Dear Sir
Postoperative urinary retention is quite common and many patients require urinary catheterization for this [1]. This results in additional morbidity in these patients. Considering the high incidence of urinary retention and large number of operations done all over the world on a daily basis, this translates into an enormous economic burden as well.
Amongst several reasons for postoperative urinary retention after anorectal surgery, one patient related factor is commonly overlooked. This factor is ‘inability to increase intraabdominal pressure’ (IRIP) due to fear of causing pain in the pelvic/anorectal operative area. This cause is important to recognize because unlike other causes, catheterization is not required in urinary retention due to this etiology. The only requirement in such patients is firm reassurance and encouragement that it is absolutely safe for them to strain and increase intraabdominal pressure. Whereas urinary retention due to epidural/spinal anesthesia would occur within 24 h of surgery, occasionally the retention or incomplete evacuation due to IRIP can happen even 24 h after surgery.
In our center dedicated to anal fistula surgery, 224 patients were operated for anal fistula under saddle block (spinal anesthesia) over a period of 1 year. The mean age was 37.1 ± 11.2 years and the M/F ratio was 179/45. There were 34 patients (15.1%) with postoperative urinary retention, 31 of whom had urinary retention on day 0 (day of surgery) and 3 of whom had urinary retention after 24 h post-surgery (postoperative days 1–7). All patients were reassured that it was safe to strain and encouraged to increase intraabdominal pressure so as to pass urine. After reassurance, 24 were able to pass urine whereas ten required urinary catheterization. Thus, about two-thirds (24/34) were perhaps suffering from IRIP and would have been routinely catheterized if IRIP was not diagnosed in them. Firm reassurance and encouragement helped prevent urinary catheterization in these patients.
To conclude, IRIP is a common cause of urinary retention in the postoperative period after pelvic/anorectal surgery. This usually happens in apprehensive patients. Unlike retention due to epidural/spinal anesthesia, IRIP retention improves after reassurance and does not usually require catheterization. Timely recognition of IRIP as a cause of postoperative urine retention can decrease morbidity by facilitating early catheter removal or preventing unnecessary urinary catheterization.
Reference
Lee Y, McKechnie T, Springer JE et al (2019) Optimal timing of urinary catheter removal following pelvic colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis 34:2011–2021
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Selected for presentation at American Society of Colon Rectum Surgeons (ASCRS) annual meeting At Boston, MA, USA on 8th June 2020.
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Garg, P. Inability to raise intraabdominal pressure (IRIP): a common missed cause of postoperative urinary retention after anorectal surgery. Tech Coloproctol 24, 499 (2020). https://doi.org/10.1007/s10151-020-02189-7
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DOI: https://doi.org/10.1007/s10151-020-02189-7