Xue Qi-Ming, MS, AD Xiang Jue-Ying, BSN, RN Chen Ben-Hui, BSN, RN Wu Jing, PhD, AD Li Ning, PhD, MD
Risk Factors for Postoperative Retention After Hemorrhoidectomy A Cohort Study
ABSTRACT The objective of this study was to identify the risk factors for urinary retention after hemorrhoidectomy. With the approval of West China Hospital of Sichuan University Ethics Board, data were abstracted from 961 charts of patients who underwent hemorrhoidectomy from January 1, 2009, to June 30, 2011. The outcome was urinary retention in the first 24 hours after surgery. Risk factors were identified using multivariable logistic regression, and they were expressed as odds ratios or 95% confidence intervals. The overall urinary retention rate was 14.8% (n = 142). Significant risk factors associated with postoperative urinary retention included female gender, anesthesia methods, severity of hemorrhoid, a large amount of intravenous fluid administered perioperatively, and length of hospital stay. Logistic regression analysis revealed that female gender (odds ratio, 2.607; p < .01), sacral anesthesia (odds ratio, 2.481; p = .02), more than 3 hemorrhoids resected (odds ratio, 2.658; p < .01), hemorrhoids having 4 degrees of severity (odds ratio, 3.101; p < .01), intravenous fluids > 700 ml (odds ratio, 1.597; p = .02), and length of stay more than 7 days (odds ratio, 1.852; p < .01) were significant predictors of urinary retention posthemorrhoidectomy.
Received May 1, 2013; accepted March 18, 2015. About the authors: Xue Qi-Ming, MS, AD, is Research Associate, Center for the Study of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. Xiang Jue-Ying, BSN, RN, is Registered Nurse, Center for the Study of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. Chen Ben-Hui, BSN, RN, is Center Director, Center for the Study of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. Wu Jing, PhD, AD, is Clinician, Center for the Study of Integrated Chinese and Western medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. Li Ning, PhD, MD, is Professor, Department of Integrated Chinese and Western Medicine, and Center Director, Center for the Study of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. The authors declare no conflicts of interest. Correspondence to: Li Ning, PhD, MD, Department of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, 37 # Guoxue Lane, Chengdu, 610041, Sichuan Province, China ([email protected]). DOI: 10.1097/SGA.0000000000000121
H
emorrhoidectomy used to be the standard treatment for patients with third-degree and fourth-degree hemorrhoids and is still being practiced around the world today. Some researchers found that acute urinary retention was the most common complication after surgery for hemorrhoids (Jee, Seo, & Song, 1997; Kim et al., 2000; Zaheer, Reilly, Pemberton, & Ilstrup, 1998). The risks for urinary retention after hemorrhoidectomy have varied widely among different reports depending on the anesthesia, analgesia, perioperative fluid intake, and anal packing, with risk estimates ranging from 4.9% to 46.1% (Lau & Lam, 2004; Mik, Rzetecki, Sygut, Trzcinski, & Dziki, 2008; Ng, Ho, Ooi, Tang, & Eu, 2006). The exact etiology of urinary retention after surgery for hemorrhoids is still not clear. The purposes of this study were to estimate the 24-hour risk of postoperative urinary retention in a cohort of patients undergoing hemorrhoidectomy and identify risk factors for postoperative urinary retention in the same cohort.
