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Physiopsychologic treatment for postoperative urinary retention
PHYSIOPSYCHOLOGIC TREATMENT FOR POSTOPERATIVE URINARY RETENTION PHILIPTREIGER, M.D., JOSEPHJOHN TOVAREK, M.D. AND NICHOLAS A. CASCIATO, M.D. Glendale,
CaliJornia
F
OR many years surgeons have slighted the care of the urinary tract in the postoperative patient. Much too frequently and definiteIy too routinely, orders for catheterization were written which did not reflect sound clinica judgment based on physiopsychologic facts. Many controversies exist throughout the literature on this subject. The two most outstanding are whether to empIoy pharmacoIogic or psychoIogic methods of treatment to promote postoperative urination and, shouId these treatments fai1, when to catheterize the patient. At St. Mary’s of Nazareth HospitaI we made a statistica survey of 2,000 consecutive operations in the hope of resoIving these probIems. Postoperative urinary retention may be defined as inability of the postoperative patient to void in spite of a fuII bIadder, norma kidney function and in the absence of organic obstruction. Using this accepted definition we compiIed statistics on 1,000 consecutive surgical patients. We then formuIated a method of treatment which we empIoyed in the next 1,000 cases. The first set of statistics was compiled without the awareness of the nurses, house staff or physicians because we did not desire any change from the postoperative urinary tract management aIready in existence. The second set, however, was compiIed with the awareness of a11 since a standard method of treatment\ carefuIIy and routinety empIoyed was found to be necessary. The 2,000 patients were in the middIe class, mainIy of PoIish and Italian extraction, of both sexes and between the ages of three days to seventy-two years. They were operated upon by seventy-four different surgeons. The preoperative treatment in the majority of the eIective operations consisted of a barbiturate and an enema the night before, and no breakfast and a premeditation of morphine and atropine the morning of surgery. The operative anesthetic in 1,900 of the patients was pentothal sodium@ suppIemented by the gases and curare when necessary. The operative technics were variabIe and depended upon each surgeon. PostoperaAugust,
1950
Chicago,
Illinois
tive treatment was fairIy routine after such operations as those for appendixes, hernias, hemorrhoids and piIonida1 cysts. It was only after the more severe operations that blood, intravenous fluids, chemotherapy, gastrointestina suction and intravenous proteins and vitamins were empIoyed. The incidence of catheterization in the first 1,000 patients was 18.3 per cent (excIuding 6 per cent in whom a retention catheter was inserted). Notice the nearness of our percentages to that of Jordan’s pubIished in 1933 (TabIe I) despite the use of the various drugs discovered in the thirteen-year interim for the treatment of postoperative urinary retention. Because of this we turned from the consideration of a pharmacologic approach to a physiopsychologic one. PrimariIy, we determined the time at which the bIadder contained sufficient urine to promote urination. The average postoperative patient voided 330 cc. of urine in fourteen hours; this was a kidney excretion rate of 23.4 cc. per hour. Compare this with 41 to 75 cc. per hour quoted by Best and TayIor for the average maIe, and understand the suppression of urinary excretion existing in the patient one day postoperativeIy, based on age, weight, sex, height, posture, humidity, temperature, diet, fluid intake and output, anesthetic, degree of narcosis and menta1 excitement. We knew that 250 to 300 cc. are needed in the average maIe as a stimulus for urination. Therefore, we set a fourteen-hour limit, at the end of which the average postoperative patient wouId have enough urine so that he couId void; otherwise, physiopsychoIogic treatment wouId have to be employed. However, any patient wouId be catheterized who compIained of bIadder pain or in whom the bladder was paIpabIe abdominally at any time that first day. TREATMENT
In 1928 Sachs upheld strongIy the psychologic approach to postoperative urinary retention; in 1944 McLaughIin and Brown definitely ‘95
Treiger
196
et al.-Postoperative
showed that postoperative urinary retention was psychologic in the young maIes in their series. We believed with Lozinski that the patients should be requested to urinate in the recumbent position preoperatively in order to overcome
Type of Operation
Appendix. ........... Gallbladder. ......... Hernia. ............. Hermorrhoid. ........ Gastric. ............. Breast. ............. Thyroid. ............ hlajor abdomen. ..... PiIonidal cyst ............
