Is prostaglandin E2 really of therapeutic value for postoperative urinary retention? Results of a prospectively randomized double-blind study. Intravesical prostaglandin F2 for promoting bladder emptying after surgery for female stress incontinence. [Intravesical prostaglandin E2 and placebo in urinary retention after gynaecological surgery (author's transl)]. The use of anxiolytic and parasympathomimetic agents in the treatment of postoperative urinary retention following anorectal surgery. A prospective, randomized, double-blind study. Management of postoperative urinary retention: a randomized trial of in-out versus overnight catheterization. [Intravesical instillation of trospium chloride, oxybutynin and verapamil for relaxation of the bladder detrusor muscle. A placebo controlled, randomized clinical test]. A comparison of suprapubic and transurethral drainage for postoperative urinary retention in general surgical patients. Prevention of urinary retention after general surgery: a controlled trial of carbachol/diazepam versus alfusozine. Sustained-release alfuzosin and trial without catheter after acute urinary retention: a prospective, placebo-controlled.
In a prospectively randomized double-blind study 28 patients with urinary retention after anterior colporrhaphy were administered either placebo or prostaglandin E2 in different doses (0.75 mg, 1.5 mg, or 2.25 mg) intravesically on postoperative days 6 and 7. Urodynamic assessment was performed before and after treatment. A moderate but not significant decrease of maximum bladder capacity, bladder compliance, and maximum urethral closure pressure was found in patients treated with 2.25 mg of prostaglandin E2. These urodynamic changes did not correspond to the clinical outcome: Residual urine decreased and effective bladder capacity increased significantly in all four groups uninfluenced by the type of therapy. The rate of success (defined by the amounts of residual urine after therapy) was similar in the four groups. A long-term effect of prostaglandin E2 could also be excluded, since the mean time interval from operation to the first day without residual urine was similar in the four groups. Therefore the therapeutic value of intravesically administered prostaglandin E2 in doses from 0.75 to 2.25 mg must be seriously questioned. Prostaglandin F2 alpha 10 mg was administered intravesically in a double-blind placebo-controlled study to promote micturition in cases of urinary retention after operative treatment of urinary stress incontinence in women. Fifteen of 18 patients (83%) succeeded in voiding after treatment with prostaglandin F2 alpha, but the placebo was ineffective in all 18 patients (P less than 0.001). Although the effect of prostaglandin F2 alpha on bladder muscle contraction was short-lived, it seemed to enhance the restoration of bladder motor function with no serious side effects, and thus to be clinically useful in the treatment of post-operative urinary retention. In a randomized single blind trial we studied the effectiveness of intravesical prostaglandin E2 in the treatment of postoperative urinary retention after vaginal hysterectomy with colposuspension. One group of patients (n = 8) received 1.5 mg prostaglandin E2 in 50 ml 0.9% NaCl on the 9th postoperative day (72 hours after removal of the Foley catheter) and 50 ml NaCl without prostaglandin E2 on the following day. In the second group (n = 12) NaCl was instilled on the first day of treatment and prostaglandin E2 on the following day. Four hours after the instillation of prostaglandin E2 5 out of 8 women were able to void spontaneously, while after the instillation of NaCl spontaneous micturition occurred in only 2 out of 12 women (p less than 0.05). In both groups the average time period until patients were free of residual urine was 4 days after the initiation of therapy. Compared to placebo intravesical prostaglandin E2 is significantly more effective in achieving spontaneous voiding after gynaecological surgery. Approximately 30 percent of patients undergoing anorectal surgery will develop acute urinary retention. The cause of this complication is poorly understood. Anxiety, anal distention, bladder distention as a result of vigorous hydration during surgery, and reflex inhibition of the urinary bladder detrusor muscle secondary to pain have been postulated as contributing factors. A four-armed prospective, double-blind, randomized trial was carried out to determine whether an anxiolytic agent (midazolam, 5 mg intramuscularly) and/or a parasympathomimetic agent (bethanechol, 10 mg subcutaneously) reduce the incidence of postoperative urinary retention following anorectal surgery. One hundred thirty-two patients (ages, 18 to 50 years), in acute urinary retention 6 to 12 hours following anorectal surgery, were enrolled. Sixty-nine percent of patients responded to bethanechol. Side effects were minimal. Midazolam alone had no effect on retention. Bethanechol and midazolam in combination resulted in less retention than midazolam and a placebo (P less than 0.05). Bethanechol alone was better than a placebo (P less than 0.002). Mean intraoperative intravenous fluid volume for the entire study group was 900 cc. Initial postoperative urinary volumes of patients who failed the treatment protocol were significantly higher than in those responding to bethanechol (mean of 527 cc vs. 241 cc, P less than 0.001). The use of an anxiolytic agent was not effective in the treatment of postoperative urinary retention. Bladder distention may increase the incidence of urinary retention. Bethanechol, in a dose of 10 mg subcutaneously, significantly lowered the incidence of postoperative urinary catheterization and should be considered as initial treatment of postoperative urinary retention following anorectal surgery. There has been no consensus on the best catheterization strategy for the management of postoperative urinary retention. A prospective randomized trial was undertaken to establish the best practice guidelines for the management of postoperative urinary retention. The authors also evaluated the contemporary incidence of urinary retention following different categories of general surgery and examined risk factors associated with its occurrence.
                All patients who underwent elective inpatient surgery between January 2002 and June 2003 were recruited into the study. Patients who developed postoperative urinary retention were randomized to either having in-out catheterization or placement of an indwelling catheter for 24 h after surgery.
