Postoperative bladder training ARTHUR ROBERT
I. SEGAL, C. CORLETT,
M.D. JR.,
M.D.
Los Angeles, Calijbnia A group of 87 women who had either a retropubic suspension or anterior colporraphy with or without hysterectomy were studied to determine an optimal method of postoperative bladder training to facilitate recovery of normal bladder function. All patients received suprapubic catheters but 43 women had their catheters on constant open drainage while the remaining 44 patients were placed on an intermittent ciamping regimen which was begun on the first postoperative day. The method of catheter management was selected randomly. Subgroups based on the operative procedure performed, patient age, and the presence or absence of postoperative infection were examined. In all groups of patients studied, those undergoing early intermittent clamping resumed normal micturition earlier than those who did not. It is recommended that this technique be utilized routinely in this group of patients to shorten the interval of time during which bladder drainage is required. (AM. J. OBSTET. GYNECOL. 133:366, 1979.)
POSTOPERATIVE suprapubic urinary bladder drainage has been popularized in gynecology since the mid1960’s. Early reports l-3 have emphasized advantages of this method, when compared to traditional transurethral bladder drainage. These investigations have documented reduced postoperative bacteriuria, a shorter period of postoperative bladder dysfunction, and improved patient compliance and convalescence. The effect upon length of hospitalization is controversial. Earlier studies of patients with transurethral catheters have demonstrated lower rates of postoperative urinary tract colonization and infection when tidal drainage was employed.“6 Patients managed with tidal drainage have demonstrated more rapid return of normal bladder function and shorter hospitalization when used with the urethral catheter. Because postoperative bladder drainage is still managed by varying techniques, a study was undertaken to define the role of passive distention and evacuation of the bladder when begun early in the postoperative course in hastening the return of normal micturition. All patients received suprapubic catheters. One
From
the Gyr-Urology
Received for publication Revised May
jr, 1978.
Accepted May
24, 1978.
Clinic, January
Women’s Hospital. 12, 1978.
Reprint requests: Dr. Robert C. Corlett, Jr., Ass&ant Professor, Director, Gyn-Urology Clinic, Women’s Hospital, 1240 N. Mission Rd., Los Angeles, Calijornia 90033.
366
group was managed by straight drainage and the other by intermittent catheter clamping-a modification of tidal drainage. These methods were then compared to determine which was associated with quicker resumption of normal bladder function. These groups were further analyzed for the effects of age, menopause, infection, and the type of operative procedure upon the principle parameter utilized in this study-residual urine. Materials
and methods
Eighty-seven patients were included in this study. All patients were hospitalized on the gynecology service at the Los Angeles County-University of Southern California Medical Center between July 1, 1976, and May 1, 1977. Each underwent surgical correction for either stress urinary incontinence or symptomatic pelvic relaxation, with or without stress incontinence. All surgical procedures were done by resident physicians with staff assistance. Each patient received a suprapubic catheter (Bonanno type), placed while under general anesthesia at the termination of the procedure. To simplify catheter management one protocol method was followed on each of two gynecologic wards. Since surgery was distributed among large groups of operating physicians responsible for these wards, the assignment of a catheter protocol by ward was felt to be random. Forty-three patients in Group I constituted those on the first ward; and 44 patients comprised those on the second ward. All patients in Group I had straight suprapubic 0002-9378/79/040366+05$00.50/O
0
1979 The C. V. Mosby CO
Volume Number
133 4
Postoperative
bladder drainage throughout their postoperative period. Twice daily on the fourth and subsequent postoperative days, each patient received bladder instillation through the suprapubic catheter of a 250 ml. normal saline solution with 0.25 ml. of Neosporin genitourinary irrigant. The patient was instructed to void with a clamped suprapubic catheter and the residual urine was measured through the catheter. The catheter was discontinued when the patient had no residual over 100 ml. for a two-day period and at least two residuals under 50 ml. If the criteria stated were not met by the time the patient had sufficiently recovered from the operation, she was discharged home with the catheter in place. Patients in Group II were managed by intermittent catheter clamping during the time period of 6 A.M. to 10 P.M. On the first