___-
I
DROPS IN CATHETERIZATION
-
‘933
‘947
Per Cent Catheterized
,
Retention
rnent employed so occasionally and haphazardly before. We had practiced early rising sporadicalIy since 1945, but now we empIoyed it routinely in those cases in which the patients did not void. This consisted of using a sitting position
TABLE PERCENTAGE
Urinary
19.8 15.8 15.7 ‘4-3 37.5 7.8 4. 0 12.7
No. Patients ___ 385 67 99
73 9 26
64
17
21
‘5 23 45 20
i
any existing psychologic block. To aid him in doing so, we added that as complete privacy as possible should be achieved by means of drapes, screens and cIosed doors. PostoperativeIy, we requested that a urina1 or bedpan be within the reach of each patient and that the patient not be requested to urinate or asked if he had urinated at any time before the fourteen hours had elapsed. This prevented him from becoming conscious of the urinary mechanism before he was actuaIIy abIe to void. AI1 patients were divided into three groups, nameIy, those who urinated before fourteen hours, those who tried to urinate and faiied and those who made no attempt at all to urinate. The first group of patients needed no treatment. The second group was to be reassured by the nurse that there was insufficient urine in the bIadder at this time. The patients were referred to the house staff at the expiration of the fourteen hours. The third group also was referred at that time. The interne evaIuated in each patient a11 the factors influencing his kidney excretion rate and decided if there was a sufficient amount of urine present in the bIadder. If there was a sufficient amount present, the patient was requested to urinate. If he failed to do so, the interne and the nurse, supervised by the resident, continued the physiopsychoIogic treat-
Per Cent Catheterized
13.0 25.0
!
5
)
20.0
1
i
No. 1Catheterized ~~~_~.~ /
25 5 4.7 6.0 4. o 13.0 25.5
for the female \vith the feet braced on a chair at the side of the bed and the standing position for the male, duplicating the body posture each had employed in previous years for urination. More important were the reassurances to the patient of his abiIity to void, the impossibility of his wound breaking open, the necessity for sustained downward pressure and the fact that he wouId have to “break through” in a gradual manner. The first indication of success came when the patient feIt the urge to urinate but couId not go beyond a certain point. One or two more words of reassurance, the use of psychologic “tricks” such as running water, drinking water, playing with ice chips, supplemented by a hot water bottle to reIax the tense perineum, and the patient voided. Remember that this treatment was not empIoyed until we thought the patient had suchcient urine in the bladder. If this treatment failed, we allowed four hours to elapse and then tried again. The patient was catheterized onIy in the event of bIadder discomfort or if the bIadder was paIpabIe or percussabIe abdominahy. Since the first statistics showed that the percentage of urinary retention was negligible in a11 ages below thirteen, and in thyroid, head, neck and extremity surgery the treatment was not therein specified. An outline of this treatAmerican
Journal
of Surgery
Treiger
et A-Postoperative
ment was placed in each chart room and lectures were given the house and nursing staffs so that everyone understood the applied physiology and psychology. RESULTS
The percentage of patients catheterized dropped from I 8.3 per cent to I .7 per cent with the employment of the physiopsychologic treatment. Refer to Table I for the percentage drops in the various kinds of surgery. Only 46 per cent of the patients voided without being asked before fourteen hours, while the other 39 per cent were treated. None of the patients developed any urinary tract infection or dysfunction noted in the hospita1 or as reported subsequently by the family physician; this was so even though we had calculated after Taussig that there was a 13 cc. residual per hour in the bladder of the voiding patient. The seventeen patients who did not void had only one factor in common; they were all neurotrc. Five of these patients had previous surgery and catheterizations which fixed a pattern in their minds to which they rigidly adhered, and out of which there was not enough time to condition them. One was a deaf mute to whom we could not converse. Another had prostatism which definitely convinced him after his operation for hemorrhoids in that region that he could not void. COMMENT
achieved a postoperative catheterization rate of 1.7 per cent without the incidence of We
urinary tract infection or dysfunction and without the use of drug therapy. Had we aIso employed a drug, couId we not have mistaken the excellent resuIts for the work of the drug? And might not this have happened already in many of the drugs described as valuable in this condition? The first 1,000 cases Ied us to believe with Jordan that postoperative urinary retention depended upon vegetative imbalance, mechanical interference with Bauchpresser and the psychic makeup of the patient. Now we recognize only the third factor. Boland also describes such factors as age, sex, duration of the operation, type and site of the operation and type of anesthesia. These factors do influence the urinary excretion rate producing a suppression of urinary excretion. Therefore, when a surgeon orders his patient catheterized on the eighth hour and only 160 cc. of urine are obtained, the
August,
1950
Urinary
Retention
797
patient should not be listed as having postoperative urinary retention but physiologic postoperative urinary suppression. The results on 1,000 patients showed that 98.3 per cent of all patients seen in the average surgical service, who did not have direct operations on the urinary tract and who voided prior to surgery, voided after surgery. No urinary tract infection or dysfunction developed in those patients as a resuIt of the treatment. Therefore, we suggest discontinuing postoperative catheterizations, except in direct urinary tract surgery and in those patients in whom the psychologic factor is too strong for the short time and kind of treatment available. As more and more work appears on this condition and as the surgeon learns to cooperate with the psychiatrist, as suggested by BIanton and Kirk, so will the condition known as postoperative urinary retention fade from the lists of the common postoperative complications of surgery. SUMM.%RY
Statistics were compiled on 1,000 unselected consecutive surgica1 patients with an incidence of catheterization postoperatively of 18.3 per cent. 2. Physiopsychologic treatment was instituted. 3. The incidence of catheterization dropped to 1.7 per cent. 4. In any hospital, in the average run of surgical patients, the incidence of postoperative urinary catheterization depends upon the knowIedge of the surgeons and house staff of the physiologic and psychologic facts involved. I.