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Risk Factors for Postoperative Retention After Hemorrhoidectomy
Patients and Methods After approval by the West China Hospital of Sichuan University’s institutional review board, a retrospective chart review was undertaken of 961 consecutive patients who underwent standard Milligan–Morgan hemorrhoidectomy and were included in a study of the incidence and determinants of urinary retention. All surgeries were performed at our institution between January 2009 and June 2011. All procedures were performed after the administration of 2% lidocaine for sacral or local anesthesia. In all cases, 300–900 ml of intravenous fluids were administered within 24 hours after surgery. For all patients, a hemostatic gauze pack was inserted into the anal canal at the end of surgery. In the ward, the patients were given ibuprofen and codeine phosphate tablets (2 tablets) orally or tramadol hydrochloride (100 mg) intramuscularly for supplementary analgesia when necessary. Catheterization was performed only when the bladder was palpable or distended after attempts by the nursing staff to assist the patient with voiding (such as by warming the lower abdomen or listening to the sound of running water) were unsuccessful and the patient was obviously uncomfortable. Urinary retention was defined as the need for catheterization within 24 hours after surgery. Factors analyzed as risks for urinary retention were age more than or less than 60 years, gender, hemorrhoid type and severity, anesthesia methods, the various operative procedures, operation time (more than or less than 60 minutes), the number of hemorrhoids resected (more than or less than 3), intravenous fluids (more than or less than 700 ml administered within 24 hours), use of analgesic drugs within 24 hours, and length of stay (more than or less than 7 days). The incidence of urinary retention was also calculated.
Statistical Analysis Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 12.0. Values were expressed as frequency, percentage, mean, and standard deviation. Univariate analysis by use of the chi-square test and multiple logistic regression analysis were performed to identify independent risk factors for urinary retention. All tests were two-tailed with significance defined by p < .05.
Results
TABLE 1. Demographic Data (n = 961) Variable
n
%
≤60
826
86.0
>60
135
14.0
Male
435
45.3
Female
526
54.7
Internal
71
7.4
External
25
2.6
Mixed
865
90.0
3 degree
709
73.8
4 degree
252
26.2
Sacral
843
87.7
Local
118
12.3
≤60
332
34.5
>60
629
65.5
≤700 ml
636
66.2
>700 ml
325
33.8
≤7
308
32.0
>7
653
68.0
Age (years)
Gender
Hemorrhoid type
Severe
Anesthesia
Operation time (minutes)
Intravenous fluids
Length of stay (days)
from 13 to 87 years, with a mean age of 44.06 years. There were 435 men (45.3%) and 526 women (54.7%). The majority of type was mixed (90.0%) and severity was three-degree hemorrhoid (73.8%). The mean duration of operating room stay was 77.25 (range 15–180) minutes. The majority of patients (87.7%) received sacral anesthesia during the surgical procedure. The length of hospital stay of patients ranged from 1 to 33 days with a mean of 9.07 days.
Characteristics of the Sample From January 1, 2009 to June 30, 2011, among the 961 patients who underwent hemorrhoidectomy, the overall urinary retention rate was 14.8%. A summary of the characteristics of the study sample is presented in Table 1. The ages of the study population ranged
VOLUME 38 | NUMBER 6 | NOVEMBER/DECEMBER 2015
The Prevalence and Risk Factors of Urinary Retention Results of univariate analysis for the total patients undergoing hemorrhoidectomy are shown in Table 2. In addition, the use of sacral anesthesia, female gender,
465
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Risk Factors for Postoperative Retention After Hemorrhoidectomy
TABLE 2. Potential Risk Factors for Postoperative Urinary Retention in Patients Undergoing Hemorrhoidectomy (n = 961) Urine Retention Variable
Nonurine Retention
n
%
n
%
p
≤60
125
88.0
701
85.6
.441
>60
17
12.0
118
14.4
Male
37
26.1
398
48.6
Female
105
73.9
421
51.4
Internal
12
8.5
59
7.2
External
2
1.5
23
2.8
128
90.1
737
90.0
3 degree
76
53.5
633
77.3
4 degree
66
46.5
186
22.7
Sacral
133
93.7
710
86.7
Local
9
6.3
109
13.3
≤60
51
35.9
281
34.3
>60
91
64.1
538
65.7
≤700 ml
77
54.2
559
68.3
>700 ml
65
45.8
260
31.7
≤3
38
26.8
397
48.5
>3
104
73.2
422
51.5
≤7
31
21.8
277
33.8
>7
111
78.2
542
66.2
Age (years)
Gender .000
Hemorrhoid type
Mixed
.519
Severe .000
Anesthesia .019
Operation time (minute) .710
Intravenous fluids .001
Number of hemorrhoids resected .000
Length of stay (days)
hemorrhoids having four degrees of severity, intravenous fluids more than 700 ml, more than three hemorrhoids resected, and length of stay more than 7 days were found to be risk factors for urinary retention.
