Urinary Retention, A Common Problem In The Elderly Following Hip Arthroplasty

N Goyal*, ALR Michael**, J Khan#, N Kumar##
*Specialist Registrar in Radiology, University Hospital of Wales, Cardiff
**Specialist Registrar in Orthopaedics, Musgrave Park Hospital, Belfast
#Senior House Officer in Orthopaedics, New Cross Hospital, Wolverhampton
## Consultant Orthopaedic Surgeon, New Cross Hospital, Wolverhampton 

Address for Correspondence:

N Goyal, 
Specialist Registrar in Radiology, University Hospital of Wales, Cardiff,
United Kingdom. CF14 4XW
Tel: 0044 2074 3030
Email: nimitgoyal@doctors.org.uk

Abstract:

We report a study of catheterisation rates following hip arthroplasty amongst the elderly compared to the less than 70 years age group and the importance of preoperative factors in predicting the patients at risk of retention. 232 consecutive patients undergoing total hip replacement were studied. A total of 81 patients (35%) required catheterisation. Elderly patients required catheterisation more frequently compared to less than 70 years age group (45% vs 22%). The difference was significant amongst the elderly ladies. A thorough literature search revealed that the rates of catheterisation especially amongst the elderly following such an intervention have not been well studied. We also investigated factors such as previous history of urinary tract infection, urinary catheterisation in the past for any reason, prostatism, evidence of cognitive impairment and a positive MSSU sample. These have been shown to be important in predicting the likelihood of patients requiring catheterisation (2). We compared the prevalence of these factors in the two age groups studied.
Keywords: Arthroplasty; Urinary Retention; Urinary Catheter; Infection

J.Orthopaedics 2007;4(2)e12

Introduction:

Hip arthroplasty is a common operative intervention amongst the elderly. Urinary problems such as retention and infections are common in the post operative period. Waterhouse et al, found an acute retention rate of about 11%, whilst investigating factors which might help predict those at risk of retention (1)

Urinary retention would often require catheterisation and this has been well established as a cause of bacteraemia and increased risk of deep infection. Irvine et al reported four cases of deep infection with organisms from the urinary tract in a series of 167 hip replacements (2). Wroblewski and Del Sel found a deep sepsis rate of 6.2 % in 192 patients who had urinary retention (3). This was significant compared to an expected rate of 0.5% deep infection described by Charnley (4) The problem is even more significant in the elderly patient due to associated co morbidity, decreased immune resistance and prolonged healing times. Our study has also shown that this age group is more likely to require catherisation following arthroplasty compared to the younger patients. The consequences of a deep infection in the elderly can be disastrous. Our study aims to highlight that elderly patients are more at risk of developing retention and consequent complications and thus it is of utmost importance to identify such at risk elderly patients.

Material and Methods :

232 consecutive patients undergoing hip replacement were studied. The males and females were studied as two seperate groups and each group was further subdivided into age groups (> or < than 70 years of age) The rates of retention and subsequent catheterisation were studied in each group. The results were chi squared to establish the statistical significance.

Each patient was assessed for preoperative risk factors which have been shown to be important in identifying patients at risk of developing retention post operatively. The factors studied included previous history of urinary tract infection, urinary catheterisation in the past for any reason, prostatism, evidence of cognitive impairment and a positive preoperative MSSU ( Mid stream specimen of urine) sample. The prevelance of predictive factors was compared in the patients requiring catheterisation in the two age groups.

Results :

There were 232 patients in the study of which 144 (62%) were females. There were 128 (55%) over 70 years of age (43 males and 85 females) and 104 patients (45%) under the age of 70 years (45 males and 59 females)

Males of all ages had higher catheterisation rates compared to females (34 (39%) vs 47 (33%)). Older females were more likely to be catheterised compared to the younger female patients (39 (46%) vs 8 (14%)) and this was statistically significant (chi-squared, p=0.00005 or simply p<0.001) (Table 1). Similarly older males tended to be catheterised more (19 (44%) vs 15 (33%)), though this was not statistically significant (chi-squared, p=0.3) (Table 1)

Each patient was studied for presence of risk factors and the total number of patients with the risk factor present in each group determined. It was seen that amongst the elderly patients requiring catheterisation, 24 (41%) had a history of previous UTI while only 9 (39%) had such history amongst the younger patients. Similar figures for history of cognitive impairment were (16 (28%) vs 2(9%)). 15(26%) of the elderly had a history of previous catheterisation compared to only 4(17%) in the other group. History of prostatism was found to be more often associated with older males (8(42%)) developing retention than the young males (2(9%)).