                A total of 1448 patients was recruited. The overall incidence of urinary retention was 4.1% (n = 60). Significant risk factors associated with postoperative urinary retention included old age, anorectal procedures and use of spinal anaesthesia. Comparison of re-catheterization and urinary tract infection rates between patients who were treated with in-out versus overnight catheterization found no significant differences.
                Postoperative urinary retention should be managed by in-out catheterization. Indwelling catheterization for 24 h appeared to bestow no additional benefits. The incidence of urinary retention increases with age, anorectal procedures and the use of spinal anaesthesia. Therapy of detrusor hyperactivity with anticholinergic agents often is followed by adverse drug reactions. Intravesical application may be an interesting alternative. A randomised, single-blind, placebo-controlled, mono-centre clinical trial was carried out in 84 patients with urgency or urge incontinence. Due to intravesical administration of oxybutynin (CAS 5633-20-5) (n = 21) and trospium chloride (CAS 10405-02-4) (n = 21), respectively, a significant increase in maximum bladder capacity and decrease of detrusor pressure accompanied by an increase of residual urine were found in comparison to placebo in urodynamical investigations. Improvement of uninhibited bladder contractions occurred leading to higher filling volume. Under verapamil (CAS 152-11-4) (n = 21) no marked changes in the efficacy variables were found compared with placebo. All patients completed the study and were assessed with regard to efficacy and safety. No adverse events or marked changes in the vital signs were reported. The immediate onset of effect and the lack of adverse drug reactions suggest that treatment with topical oxybutynin or trospium chloride is an effective alternative in patients with intolerable side effects when orally treated. In addition, intravesical administration may be indicated in patients with bladder spasms due to indwelling catheter or in order to increase bladder capacity before percutaneous cystostomy. Percutaneous suprapubic bladder drainage, using an indwelling Silastic catheter, was compared with transurethral catheterization for the management of postoperative urinary retention in general surgical patients. In a prospective controlled trail, the overall incidence of postoperative retention was 7%. The urinary infection rate was 70% with transurethral catheterization and 8% with suprapubic drainage. Patients accepted suprapubic damage much more readily than transurethral cateterization and both medical and nursing personnel found the former method easier to manage effectively. Also, the patients' ability to pass urine spontaneously could be assessed without removing the catheter. However, minor mechanical complications were more common with suprapubic drainage. The cost of the two systems is comparable. We conclude that the routine use of suprapubic catheter drainage in the management of postoperative urinary retention significantly reduces the incidence of infection and is the preferred method of treating this common complication. Postoperative urinary retention is a common complication after surgical procedures. It can cause bladder dilatation, infection, and even sepsis. Carbachol/diazepam and alfusozine have been reported to lower the incidence of postoperative urinary retention, but no study showed the benefits of these drugs in a randomized, placebo-controlled trial.
                We used a double blind, placebo-controlled trial in which 249 patients with postoperative urinary retention were randomly assigned to receive carbachol/diazepam (n = 72), alfusozine (n = 82), or placebo (n = 95). The primary endpoint was miction within 2 hours after taking the medication.
                There was no significant difference in miction frequency after taking the medication among the three groups (p = 0.31). The miction rate was 60% for patients in the alfusozine group, 61% in the carbachol/diazepam group, and 51% in the placebo group.
                Alfusozine and carbachol/diazepam had no apparent benefit on the incidence of postoperative urinary retention. To establish whether the administration of sustained-release (SR) alfuzosin improves the outcome of a trial without catheter (TWOC) after an episode of acute urinary retention.
                In a prospective, randomized, placebo-controlled trial, 81 patients with acute urinary retention related to benign prostatic obstruction received either SR alfuzosin (n=40), an alpha1-selective blocker, given at a dose of 5 mg twice daily, or placebo (n=41) for 48 h. The catheter was removed after 24 h of treatment. The main outcome measurement was success or failure of the TWOC. At the end of this double-blind phase the patients were followed up on an open basis.
                After removal of the catheter, 42% of patients voided successfully, 22 of 40 (55%) with SR alfuzosin and 12 of 41 (29%) with placebo (P=0.03). The mean age of patients voiding successfully, regardless of treatment group, was 68. 4 years, whilst the mean age of those who were not successful was 72. 9 years (P=0.015). In an intention-to-treat analysis of outcome adjusted for this age difference, the benefit in favour of those receiving SR alfuzosin was not significant, but at P=0.052 there was a strong suggestion of a positive treatment effect. The observed benefit remained significant in a per-protocol analysis adjusted for age. Taken together, these results indicate that treatment with SR alfuzosin was effective and that the observed benefit was not simply the effect of age difference between the groups. Of the 34 patients who voided successfully 23 (68%) required no further intervention within a mean follow-up of 7 months.
                Treatment with SR alfuzosin is effective in improving the success rate of a TWOC after an episode of acute urinary retention, although older patients are less likely to void successfully. By reducing the numbers of men sent home with urinary catheters, such treatment may result in a reduction in the associated perioperative morbidity in those undergoing prostatic surgery, and is clearly desirable for the patients' comfort and convenience.
Whilst it may appear that cholinergic agents and intravesically administered prostaglandin offer most promise in the treatment of post-operative urinary retention, the evidence is weak. There is a need for further research into pharmacological alternatives to catheterisation in the treatment of this common surgical complication.