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Postoperative Catheter Management After Pelvic

Reconstructive Surgery: A Survey of Practice Strategies
Sarah S. Boyd, MD,* Elena Tunitsky-Bitton, MD,* David M. O'Sullivan, PhD,† and Adam C. Steinberg, DO*
postoperatively because complications of urinary retention in-
Objective: The aim of this study was to evaluate practice preferences cluding infection and urosepsis are responsible for up to 20% to
in catheter management after a failed inpatient voiding trial after pelvic 25% of unplanned admissions after outpatient surgery, and persis-
reconstructive surgery. tent retention can further worsen voiding function in the long
Methods: This is a cross-sectional study of postoperative catheter man- term.1,2 Management of patients with acute postoperative voiding
agement after pelvic reconstructive surgery after failed voiding trial. Physi- dysfunction can include the placement of indwelling transurethral
cians practicing at ACGME-accredited residencies and fellowships in catheters (TUC), suprapubic tubes (SPC), and clean intermittent
Obstetrics and Gynecology (Ob/Gyn), Urology, and Female Pelvic Medi- self-catheterization (CISC). Furthermore, TUC and SPC can be
cine and Reconstructive Surgery (FPMRS) within the United States com- managed with continuous drainage or with intermittent drainage
pleted a Web-based questionnaire in March 2017. Respondents were using catheter valves or manually using plastic plugs. Typically,
asked about voiding trial protocols, definitions of abnormal postvoid resid- patients who fail voiding trials after pelvic reconstructive surgery
ual (PVR), type of catheterization used after failed voiding trials, and anti- are discharged home with 1 of the aforementioned catheter man-
biotic use. Primary outcome was type of catheterization after failure of an agement techniques until a repeat voiding trial is performed in
inpatient voiding trial. Data were analyzed using χ2 statistical tests. the office.
Results: One hundred five respondents had a mean age of 36.5 years Specific practices of catheter management by physicians in
(range, 36 years). A total of 45.9% of participants practiced in FPMRS, the perioperative period can vary widely including duration of
36.5% in Ob/Gyn, and 17.6% in Urology. Catheters were discontinued catheterization, use of prophylactic antibiotics, and timing of
most frequently by postoperative day 1 after all procedures. Distribution voiding trials both during initial hospitalization and on discharge
of catheterization by specialty differed. Clean-intermittent straight catheter- home.3 Prior studies have individually assessed outcomes such
ization had the greatest prevalence in all specialties and was the highest, by as infection rates, patient satisfaction, and cost-effectiveness of
percentage, in Urology (33% Ob/Gyn, 40.6% FPMRS, and 69% Urology); specific catheterization techniques without consensus on optimal
P = 0.026. Type of catheterization differed significantly between Ob/Gyn method of catheterization postoperatively.4–8 As such, there is cur-
and FPMRS respondents (P = 0.045). A total of 77.7% measured PVR rently no standard of care on management of patients with voiding
by ultrasound and 22.3% performed catheterization. This distribution was trial failure after pelvic reconstructive surgery, and strategies are
similar across the specialties (70% Ob/Gyn, 79% FPMRS, and 100% Urol- often provider dependent. We present data from a survey of physi-
ogy; P = 0.092). Abnormal PVR was defined most frequently as 150 mL or cians practicing at Accreditation Council of Graduate Medical Ed-
greater (30.5%). A minority of respondents routinely administer antibiotics ucation (ACGME)-accredited residency and fellowship programs
during catheterization (17.1%). Duration and time until repeat voiding trial in Urology, Obstetrics and Gynecology (Ob/Gyn), and Female
varied from 1 day to 2 weeks. Pelvic Medicine and Reconstructive Surgery (FPMRS) on periop-
Conclusions: Practice variability in catheterization after pelvic recon- erative catheter management of patients undergoing pelvic recon-
structive and incontinence surgery is high. Distribution of catheterization structive and incontinence surgeries. Specifically, our primary
type by specialty varies significantly, with clean-intermittent straight cath- outcome was to assess the type of catheterization technique used
eterization most prevalent. Future studies are necessary to establish a con- after failed inpatient voiding trial. Secondary outcomes included
sensus on optimal catheterization management technique for patients with characteristics of the hospitals and respondents surveyed as well
acute postoperative voiding dysfunction. as criteria for the diagnosis of urinary tract infections and use of
Key Words: catheter, pelvic organ prolapse, antibiotics during catheterization.
postoperative voiding dysfunction
(Female Pelvic Med Reconstr Surg 2017;00: 00–00) MATERIALS AND METHODS
This was a cross-sectional study of postoperative catheter