The Predictor Factor of the Urinary Retention The results of logistic regression analysis in each of these groups are shown in Table 3. In the hemorrhoidectomy
.005
group, female gender (odds ratio [OR], 2.607; p < .01; 95% confidence interval [CI]: 1.716–3.961), sacral anesthesia (OR, 2.481; p = .02; 95% CI: 0.226–0.977), more than three hemorrhoids resected (OR, 2.658; p < .01; 95% CI: 1.756–4.023), hemorrhoids having four degrees of severity (OR, 3.101; p < .01; 95% CI: 2.096– 4.586), intravenous fluids more than 700 ml (OR, 1.597; p = .02; 95% CI: 1.079–2.364), and length of stay more than 7 days (OR, 1.852; p < .01; 95% CI:
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Risk Factors for Postoperative Retention After Hemorrhoidectomy
TABLE 3. Logistic Regression Model for the Patients Undergoing Hemorrhoidectomy (n = 961) Variable
Odds Ratio
95% CI
p
Female gender
2.607
1.716–3.961
.000
Sacral anesthesia
2.481
1.174–5.241
.017
More than 3 hemorrhoids resected
2.658
1.756–4.023
.000
1.852
1.180–2.907
.007
3.101
2.096–4.586
.000
1.597
1.079–2.364
.019
Length of stay >7 days Severe 4 degree Intravenous fluids >700 ml Note. CI = confidence interval.
1.180–2.907) were found to be independent determinants of urinary retention. All other variables (age, type of hemorrhoid, and operation time) failed to enter into the equation.
Discussion The reported incidence of urinary retention after hemorrhoidectomy ranged widely from less than 1% to more than 50% (Mik et al., 2008; Ng et al., 2006). This variation may be the result of differences between studies in the definition of urinary retention, exclusion criteria, types of operative procedures, and type of anesthesia. Our overall urinary retention rate of 14.8% is within the reported range. The exact cause of urinary retention after hemorrhoidectomy is not clearly understood. The previous study showed that the major factor leading to urinary retention was the inhibition of the detrusor muscle (Barone & Cummings, 1994). Inhibition of the detrusor muscle is the result of a reflex involving afferent fibers of the pudendal nerve, sacral spinal cord, and efferent pelvic sympathetic nerves. In the logistic regression model, anesthesia was one of the predictors of urinary retention. The odds of urinary retention increased 2.481-fold in the sacral group when compared with local anesthesia. This result is consistent with the fact that spinal area anesthesia significantly increases the risk of urinary retention after hemorrhoidectomy, as reported (Bansal, Jenaw, Mandia, & Yadav, 2012; Lohsiriwat & Lohsiriwat, 2007). Sacral anesthesia leads to rapid blockages of the micturition reflex, and complete recovery of detrusor muscle function occurs in a few hours. Many investigators have shown that increased fluid intake is an important determinant of urinary retention (Kim et al., 2000; Zaheer et al., 1998). Bailey and Ferguson reported a reduction in postoperative urinary VOLUME 38 | NUMBER 6 | NOVEMBER/DECEMBER 2015
retention from 15% to 4% in patients for whom both intravenous and oral fluids were restricted (Bailey & Ferguson, 1976). Our analysis showed that intravenous fluid intake of more than 700 ml was an independent risk factor for urinary retention after surgery for hemorrhoidectomy. In addition, we showed that perioperative fluid restriction significantly decreased the incidence of urinary retention after anorectal surgery. Therefore, perioperative fluid restriction is recommended for prevention of urinary retention after anorectal surgery. Our analysis showed that the disease severity, measured as the number of resected hemorrhoids, was an independent risk factor for urinary retention. This may lead to increased postoperative edema and pain and thus give rise to detrusor inhibition and bladder outlet obstruction, resulting in urinary retention. The study found that hospital stay was prolonged significantly in patients with urinary retention (Zaheer et al., 1998). In our study, the urinary retention rate of those patients having a length of hospital stay over 7 days increased 1.852-fold when compared with those less than 7 days. The influence of gender on urinary retention is controversial (Petros & Bradley, 1990). However, surprisingly, female gender was shown in our study to be an independent risk factor. There were several possible reasons for this result. Voiding was hindered in the women because they were lying in the supine position on the bed, immobilized by the intravenous line, and hampered by the gauze over the anal region. Women, especially in China, might feel more reluctant than men to void in an unfamiliar surrounding without privacy. Further investigation is warranted to clarify the influence of gender on postoperative urinary retention. Urinary retention is a common and frustrating complication during surgery for hemorrhoidectomy. Nurses 467
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Risk Factors for Postoperative Retention After Hemorrhoidectomy
use measures such as oral analgesia, hot pack application, listening to the sound of water, sacral region massage, and ambulation for patients who cannot void after 6 hours following hemorrhoidectomy. If these measures are not successful, catheterization can be performed. The common useful strategies applied to deal with urinary retention were overnight catheterization and in–out catheterization. Well-known catheter problems include recurrent and persistent blockage, catheter-related urinary tract infection, accidental dislodgment, and leakage of urine. We could not recognize whether patients who could not urinate after their operations were impacted by nursing interventions to promote urination. However, nurses may have the opportunity to pay more attention to preoperative instructions.
Limitations Our study has limitations. Data from this study were limited to what was documented in the medical charts. The medical charts might not have identified events that occurred but were not recorded. Limitations owing to the retrospective design of this study and possible recall bias are also acknowledged. We did not expand our investigation to include the other parameters relevant to urinary retention such as pain level, analgesic requirements, urinary symptoms, and anal packing, which are all suggested for future study.
Conclusions Urinary retention often occurs in patients undergoing hemorrhoidectomy. Furthermore, female gender, anesthesia methods, severity of hemorrhoid, large amount of intravenous fluid administered perioperatively, and length of hospital stay are independent risk factors for urinary retention in selected cases of hemorrhoidectomy. Careful follow-up of patients with these risk factors can help nurses spot posthemorrhoidectomy urinary retention early and take appropriate interventions to help promote patient voiding. Once urinary retention occurs, intermittent sterile catheterization is
required to avoid irreversible damage to the detrusor muscle, which prolongs bladder acontractility and urinary retention. ✪
REFERENCES Bailey, H. R., & Ferguson, J. A. (1976). Prevention of urinary retention by fluid restriction following anorectal operations. Dis Colon Rectum, 19(3), 250–252. Bansal, H., Jenaw, R. K., Mandia, R., & Yadav, R. (2012). How to do open hemorrhoidectomy under local anesthesia and its comparison with spinal anesthesia. Indian Journal of Surgery, 74(4), 330–333. Barone, J. B., & Cummings, K. B. (1994). Etiology of acute urinary retention following benign anorectal surgery. The American Journal of Surgery, 60(3), 210–211. Jee, D. L., Seo, D. H., & Song, S. O. (1997). Factors influencing postoperative urinary retention after hemorrhoidectomy. Korean Journal of Anesthesiology, 33(3), 491–496. Kim, S. B., Lee, I. O., Kong, M. H., Lee, M. K., Kim, N. S., Choi, Y. S., & Lim, S. H. (2000). The effect of anal packing on urinary retention after hemorrhoidectomy under the spinal anesthesia. Korean Journal of Anesthesiology, 38(1), 30–34. Lau, H., & Lam, B. (2004). Management of postoperative urinary retention: A randomized trial of in–out versus overnight catheterization. Australian and New Zealand Journal Surgery, 74(8), 658–661. Lohsiriwat, V., & Lohsiriwat, D. (2007). Ambulatory anorectal surgery under perianal anesthetics infiltration: Analysis of 222 cases. Journal of the Medical Association of Thailand, 90(2), 