REFERENCES I. BOLAND, F. K. JR. Postoperative 2.
3.
4,
5.
6. 7. 8.
urinary retention. UrOl. I?? CUtan. KU.‘., 43; 323-327, ‘93;. JORDAN, C. G. PostoDerative urinarvi retention. Ann. ‘Surg., 98: 125, ;933. BEST and TAYLOR. Physiologic Basis of hledical ,945. WiIliams Practice. Chapt. 36. Baltimore, and WiIkins Co. SACHS, E. ijber die Behandlung der postoperativen Harnverhaltung. Zentralbl. f. Gyntik., 52: ,331, 1928. ~~CLAUGHLIN, C. W., JR. and BROWN, J. R. Postoperative urinary retention. U. S. Nav. M. Bull., 42: 1025-1032, 1944. LOZINSKI, L. J. Zentralbl. f. Gyniik , 52: 1531-1544, 1928. T~ussrc, FRED J. Tr. Am. Gynec. SIX., 40: 351, rgro. BLANTON, S. and KIRK, V. Psychiatric study of 61 appendectomy cases. Ann. Surg., 126: 3o-314 1947.
CaliJornia
F
OR many years surgeons have slighted the care of the urinary tract in the postoperative patient. Much too frequently and definiteIy too routinely, orders for catheterization were written which did not reflect sound clinica judgment based on physiopsychologic facts. Many controversies exist throughout the literature on this subject. The two most outstanding are whether to empIoy pharmacoIogic or psychoIogic methods of treatment to promote postoperative urination and, shouId these treatments fai1, when to catheterize the patient. At St. Mary’s of Nazareth HospitaI we made a statistica survey of 2,000 consecutive operations in the hope of resoIving these probIems. Postoperative urinary retention may be defined as inability of the postoperative patient to void in spite of a fuII bIadder, norma kidney function and in the absence of organic obstruction. Using this accepted definition we compiIed statistics on 1,000 consecutive surgical patients. We then formuIated a method of treatment which we empIoyed in the next 1,000 cases. The first set of statistics was compiled without the awareness of the nurses, house staff or physicians because we did not desire any change from the postoperative urinary tract management aIready in existence. The second set, however, was compiIed with the awareness of a11 since a standard method of treatment\ carefuIIy and routinety empIoyed was found to be necessary. The 2,000 patients were in the middIe class, mainIy of PoIish and Italian extraction, of both sexes and between the ages of three days to seventy-two years. They were operated upon by seventy-four different surgeons. The preoperative treatment in the majority of the eIective operations consisted of a barbiturate and an enema the night before, and no breakfast and a premeditation of morphine and atropine the morning of surgery. The operative anesthetic in 1,900 of the patients was pentothal sodium@ suppIemented by the gases and curare when necessary. The operative technics were variabIe and depended upon each surgeon. PostoperaAugust,
1950
Chicago,
Illinois
tive treatment was fairIy routine after such operations as those for appendixes, hernias, hemorrhoids and piIonida1 cysts. It was only after the more severe operations that blood, intravenous fluids, chemotherapy, gastrointestina suction and intravenous proteins and vitamins were empIoyed. The incidence of catheterization in the first 1,000 patients was 18.3 per cent (excIuding 6 per cent in whom a retention catheter was inserted). Notice the nearness of our percentages to that of Jordan’s pubIished in 1933 (TabIe I) despite the use of the various drugs discovered in the thirteen-year interim for the treatment of postoperative urinary retention. Because of this we turned from the