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

Voiding Algorithm for Preventing Postoperative Urinary Retention (POUR)

in Phase II Patients

Approved by:
Owner: AIP PACU
Submitted by: Raelyn Nicholson, RN, BSN, PCCN
Date updated/reviewed: 4/2/2014
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 Phase II patients 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.

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.

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.

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

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/j.jopan.2012.07.012

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

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

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

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

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.

University of Colorado Health-Central, Unit-Based Guideline: Perioperative Services
Guideline:
Postoperative urinary retention (POUR) is defined as a bladder volume greater than 400
ml and the inability to void. Signs and symptoms include: restlessness, confusion,
anxiety, hypertension, tachycardia or bradycardia, and tachypnea. The patient may also
be asymptomatic.

Risk factors for POUR include:
Spinal Blocks: Depresses 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.
Gynecologic, urologic, rectal (hemorrhoidectomies), and pelvic procedures
(inguinal hernia repairs). Patients receive local anesthetic in these procedures
which can lead to 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
Medications:
o Opioids decrease the urge sensation, which increases bladder capacity.
o Anticholinergics (glycopyrrolate, atropine, ditropan) block detrusor
contractions causing bladder hypotonia
o Sympathomimetics increase urethral resistance.
o Beta blockers reduce sphincter tone; blocking that may cause retention
Length of procedure greater than 60 minutes.
Intraoperative fluid greater than 1000 ml.
History of BPH and/or urinary retention.
65 years or greater due to neuronal degeneration leading to bladder dysfuntion.

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.

1. The post anesthesia nurse identifies outpatients with a high risk for developing
POUR.
2. Outpatients with no risk factors are discharged and advised to call if they are
unable to void within 8 hours of last void.
3. Outpatients 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.

See below for the guideline:
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