278–281. Mik, M., Rzetecki, T., Sygut, A., Trzcinski, R., & Dziki, A. (2008). Open and closed haemorrhoidectomy for fourth degree haemorrhoids—comparative one center study. Acta Chirurgia Iugoslavica, 55(3), 119–125. Ng, K. H., Ho, K. S., Ooi, B. S., Tang, C. L., & Eu, K. W. (2006). Experience of 3711 stapled haemorrhoidectomy operations. British Journal of Surgery, 93(2), 226–230. Petros, J. G., & Bradley, T. M. (1990). Factors influencing postoperative urinary retention in patients undergoing surgery for benign anorectal disease. The American Journal of Surgery, 159(4), 374–376. Zaheer, S., Reilly, W. T., Pemberton, J. H., & Ilstrup, D. (1998). Urinary retention after operations for benign anorectal diseases. Diseases of the Colon & Rectum, 41(6), 696–704.
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Risk Factors for Postoperative Retention After Hemorrhoidectomy A Cohort Study
ABSTRACT The objective of this study was to identify the risk factors for urinary retention after hemorrhoidectomy. With the approval of West China Hospital of Sichuan University Ethics Board, data were abstracted from 961 charts of patients who underwent hemorrhoidectomy from January 1, 2009, to June 30, 2011. The outcome was urinary retention in the first 24 hours after surgery. Risk factors were identified using multivariable logistic regression, and they were expressed as odds ratios or 95% confidence intervals. The overall urinary retention rate was 14.8% (n = 142). Significant risk factors associated with postoperative urinary retention included female gender, anesthesia methods, severity of hemorrhoid, a large amount of intravenous fluid administered perioperatively, and length of hospital stay. Logistic regression analysis revealed that female gender (odds ratio, 2.607; p < .01), sacral anesthesia (odds ratio, 2.481; p = .02), more than 3 hemorrhoids resected (odds ratio, 2.658; p < .01), hemorrhoids having 4 degrees of severity (odds ratio, 3.101; p < .01), intravenous fluids > 700 ml (odds ratio, 1.597; p = .02), and length of stay more than 7 days (odds ratio, 1.852; p < .01) were significant predictors of urinary retention posthemorrhoidectomy.
Received May 1, 2013; accepted March 18, 2015. About the authors: Xue Qi-Ming, MS, AD, is Research Associate, Center for the Study of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. Xiang Jue-Ying, BSN, RN, is Registered Nurse, Center for the Study of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. Chen Ben-Hui, BSN, RN, is Center Director, Center for the Study of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. Wu Jing, PhD, AD, is Clinician, Center for the Study of Integrated Chinese and Western medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. Li Ning, PhD, MD, is Professor, Department of Integrated Chinese and Western Medicine, and Center Director, Center for the Study of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China. The authors declare no conflicts of interest. Correspondence to: Li Ning, PhD, MD, Department of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, 37 # Guoxue Lane, Chengdu, 610041, Sichuan Province, China ([email protected]). DOI: 10.1097/SGA.0000000000000121
H
emorrhoidectomy used to be the standard treatment for patients with third-degree and fourth-degree hemorrhoids and is still being practiced around the world today. Some researchers found that acute urinary retention was the most common complication after surgery for hemorrhoids (Jee, Seo, & Song, 1997; Kim et al., 2000; Zaheer, Reilly, Pemberton, & Ilstrup, 1998). The risks for urinary retention after hemorrhoidectomy have varied widely among different reports depending on the anesthesia, analgesia, perioperative fluid intake, and anal packing, with risk estimates ranging from 4.9% to 46.1% (Lau & Lam, 2004; Mik, Rzetecki, Sygut, Trzcinski, & Dziki, 2008; Ng, Ho, Ooi, Tang, & Eu, 2006). The exact etiology of urinary retention after surgery for hemorrhoids is still not clear. The purposes of this study were to estimate the 24-hour risk of postoperative urinary retention in a cohort of patients undergoing hemorrhoidectomy and identify risk factors for postoperative urinary retention in the same cohort.