consideration of a pharmacologic approach to a physiopsychologic one. PrimariIy, we determined the time at which the bIadder contained sufficient urine to promote urination. The average postoperative patient voided 330 cc. of urine in fourteen hours; this was a kidney excretion rate of 23.4 cc. per hour. Compare this with 41 to 75 cc. per hour quoted by Best and TayIor for the average maIe, and understand the suppression of urinary excretion existing in the patient one day postoperativeIy, based on age, weight, sex, height, posture, humidity, temperature, diet, fluid intake and output, anesthetic, degree of narcosis and menta1 excitement. We knew that 250 to 300 cc. are needed in the average maIe as a stimulus for urination. Therefore, we set a fourteen-hour limit, at the end of which the average postoperative patient wouId have enough urine so that he couId void; otherwise, physiopsychoIogic treatment wouId have to be employed. However, any patient wouId be catheterized who compIained of bIadder pain or in whom the bladder was paIpabIe abdominally at any time that first day. TREATMENT
In 1928 Sachs upheld strongIy the psychologic approach to postoperative urinary retention; in 1944 McLaughIin and Brown definitely ‘95
Treiger
196
et al.-Postoperative
showed that postoperative urinary retention was psychologic in the young maIes in their series. We believed with Lozinski that the patients should be requested to urinate in the recumbent position preoperatively in order to overcome
Type of Operation
Appendix. ........... Gallbladder. ......... Hernia. ............. Hermorrhoid. ........ Gastric. ............. Breast. ............. Thyroid. ............ hlajor abdomen. ..... PiIonidal cyst ............
___-
I
DROPS IN CATHETERIZATION
-
‘933
‘947
Per Cent Catheterized
,
Retention
rnent employed so occasionally and haphazardly before. We had practiced early rising sporadicalIy since 1945, but now we empIoyed it routinely in those cases in which the patients did not void. This consisted of using a sitting position
TABLE PERCENTAGE
Urinary
19.8 15.8 15.7 ‘4-3 37.5 7.8 4. 0 12.7
No. Patients ___ 385 67 99
73 9 26
64
17
21
‘5 23 45 20
i
any existing psychologic block. To aid him in doing so, we added that as complete privacy as possible should be achieved by means of drapes, screens and cIosed doors. PostoperativeIy, we requested that a urina1 or bedpan be within the reach of each patient and that the patient not be requested to urinate or asked if he had urinated at any time before the fourteen hours had elapsed. This prevented him from becoming conscious of the urinary mechanism before he was actuaIIy abIe to void. AI1 patients were divided into three groups, nameIy, those who urinated before fourteen hours, those who tried to urinate and faiied and those who made no attempt at all to urinate. The first group of patients needed no treatment. The second group was to be reassured by the nurse that there was insufficient urine in the bIadder at this time. The patients were referred to the house staff at the expiration of the fourteen hours. The third group also was referred at that time. The interne evaIuated in each patient a11 the factors influencing his kidney excretion rate and decided if there was a sufficient amount of urine present in the bIadder. If there was a sufficient amount present, the patient was requested to urinate. If he failed to do so, the interne and the nurse, supervised by the resident, continued the physiopsychoIogic treat-
Per Cent Catheterized
13.0 25.0
!