Table 1. Rates of catheterisation in the patients studied

Table 2 .Number of patients with positive predictive factors

Discussion :

Post operative retention is a common problem amongst the elderly. Three factors have been described causing impaired micturition postoperatively. These are the side effects of anaesthetics upon the autonomic nervous system, operative trauma causing inhibition of abdominoplevic reflex which initiates micturition and the third cause may be direct operative injury of the sacroplexus pelvus. (5).

Waterhouse et al in their study showed that the patients at risk of developing retention can be identified preoperatively by looking for certain risk factors, they also described a bottle test where a patients preoperative ability to pass urine in supine position was found to be important in predicting postoperative problems (1) International Prostate Symptoms Score (IPSS) has also been shown to be a simple and reliable test to help in predicting the possibility of developing acute retention. (6)

A referral to the urologist should be made for at risk elective patients. Several suggestions have been made to prevent retention. Use of three post operative doses of 10 mg phenoxybenzamine has been recommended for prevention of urinary retention in male patients without impaired cerebral circulation or serious coronary heart disease. (7, 8) One preoperative dose of 1 mg of prazosin followed by two postoperative doses has also been shown to reduce the incidence of urinary retention and catheterisation in post-herniorrhaphy patients. (9)

Studies have also shown that short term use of an indwelling catheter after extended surgery reduces the incidence of urinary retention and bladder overdistention without increasing the rate of urinary tract infection (10) This regime has also been recommended for elderly females undergoing total joint replacement (11)

Our study emphasises that the elderly patients especially females undergoing total hip replacement are more at risk of suffering post operative retention. We have shown that the predictive factors are positive more often in the elderly patient group.  It is of utmost importance to identify such patients and manage them appropriately in the pre and postoperative period to minimise the occurrence of deep infection and consequent morbidity.

Table 1. Rates of catheterisation in the patients studied

Table 2. Number of patients with positive predictive factors

Reference :

1. Waterhouse N, Beaumont AR, Murray K, Staniforth P, Stone MH. Urinary Retention after Total Hip Replacement. A Prospective Study. J Bone Joint Surg Br. 1987 Jan;69(1):64-6

2. Irvine R, Johnson BL Jr, Amstutz HC. The relationship of genitourinary tract procedures and deep sepsis after total hip replacements. Surg Gynaecol Obstet 1974; 139: 701-6

3. Wroblewski BM, del Sel HJ. Urethral instrumentation and deep sepsis in total hip replacement. Clin Orthop Relat Res. 1980 Jan-Feb ;( 146):209-12.  

4. Charnley J. Acrylic Cement in Orthopaedic Surgery. Edinburgh etc : E & S Livingstone, 1970

5. Sigel A, Schrott KM. Disturbances of micturition after general surgical operations. Langenbecks Arch Chir. 1977 Nov; 345: 563-4

6. Elkhodair S, Parmar HV, Vanwaeyenbergh J. The role of the IPSS (International Prostate Symptoms Score) in predicting acute retention of urine in patients undergoing major joint arthroplasty. Surgeon 2005 Apr; 3(2):63-5

7. Tammela T, Kontturi M, Puranen J. Prevention of postoperative urinary retention after total hip arthroplasty in male patients. Ann Chir Gynaecol. 1987;76(3):170-2

8. Leventhal A, Pfau A. Pharmacologic management of postoperative overdistention of the bladder. Surg Gynecol Obstet. 1978; 146(3): 347-8

9. Gonullu NN, Dulger M, Utkan NZ, Canturk NZ, Alponat A. Prevention of postherniorrhaphy urinary retention with prazosin. Am Surg. 1999; 65(1): 55-8

10. Michelson JD, Lotke PA, Steinburg ME. Urinary bladder management after total joint replacement surgery. N Eng J Med. 1988; 319(6): 321-6

11. Carpiniello VL, Cendron M, Altman HG, Malloy TR, Booth R. Treatment of urinary complications after total joint replacement in elderly females. Urology. 1988; 32(3):186-8

This is a peer reviewed paper 

Please cite as : N Goyal :Urinary Retention, A Common Problem In The Elderly Following Hip Arthroplasty

J.Orthopaedics 2007;4(2)e12

URL: http://www.jortho.org/2007/4/2/e12

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