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GNJ-D-13-00047_LR 464
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Risk Factors for Postoperative Retention After Hemorrhoidectomy
Patients and Methods After approval by the West China Hospital of Sichuan University’s institutional review board, a retrospective chart review was undertaken of 961 consecutive patients who underwent standard Milligan–Morgan hemorrhoidectomy and were included in a study of the incidence and determinants of urinary retention. All surgeries were performed at our institution between January 2009 and June 2011. All procedures were performed after the administration of 2% lidocaine for sacral or local anesthesia. In all cases, 300–900 ml of intravenous fluids were administered within 24 hours after surgery. For all patients, a hemostatic gauze pack was inserted into the anal canal at the end of surgery. In the ward, the patients were given ibuprofen and codeine phosphate tablets (2 tablets) orally or tramadol hydrochloride (100 mg) intramuscularly for supplementary analgesia when necessary. Catheterization was performed only when the bladder was palpable or distended after attempts by the nursing staff to assist the patient with voiding (such as by warming the lower abdomen or listening to the sound of running water) were unsuccessful and the patient was obviously uncomfortable. Urinary retention was defined as the need for catheterization within 24 hours after surgery. Factors analyzed as risks for urinary retention were age more than or less than 60 years, gender, hemorrhoid type and severity, anesthesia methods, the various operative procedures, operation time (more than or less than 60 minutes), the number of hemorrhoids resected (more than or less than 3), intravenous fluids (more than or less than 700 ml administered within 24 hours), use of analgesic drugs within 24 hours, and length of stay (more than or less than 7 days). The incidence of urinary retention was also calculated.
Statistical Analysis Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 12.0. Values were expressed as frequency, percentage, mean, and standard deviation. Univariate analysis by use of the chi-square test and multiple logistic regression analysis were performed to identify independent risk factors for urinary retention. All tests were two-tailed with significance defined by p < .05.
Results
TABLE 1. Demographic Data (n = 961) Variable
n
%
≤60
826
86.0
>60
135
14.0
Male
435
45.3
Female
526
54.7
Internal
71
7.4
External
25
2.6
Mixed
865
90.0
3 degree
709
73.8
4 degree
252
26.2
Sacral
843
87.7
Local
118
12.3
≤60
332
34.5
>60
629
65.5
≤700 ml
636
66.2
>700 ml
325
33.8
≤7
308
32.0
>7
653
68.0
Age (years)
Gender
Hemorrhoid type
Severe
Anesthesia
Operation time (minutes)
Intravenous fluids
Length of stay (days)
from 13 to 87 years, with a mean age of 44.06 years. There were 435 men (45.3%) and 526 women (54.7%). The majority of type was mixed (90.0%) and severity was three-degree hemorrhoid (73.8%). The mean duration of operating room stay was 77.25 (range 15–180) minutes. The majority of patients (87.7%) received sacral anesthesia during the surgical procedure. The length of hospital stay of patients ranged from 1 to 33 days with a mean of 9.07 days.