and second postoperative days, the suprapubic catheter was clamped for 1 hour, 45 minutes and opened fol- 15 minutes in each two-hour interval. On the third and all succeeding postoperative hospital days, the catheter was clamped for an interval of 3 hours, 45 minutes followed by open drainage for 15 minutes. Bladder instillations were carried out starting on Da): 4 postoperatively as in Group I. Preoperatively, all patients underwent urethroscopy, urethral pressure profilometry, and cystometry. Patients with mixed component incontinence, stress, and urge incontinence (sensory or motor in nature) as noted by history and confirmed by an early first desire to void, and small bladder capacity were treated for the urge component for at least three weeks preoperatively with anticholinergics. Patients with a diagnosis of bladder instability (detrusor dyssynergia) as demonstrated by cystometry were also treated preoperatively with anticholinergics for at least three weeks. A culture was obtained at the time of endoscopy, again on the third postoperative day, and when the suprapubic catheter was removed in approximately 80 per cent of the patients. All premenopausal patients undergoing vaginal hysterectomy with bladder repair received pre- and postoperative cephaloridine. One gram was administered intramuscularly one to two hours prior to surgery, one gram intramuscularly shortly after return to the recovery room, and one gram given six to eight hours postoperatively.’ Prophylactic antibiotics were not otherwise used. Results The two groups surgical procedure, for surgery (Table Group I, 32 (74 per
were similar with respect to age, menopausal status, and indication I and II). Of the 43 patients in cent) were voiding spontaneously
Table
I. Comparison
Procedure
t@e
367
procedure
m
25 16
58 37 - 5
2
43
100
46.6 41.8 38.5
29 13 2
66 29 5
43.3 51.7 40.5
45.7
44
100
45.7
II. Effect of menopause Group I No.
Postmenopause Premenopause Total
13 30 43
Postmenopausal
70
No.
R
100
16 28 44
- 64 100
46
13
Catheter out at discharge
12
40
20
(30)
Postoperative
P value
36
(16)
6
Premenopausal
III.
Group !I
(13)
Catheter out at discharge
Table
training
of age and operative
Anterior colporrhaphy Retropubic &p&ion Pereyra Total
Table
bladder
voiding
Spontaneously voiding POD 5 No. meeting criteria for catheter removal by POD 5 POD 6 Discharge No. failing to meet criteria for catheter removal at discharge
(28)
81
co.05
71
I. SEGAL, C. CORLETT,
M.D. JR.,
M.D.
Los Angeles, Calijbnia A group of 87 women who had either a retropubic suspension or anterior colporraphy with or without hysterectomy were studied to determine an optimal method of postoperative bladder training to facilitate recovery of normal bladder function. All patients received suprapubic catheters but 43 women had their catheters on constant open drainage while the remaining 44 patients were placed on an intermittent ciamping regimen which was begun on the first postoperative day. The method of catheter management was selected randomly. Subgroups based on the operative procedure performed, patient age, and the presence or absence of postoperative infection were examined. In all groups of patients studied, those undergoing early intermittent clamping resumed normal micturition earlier than those who did not. It is recommended that this technique be utilized routinely in this group of patients to shorten the interval of time during which bladder drainage is required. (AM. J. OBSTET. GYNECOL. 133:366, 1979.)
POSTOPERATIVE suprapubic urinary bladder drainage has been popularized in gynecology since the mid1960’s. Early reports l-3 have emphasized advantages of this method, when compared to traditional transurethral bladder drainage. These investigations have documented reduced postoperative bacteriuria, a shorter period of postoperative bladder dysfunction, and improved patient compliance and convalescence. The effect upon length of hospitalization is controversial. Earlier studies of patients with transurethral catheters have demonstrated lower rates of postoperative urinary tract colonization and infection when tidal drainage was employed.“6 Patients managed with tidal drainage have demonstrated more rapid return of normal bladder function and shorter hospitalization when used with the urethral catheter. Because postoperative bladder drainage is still managed by varying techniques, a study was undertaken to define the role of passive distention and evacuation of the bladder when begun early in the postoperative course in hastening the return of normal micturition. All patients received suprapubic catheters. One
From
the Gyr-Urology
Received for publication Revised May
jr, 1978.
Accepted May
24, 1978.
Clinic, January
Women’s Hospital. 12, 1978.
Reprint requests: Dr. Robert C. Corlett, Jr., Ass&ant Professor, Director, Gyn-Urology Clinic, Women’s Hospital, 1240 N. Mission Rd., Los Angeles, Calijornia 90033.