5
)
20.0
1
i
No. 1Catheterized ~~~_~.~ /
25 5 4.7 6.0 4. o 13.0 25.5
for the female \vith the feet braced on a chair at the side of the bed and the standing position for the male, duplicating the body posture each had employed in previous years for urination. More important were the reassurances to the patient of his abiIity to void, the impossibility of his wound breaking open, the necessity for sustained downward pressure and the fact that he wouId have to “break through” in a gradual manner. The first indication of success came when the patient feIt the urge to urinate but couId not go beyond a certain point. One or two more words of reassurance, the use of psychologic “tricks” such as running water, drinking water, playing with ice chips, supplemented by a hot water bottle to reIax the tense perineum, and the patient voided. Remember that this treatment was not empIoyed until we thought the patient had suchcient urine in the bladder. If this treatment failed, we allowed four hours to elapse and then tried again. The patient was catheterized onIy in the event of bIadder discomfort or if the bIadder was paIpabIe or percussabIe abdominahy. Since the first statistics showed that the percentage of urinary retention was negligible in a11 ages below thirteen, and in thyroid, head, neck and extremity surgery the treatment was not therein specified. An outline of this treatAmerican
Journal
of Surgery
Treiger
et A-Postoperative
ment was placed in each chart room and lectures were given the house and nursing staffs so that everyone understood the applied physiology and psychology. RESULTS
The percentage of patients catheterized dropped from I 8.3 per cent to I .7 per cent with the employment of the physiopsychologic treatment. Refer to Table I for the percentage drops in the various kinds of surgery. Only 46 per cent of the patients voided without being asked before fourteen hours, while the other 39 per cent were treated. None of the patients developed any urinary tract infection or dysfunction noted in the hospita1 or as reported subsequently by the family physician; this was so even though we had calculated after Taussig that there was a 13 cc. residual per hour in the bladder of the voiding patient. The seventeen patients who did not void had only one factor in common; they were all neurotrc. Five of these patients had previous surgery and catheterizations which fixed a pattern in their minds to which they rigidly adhered, and out of which there was not enough time to condition them. One was a deaf mute to whom we could not converse. Another had prostatism which definitely convinced him after his operation for hemorrhoids in that region that he could not void. COMMENT
achieved a postoperative catheterization rate of 1.7 per cent without the incidence of We
urinary tract infection or dysfunction and without the use of drug therapy. Had we aIso employed a drug, couId we not have mistaken the excellent resuIts for the work of the drug? And might not this have happened already in many of the drugs described as valuable in this condition? The first 1,000 cases Ied us to believe with Jordan that postoperative urinary retention depended upon vegetative imbalance, mechanical interference with Bauchpresser and the psychic makeup of the patient. Now we recognize only the third factor. Boland also describes such factors as age, sex, duration of the operation, type and site of the operation and type of anesthesia. These factors do influence the urinary excretion rate producing a suppression of urinary excretion. Therefore, when a surgeon orders his patient catheterized on the eighth hour and only 160 cc. of urine are obtained, the
August,
1950
Urinary
Retention
797
patient should not be listed as having postoperative urinary retention but physiologic postoperative urinary suppression. The results on 1,000 patients showed that 98.3 per cent of all patients seen in the average surgical service, who did not have direct operations on the urinary tract and who voided prior to surgery, voided after surgery. No urinary tract infection or dysfunction developed in those patients as a resuIt of the treatment. Therefore, we suggest discontinuing postoperative catheterizations, except in direct urinary tract surgery and in those patients in whom the psychologic factor is too strong for the short time and kind of treatment available. As more and more work appears on this condition and as the surgeon learns to cooperate with the psychiatrist, as suggested by BIanton and Kirk, so will the condition known as postoperative urinary retention fade from the lists of the common postoperative complications of surgery. SUMM.%RY
Statistics were compiled on 1,000 unselected consecutive surgica1 patients with an incidence of catheterization postoperatively of 18.3 per cent. 2. Physiopsychologic treatment was instituted. 3. The incidence of catheterization dropped to 1.7 per cent. 4. In any hospital, in the average run of surgical patients, the incidence of postoperative urinary catheterization depends upon the knowIedge of the surgeons and house staff of the physiologic and psychologic facts involved. I.
REFERENCES I. BOLAND, F. K. JR. Postoperative 2.
3.
4,
5.
6. 7. 8.
urinary retention. UrOl. I?? CUtan. KU.‘., 43; 323-327, ‘93;. JORDAN, C. G. PostoDerative urinarvi retention. Ann. ‘Surg., 98: 125, ;933. BEST and TAYLOR. Physiologic Basis of hledical ,945. WiIliams Practice. Chapt. 36. Baltimore, and WiIkins Co. SACHS, E. ijber die Behandlung der postoperativen Harnverhaltung. Zentralbl. f. Gyntik., 52: ,331, 1928. ~~CLAUGHLIN, C. W., JR. and BROWN, J. R. Postoperative urinary retention. U. S. Nav. M. Bull., 42: 1025-1032, 1944. LOZINSKI, L. J. Zentralbl. f. Gyniik , 52: 1531-1544, 1928. T~ussrc, FRED J. Tr. Am. Gynec. SIX., 40: 351, rgro. BLANTON, S. and KIRK, V. Psychiatric study of 61 appendectomy cases. Ann. Surg., 126: 3o-314 1947.