Characteristics of the Sample From January 1, 2009 to June 30, 2011, among the 961 patients who underwent hemorrhoidectomy, the overall urinary retention rate was 14.8%. A summary of the characteristics of the study sample is presented in Table 1. The ages of the study population ranged
VOLUME 38 | NUMBER 6 | NOVEMBER/DECEMBER 2015
The Prevalence and Risk Factors of Urinary Retention Results of univariate analysis for the total patients undergoing hemorrhoidectomy are shown in Table 2. In addition, the use of sacral anesthesia, female gender,
465
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Risk Factors for Postoperative Retention After Hemorrhoidectomy
TABLE 2. Potential Risk Factors for Postoperative Urinary Retention in Patients Undergoing Hemorrhoidectomy (n = 961) Urine Retention Variable
Nonurine Retention
n
%
n
%
p
≤60
125
88.0
701
85.6
.441
>60
17
12.0
118
14.4
Male
37
26.1
398
48.6
Female
105
73.9
421
51.4
Internal
12
8.5
59
7.2
External
2
1.5
23
2.8
128
90.1
737
90.0
3 degree
76
53.5
633
77.3
4 degree
66
46.5
186
22.7
Sacral
133
93.7
710
86.7
Local
9
6.3
109
13.3
≤60
51
35.9
281
34.3
>60
91
64.1
538
65.7
≤700 ml
77
54.2
559
68.3
>700 ml
65
45.8
260
31.7
≤3
38
26.8
397
48.5
>3
104
73.2
422
51.5
≤7
31
21.8
277
33.8
>7
111
78.2
542
66.2
Age (years)
Gender .000
Hemorrhoid type
Mixed
.519
Severe .000
Anesthesia .019
Operation time (minute) .710
Intravenous fluids .001
Number of hemorrhoids resected .000
Length of stay (days)
hemorrhoids having four degrees of severity, intravenous fluids more than 700 ml, more than three hemorrhoids resected, and length of stay more than 7 days were found to be risk factors for urinary retention.
The Predictor Factor of the Urinary Retention The results of logistic regression analysis in each of these groups are shown in Table 3. In the hemorrhoidectomy
.005
group, female gender (odds ratio [OR], 2.607; p < .01; 95% confidence interval [CI]: 1.716–3.961), sacral anesthesia (OR, 2.481; p = .02; 95% CI: 0.226–0.977), more than three hemorrhoids resected (OR, 2.658; p < .01; 95% CI: 1.756–4.023), hemorrhoids having four degrees of severity (OR, 3.101; p < .01; 95% CI: 2.096– 4.586), intravenous fluids more than 700 ml (OR, 1.597; p = .02; 95% CI: 1.079–2.364), and length of stay more than 7 days (OR, 1.852; p < .01; 95% CI:
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Risk Factors for Postoperative Retention After Hemorrhoidectomy
TABLE 3. Logistic Regression Model for the Patients Undergoing Hemorrhoidectomy (n = 961) Variable
Odds Ratio
95% CI
p
Female gender
2.607
1.716–3.961
.000
Sacral anesthesia
2.481
1.174–5.241
.017
More than 3 hemorrhoids resected
2.658
1.756–4.023
.000
1.852
1.180–2.907
.007
3.101
2.096–4.586
.000
1.597
1.079–2.364
.019
Length of stay >7 days Severe 4 degree Intravenous fluids >700 ml Note. CI = confidence interval.
1.180–2.907) were found to be independent determinants of urinary retention. All other variables (age, type of hemorrhoid, and operation time) failed to enter into the equation.
