( 62% ) of the 128 patients with urinary retention were subm itted
to interm ittent catheterization, 26 ( 20% ) were subm itted
t o i n d w e l l i n g ca t h e t e r i za t i o n a n d 2 3 ( 1 8 % ) u se d com bined cat het erizat ion, t hat is, init ially int erm it t ent
and t hen indwelling cat het erizat ion ( Figure 2) .
a i s e g l a n A y r a n i r U n o i t n e t e r * * ) % ( n y r a n i r u o N n o i t n e t e r * * ) % (
n Totaln(%)
l a r u d i p E s u o u n it n o
C 115*(24) 372(76) 487(100)
) P C A ( a i s e g l a n a s u o n e
V 13(12) 94(88) 107(100)
l a t o
Figur e 2 - Fr equency dist r ibut ion of t y pe of cat het er
in pat ient s w it h urinary ret ent ion. Brasília, DF, 2003
Fr om t he 102 w ho r eceiv ed t he int er m it t ent
or com bin ed cat h et er, in 7 1 ( 6 9 % ) cases, on ly on e
ca t h e t e r i z a t i o n h a d t o b e p e r f o r m e d b e f o r e t h e
s p o n t a n e o u s u r i n a t i o n ; i n 2 1 ( 2 1 % ) , t w o
cat het erizat ions were needed, in eight pat ient s ( 8% ) ,
t h r e e c a t h e t e r i z a t i o n s a n d , i n t w o ( 2 % ) , f o u r
cat het er izat ions w er e per for m ed ( Figur e 3) .
aim ing t o r educe t he r isk of post er ior com plicat ions
for t he pat ient( 3,10).
Th e p r ed o m i n a n ce o f t h e m a l e g en d er i n
u r i n a r y r e t e n t i o n i s a l so si m i l a r t o t h e r e v i e w e d
st u dies( 3 , 7 , 1 0 ). Th is pr edom in an ce can be j u st if ied by
t h e f act t h at t h e su p in e p osit ion in h ib it s p at ien t s’
s p o n t a n e o u s u r i n a t i o n , e s p e c i a l l y i n m e n w h o
u n d e r w e n t o r t h o p e d i c s u r g e r i e s , w h o s e t i m e o f
per m anence in bed and dependence on nur sing car e
ar e higher( 6,10).
S o m e s t u d i e s h a v e d e m o n s t r a t e d a n
associat ion bet w een ur inar y r et ent ion and adv anced
age( 7, 10). Besides ot her fact or s, one of t hese st udies
descr ibed pr ev iou s h ist or y of u r in ar y r et en t ion an d
t he presence of sym pt om s suggest ive of urinary t ract
obst r uct ion, t hr ough logist ic r egr ession analy sis. This
st udy concluded t hat t he m ale gender, advanced age
a n d u s e o f p a t i e n t - c o n t r o l l e d a n a l g e s i a w e r e
det er m ining fact or s of ur inar y r et ent ion, w it h a r at e
of 18%( 7). I t is im port ant t o m ent ion t hat , in t he m ale
gen der, agin g sign if ican t ly in cr eases t h e occu r r en ce
of uret hral and prost at e hyperplasia, wit h consequent
ur inat ion difficult ies( 8, 16). I n t he pr esent st udy, t hese
sym pt om s suggest ive of urinary t ract obst ruct ion were
not st udied.
The result s of t his st udy showed a st at ist ically
significant associat ion bet ween t he cont inuous epidural
an al g esi c t ech n i q u e w i t h f en t an y l ci t r at e an d t h e
occurrence of urinary ret ent ion. Fent anyl cit rat e is an
o p i o i d w i t h h i g h l i p o so l u b i l i t y, p r o v o k i n g a f a st er
c o n n e c t i o n t o t h e s p i n a l n e r v o u s s y s t e m a n d ,
consequent ly, higher absor pt ion by t he blood v essels
of t he epidural space. This fact would m ake it difficult
f o r p a t i e n t s t o p e r f o r m s p o n t a n e o u s u r i n a t i o n ,
especially because t his drug inhibit s t he reflexes below
t h e l e v e l o f t h e e p i d u r a l l u m b o sa cr a l p u n ct u r e .
Th er ef or e, t h is f act can ex p lain t h e occu r r en ce of
ur inar y r et ent ion and is com par able w it h dat a found
in lit erat ure( 3,10- 11).
Many st udies agr ee t hat int er m it t ent v esical
cat h et er izat ion m u st be t h e pr ocedu r e of ch oice in
t h e t r eat m en t of u r in ar y r et en t ion , w it h a v iew t o
reducing m ainly asym pt om at ic bact eriuria and urinary
t ract infect ion( 1,5,8), which has been relat ively frequent
in pat ient s wit h indwelling cat het ers( 15- 16).
Fe w s t u d i e s l o o k a t t h e n u m b e r o f
c a t h e t e r i z a t i o n s p e r f o r m e d b e f o r e s p o n t a n e o u s
ur inat ion. Only t w o st udies m ent ion t he per for m ance
of cat h et er izat ion befor e u r in at ion , bu t u se an ot h er
m et h odology( 1 0 - 1 1 ). I n t h e pr esen t st u dy, 7 1 ( 6 9 % )
+PFYGNNKPIECVJGVGT +PVGTOKVVGPVECVJGVGT +PVGTOKVVGPVECVJGVGT KPFYGNNKPIECVJGVGT
ECV ECV ECV ECV
Figur e 3 - Dist r ibut ion of num ber of cat het er izat ions
( cat ) realized before spont aneous urinat ion in pat ient s
w it h ur inar y r et ent ion. Br asília, DF, 2003
Regar din g t h e lev el of pat ien t s’ sat isfact ion
relat ed t o t he cont inuous epidural or venous pat ient
-cont rolled analgesia, it w as verified t hat around 98%
of t he pat ient s were sat isfied wit h t his t herapeut ic pain
cont r ol t echnique.
DI SCUSSI ON
The incidence rat e of urinary ret ent ion in case
of p ost op er at iv e an alg esia f ou n d in t h is st u d y, i. e.
22% , is sim ilar t o t he lit er at ur e w e r ev iew ed( 2- 3,5- 11).
The incidence of ur inar y r et ent ion, associat ed t o t he
num ber of cat het erizat ions found in t he present st udy,
i n d i cat es t h at a sp eci al l y t r ai n ed n u r si n g t eam i s
pat ient s wit h urinary ret ent ion present ed spont aneous
urinat ion aft er one single vesical cat het erizat ion. This
result shows t hat , m ost of t he t im e, pat ient s wit h urinary
ret ent ion can be helped wit h only one cat het erizat ion.
CONCLUSI ON
Th e in ciden ce of u r in ar y r et en t ion f ou n d in
t his st udy ( 22% ) is in accordance wit h lit erat ure dat a.
I t i s co n si d e r e d l o w a n d , d e sp i t e b e i n g q u i t e a n
u n com f or t ab le ad v er se ef f ect , it is n ot con sid er ed
ser iou s. I n t er m it t en t asept ic v esical cat h et er izat ion
is t h e pr ocedu r e of ch oice in t h e occu r r en ce of t h e
u r i n a r y r e t e n t i o n t o p r e v e n t u r i n a r y t r a c t
com p licat ion s.
Co n t r o l l e d a n d r a n d o m i z e d s t u d i e s a r e
n eeded t o ev alu at e post oper at iv e u r in ar y r et en t ion
w h en an alg esia w it h op ioid s is u sed , esp ecially in
or t h opedic su r ger ies.
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