University of Colorado Health-Central, Unit-Based Guideline: Perioperative Services

Voiding Algorithm for

Preventing Postoperative Urinary Retention (POUR)
in Phase II Patients

Related Policies and Procedures:
Insertion, Removal and Care of an Indwelling Foley Catheter
Pediatric Post Anesthesia Care
Post Anesthesia Care
Bladder Scan Use in the Post Anesthesia Care Units

Approved By:




Owner: Perioperative Quality and Patient Safety Council
Submitted by: Raelyn Nicholson, RN, BSN, PCCN
Date updated/reviewed: 6/10/2014
Perioperative Guideline Task Force review date: (PGTF will review every two
years following PPPPC)

Purpose:
The purpose of this unit based guideline (UBG) is to provide the post anesthesia nurse
with clear and concise direction on preventing postoperative urinary retention (POUR) in
patients being discharged the day of surgery by utilizing an evidence based algorithm.

Sources:
Baldini, G., Bagry, H., Aprikian, A., & Carli, F. (2009). Postoperative urinary retention:
anesthetic and perioperative considerations. Anesthesiology, 110(5), 1139-1157. (Level
I)

Beatty, A.M., Martin, D.E., Couch, M., & Long, N. (1997). Relevance of oral intake an
necessity to void as ambulatory surgical discharge criteria. Journal of PeriAnesthesia
Nursing, 12(6), 413-421. (Level VI)

Buchko, B.L. & Robinson, L.E. (2012). An evidence-based approach to decrease early
post-operative urinary retention following urogynecologic surgery. Urologic Nursing,
32(5), 260-273. (Level VI)

Buchko, B.L., Robinson, L.E., & Bell, T.D. (2013). Translating an evidence-based
algorithm to decrease early post-operative urinary retention after urogynecologic surgery.
Urologic Nursing, 33(1), 24-32. doi: 10.7257/1053-816X2013.33.1.24 (Level VI)

University of Colorado Health-Central, Unit-Based Guideline: Perioperative Services
DiBlasi, S.M. (2013). Planned cesarean delivery and urinary retention associated with
spinal morphine. Journal of PeriAnesthesia Nursing, 28(3), 128-135. doi:
10.1016/jopan.2012.07.012 (Level III)

Dreijer, B., Moller, M.H., & Bartholdy, J. (2011). Post-operative urinary retention in a
general surgical population. European Journal of Anaesthesiology, 28(3), 190-194. doi:
10.1097/EJA.0b013e328341ac3b (Level IV)

Hansen, B.S., Soreide, E., Warland, A.M., & Nilsen, O.B. (2011). Risk factors of post-
operative urinary retention in hospitalised patients. Acta Anaesthesiologica Scandinavica,
55, 545-548. doi: 10.1111/j.1399-6576.2011.02416.x (Level IV)

Feliciano, T., Montero, J., McCarthy, M., & Priester, M. (2008). A retrospective,
descriptive, exploratory study evaluating incidence of postoperative urinary retention
after spinal anesthesia and its effect on PACU discharge. Journal of PeriAnesthesia
Nursing, 23(6), 394-400. doi: 10.1016/j.jopan.2008.09.006 (Level VI)

McLeod, L., Southerland, K., & Bond, J. (2013). A clinical audit of postoperative urinary
retention in the postanesthesia care unit. Journal of PeriAnesthesia Nursing, 28(4), 210-
216. doi: 10.1016/j.jopan.2013.10.0006 (Level VII)

Warner, A.J., Phillips, S., Riske, K., Haubert, M., & Lash, N. (2000). Postoperative
bladder distension: Measurement with bladder ultrasonography. Journal of
PeriAnesthesia Nursing, 15(1), 20-25. (Level VII)

Definitions:
PACU- Post Anesthesia Care Unit
POUR - Postoperative Urinary Retention
Phase II Patient - Patient going home the day of surgery who meets post anesthesia
discharge criteria

Guideline
A. Definition: Postoperative urinary retention (POUR) is defined as a bladder
volume greater than 400 ml and the inability to void.

B. Signs and symptoms: restlessness, confusion, anxiety, hypertension, tachycardia
or bradycardia, and tachypnea. The patient may also be asymptomatic.

C. Risk factors for POUR:
1) Spinal Blocks
a. Depresses the ability to sense bladder fullness and lack of
voluntary muscle coordination to consciously initiate voiding.
Once the dermatome is L5 or lower, detrusor contractions return,
meaning patient
should be able to void.
University of Colorado Health-Central, Unit-Based Guideline: Perioperative Services
2) Gynecologic, urologic, rectal (i.e. hemorrhoidectomies), and pelvic
procedures (i.e. inguinal hernia repairs).
a. The local anesthetics in these procedures can cause a lack of
voluntary muscle coordination to consciously initiate voiding.
These procedures also have the potential to inflame the perineum,
obstructing the urethra or damaging nerves that innervate the
bladder
3) Medications:
a. Opioids decrease the urge sensation, which increases bladder
capacity.
b. Anticholinergics (glycopyrrolate, atropine, ditropan) block
detrusor contractions causing bladder hypotonia
c. Sympathomimetics increase urethral resistance.
d. Beta blockers reduce sphincter tone; blocking that may cause
retention
4) Length of procedure greater than 60 minutes.
5) Intraoperative fluid greater than 1000 ml.
6) History of benign prostatic hyperplasia (BPH) and/or urinary retention.
7) 65 years old or greater due to neuronal degeneration leading to bladder
dysfunction.

D. POUR Algorithm: To reduce the incidences of POUR in the Phase II patient, the
post anesthesia nurse uses an algorithm. Using the algorithm decreases urinary
retention, frequency of catheterization, duration of Foley catheter, in addition to
improving patient safety, satisfaction, and outcomes.

E. How to use the Algorithm:
1. The post anesthesia nurse identifies phase II patients with a high risk for
developing POUR.
a. Important Note: According to the risk factors, every patient could
be at risk for developing POUR. This does not indicate that every
patient should void prior to discharge.
b. A patient is only required to void prior to discharge if there is an
MD order. Without an order, the PACU nurse must use his/her
critical thinking skills to assess the patients risk and whether or
not the patient should be required to void before discharge.
2. Phase II patients with no risk factors are discharged and advised to call if
they are unable to void within 8 hours of last void.
3. Phase II patients with risk factors must void at least 150 ml.
4. If the patient is unable to void or voids less than 150 ml, the PACU nurse
assesses the patients volume by bladder scan.
5. For bladder volumes greater than 400 ml, the nurse calls the surgical team
for further orders.
6. For bladder volumes less than 400 ml, the PACU nurse may discharge the
patient if appropriate.

University of Colorado Health-Central, Unit-Based Guideline: Perioperative Services
Is patient at risk
for POUR?
Outpatient with
no risk factors
for POUR
Discharge
Outpatient with
risk factors
for POUR
Unable
to void
Assess volume by
bladder scan
Bladder volume
> 400 ml
Call MD for
catheterization
order
Bladder volume
< 400 ml
Discharge
Advise patient
to seek medical
assistance if
unable to void
within 8 hours
Void
< 150 ml > 150 ml
POUR Algorithm