Discussion The reported incidence of urinary retention after hemorrhoidectomy ranged widely from less than 1% to more than 50% (Mik et al., 2008; Ng et al., 2006). This variation may be the result of differences between studies in the definition of urinary retention, exclusion criteria, types of operative procedures, and type of anesthesia. Our overall urinary retention rate of 14.8% is within the reported range. The exact cause of urinary retention after hemorrhoidectomy is not clearly understood. The previous study showed that the major factor leading to urinary retention was the inhibition of the detrusor muscle (Barone & Cummings, 1994). Inhibition of the detrusor muscle is the result of a reflex involving afferent fibers of the pudendal nerve, sacral spinal cord, and efferent pelvic sympathetic nerves. In the logistic regression model, anesthesia was one of the predictors of urinary retention. The odds of urinary retention increased 2.481-fold in the sacral group when compared with local anesthesia. This result is consistent with the fact that spinal area anesthesia significantly increases the risk of urinary retention after hemorrhoidectomy, as reported (Bansal, Jenaw, Mandia, & Yadav, 2012; Lohsiriwat & Lohsiriwat, 2007). Sacral anesthesia leads to rapid blockages of the micturition reflex, and complete recovery of detrusor muscle function occurs in a few hours. Many investigators have shown that increased fluid intake is an important determinant of urinary retention (Kim et al., 2000; Zaheer et al., 1998). Bailey and Ferguson reported a reduction in postoperative urinary VOLUME 38 | NUMBER 6 | NOVEMBER/DECEMBER 2015
retention from 15% to 4% in patients for whom both intravenous and oral fluids were restricted (Bailey & Ferguson, 1976). Our analysis showed that intravenous fluid intake of more than 700 ml was an independent risk factor for urinary retention after surgery for hemorrhoidectomy. In addition, we showed that perioperative fluid restriction significantly decreased the incidence of urinary retention after anorectal surgery. Therefore, perioperative fluid restriction is recommended for prevention of urinary retention after anorectal surgery. Our analysis showed that the disease severity, measured as the number of resected hemorrhoids, was an independent risk factor for urinary retention. This may lead to increased postoperative edema and pain and thus give rise to detrusor inhibition and bladder outlet obstruction, resulting in urinary retention. The study found that hospital stay was prolonged significantly in patients with urinary retention (Zaheer et al., 1998). In our study, the urinary retention rate of those patients having a length of hospital stay over 7 days increased 1.852-fold when compared with those less than 7 days. The influence of gender on urinary retention is controversial (Petros & Bradley, 1990). However, surprisingly, female gender was shown in our study to be an independent risk factor. There were several possible reasons for this result. Voiding was hindered in the women because they were lying in the supine position on the bed, immobilized by the intravenous line, and hampered by the gauze over the anal region. Women, especially in China, might feel more reluctant than men to void in an unfamiliar surrounding without privacy. Further investigation is warranted to clarify the influence of gender on postoperative urinary retention. Urinary retention is a common and frustrating complication during surgery for hemorrhoidectomy. Nurses 467
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Risk Factors for Postoperative Retention After Hemorrhoidectomy
use measures such as oral analgesia, hot pack application, listening to the sound of water, sacral region massage, and ambulation for patients who cannot void after 6 hours following hemorrhoidectomy. If these measures are not successful, catheterization can be performed. The common useful strategies applied to deal with urinary retention were overnight catheterization and in–out catheterization. Well-known catheter problems include recurrent and persistent blockage, catheter-related urinary tract infection, accidental dislodgment, and leakage of urine. We could not recognize whether patients who could not urinate after their operations were impacted by nursing interventions to promote urination. However, nurses may have the opportunity to pay more attention to preoperative instructions.
Limitations Our study has limitations. Data from this study were limited to what was documented in the medical charts. The medical charts might not have identified events that occurred but were not recorded. Limitations owing to the retrospective design of this study and possible recall bias are also acknowledged. We did not expand our investigation to include the other parameters relevant to urinary retention such as pain level, analgesic requirements, urinary symptoms, and anal packing, which are all suggested for future study.
Conclusions Urinary retention often occurs in patients undergoing hemorrhoidectomy. Furthermore, female gender, anesthesia methods, severity of hemorrhoid, large amount of intravenous fluid administered perioperatively, and length of hospital stay are independent risk factors for urinary retention in selected cases of hemorrhoidectomy. Careful follow-up of patients with these risk factors can help nurses spot posthemorrhoidectomy urinary retention early and take appropriate interventions to help promote patient voiding. Once urinary retention occurs, intermittent sterile catheterization is
required to avoid irreversible damage to the detrusor muscle, which prolongs bladder acontractility and urinary retention. ✪
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