366
group was managed by straight drainage and the other by intermittent catheter clamping-a modification of tidal drainage. These methods were then compared to determine which was associated with quicker resumption of normal bladder function. These groups were further analyzed for the effects of age, menopause, infection, and the type of operative procedure upon the principle parameter utilized in this study-residual urine. Materials
and methods
Eighty-seven patients were included in this study. All patients were hospitalized on the gynecology service at the Los Angeles County-University of Southern California Medical Center between July 1, 1976, and May 1, 1977. Each underwent surgical correction for either stress urinary incontinence or symptomatic pelvic relaxation, with or without stress incontinence. All surgical procedures were done by resident physicians with staff assistance. Each patient received a suprapubic catheter (Bonanno type), placed while under general anesthesia at the termination of the procedure. To simplify catheter management one protocol method was followed on each of two gynecologic wards. Since surgery was distributed among large groups of operating physicians responsible for these wards, the assignment of a catheter protocol by ward was felt to be random. Forty-three patients in Group I constituted those on the first ward; and 44 patients comprised those on the second ward. All patients in Group I had straight suprapubic 0002-9378/79/040366+05$00.50/O
0
1979 The C. V. Mosby CO
Volume Number
133 4
Postoperative
bladder drainage throughout their postoperative period. Twice daily on the fourth and subsequent postoperative days, each patient received bladder instillation through the suprapubic catheter of a 250 ml. normal saline solution with 0.25 ml. of Neosporin genitourinary irrigant. The patient was instructed to void with a clamped suprapubic catheter and the residual urine was measured through the catheter. The catheter was discontinued when the patient had no residual over 100 ml. for a two-day period and at least two residuals under 50 ml. If the criteria stated were not met by the time the patient had sufficiently recovered from the operation, she was discharged home with the catheter in place. Patients in Group II were managed by intermittent catheter clamping during the time period of 6 A.M. to 10 P.M. On the first and second postoperative days, the suprapubic catheter was clamped for 1 hour, 45 minutes and opened fol- 15 minutes in each two-hour interval. On the third and all succeeding postoperative hospital days, the catheter was clamped for an interval of 3 hours, 45 minutes followed by open drainage for 15 minutes. Bladder instillations were carried out starting on Da): 4 postoperatively as in Group I. Preoperatively, all patients underwent urethroscopy, urethral pressure profilometry, and cystometry. Patients with mixed component incontinence, stress, and urge incontinence (sensory or motor in nature) as noted by history and confirmed by an early first desire to void, and small bladder capacity were treated for the urge component for at least three weeks preoperatively with anticholinergics. Patients with a diagnosis of bladder instability (detrusor dyssynergia) as demonstrated by cystometry were also treated preoperatively with anticholinergics for at least three weeks. A culture was obtained at the time of endoscopy, again on the third postoperative day, and when the suprapubic catheter was removed in approximately 80 per cent of the patients. All premenopausal patients undergoing vaginal hysterectomy with bladder repair received pre- and postoperative cephaloridine. One gram was administered intramuscularly one to two hours prior to surgery, one gram intramuscularly shortly after return to the recovery room, and one gram given six to eight hours postoperatively.’ Prophylactic antibiotics were not otherwise used. Results The two groups surgical procedure, for surgery (Table Group I, 32 (74 per
were similar with respect to age, menopausal status, and indication I and II). Of the 43 patients in cent) were voiding spontaneously
Table
I. Comparison
Procedure
t@e
367
procedure
m
25 16
58 37 - 5
2
43
100
46.6 41.8 38.5
29 13 2
66 29 5
43.3 51.7 40.5
45.7
44
100
45.7
II. Effect of menopause Group I No.
Postmenopause Premenopause Total
13 30 43
Postmenopausal
70
No.
R
100
16 28 44
- 64 100
46
13
Catheter out at discharge
12
40
20
(30)
Postoperative
P value
36
(16)
6
Premenopausal
III.
Group !I
(13)
Catheter out at discharge
Table
training
of age and operative
Anterior colporrhaphy Retropubic &p&ion Pereyra Total
Table
bladder
voiding
Spontaneously voiding POD 5 No. meeting criteria for catheter removal by POD 5 POD 6 Discharge No. failing to meet criteria for catheter removal at discharge
(28)
81
co.05
71