P ostoperative voiding dysfunction can complicate up to 42% of

pelvic reconstructive procedures, depending on the surgery.1
The occurrence of urinary retention is not isolated to pelvic recon-
management after pelvic reconstructive surgery after failed
voiding trial. A Web-based survey (see Supplemental Digital
Content, http://links.lww.com/FPMRS/A55) was sent to physicians
structive cases alone because the reported incidence of postopera- practicing at ACGME-accredited Urology, Ob/Gyn, and FPMRS
tive urinary retention in surgical patients overall ranges from 14% residencies and fellowships within the United States using the
to 16%.2 Adequate drainage of the bladder is imperative ACGME email correspondence list. A reminder was sent to
nonresponders 1 and 2 months after the first request. Hartford
From the Departments of *Female Pelvic Medicine and Reconstructive Surgery, HealthCare Institutional Review Board approval was obtained be-
and †Research Administration, Hartford Hospital, Hartford, CT. fore dissemination of surveys.
Reprints: Sarah S. Boyd, MD, Department of Female Pelvic Medicine and The questionnaire addressed physician characteristics including
Reconstructive Surgery, Hartford Hospital, 85 Seymour St, Suite 525,
Hartford, CT 06106. E‐mail: sarah.boyd@hhchealth.org.
age, specialty (eg, Urology, Ob/Gyn, or FPMRS), role (eg, attend-
The authors have declared they have no conflicts of interest. ing, fellow, or resident), private or hospital-affiliated practice, and
IRB approved: HHC-2016-0239. number of years practicing medicine. Additional topics included
Supplemental digital content is available for this article. Direct URL citations characteristics of the hospital, details of voiding trials including
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.fpmrs.net).
specific procedures in which voiding trials are performed, the def-
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. inition of abnormal postvoid residual (PVR), measurement of
DOI: 10.1097/SPV.0000000000000542 PVR (eg, ultrasound of bladder or straight catheterization), number

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Boyd et al Female Pelvic Medicine & Reconstructive Surgery • Volume 00, Number 00, Month 2017

declared for all results yielding P value less than 0.05. The SPSS
TABLE 1. Characteristics of Survey Respondents (N = 105) v. 21 (IBM, Armonk, NY) was used for all data analyses.
Characteristic n (%)
RESULTS
Specialty of practice*
A total of 105 respondents completed surveys. Participants
- Ob/Gyn 27 (36.5)
had a mean age of 36.5 years (range, 36 years) and averaged
- FPMRS 34 (45.9) 5.7 years of clinical practice (range, 34 years). Table 1 shows char-
- Urology 13 (17.6) acteristics of the responding physicians.
Type of hospital Table 2 contains responses regarding type of catheterization
- University affiliated 88 (83.8) after voiding trial failure by specialty, region of practice, and hos-
- Community based 17 (16.2) pital setting. Distribution of catheterization by specialty differed.
Role of provider CISC had the greatest prevalence in all specialties and was the
- Resident 39 (37.1) highest, by percentage, in Urology (33% Ob/Gyn, 41% FPMRS,
- Fellow 28 (26.7) and 60% Urology; P = 0.026; Table 2). Type of catheterization dif-
- Attending 38 (36.2) fered significantly between Ob/Gyn and FPMRS respondents
(P = 0.045). There was no difference in type of catheterization
Region of practice
by region or hospital setting. Furthermore, there was no difference
- Northeast 37 (35.2) in type of catheterization when comparing physicians in Urology
- Midwest 23 (21.9) to Ob/Gyn (P = 0.125) or FPMRS (P = 0.219).
- South 38 (36.2) Table 3 depicts responses regarding initial duration of catheter
- West 7 (6.7) use based on procedures performed. Catheters were discontinued
most frequently (93.4%–98%) by postoperative day 1 across all
*n = 75.
procedures evaluated in the survey. Survey participants most fre-
quently performed voiding trials after incontinence procedures
of void attempts before voiding trial failure, and management of ab- and least frequently after vaginal hysterectomy alone and poste-
normal PVR including type of catheter, administration of antibi- rior repair alone (95% vs 57% and 59%, respectively).
otics, and duration of catheterization until repeat voiding trial. Table 4 shows the responses to questions regarding the as-
Providers were asked if their standard management included 1 of sessment and definition of abnormal PVR. The definition of ab-
the following techniques of postoperative catheterization: CISC, normal PVR varied. Responses included defined cutoffs ranging
TUC with continuous drainage, TUC drained intermittently by from 50 to 250 mL and proportions of urine voided out of volume
the patient (“plug-unplug” method or catheter valve), SPC, or pa- instilled. Measurement of PVR was performed most frequently
tient preference. In the plug-unplug method, the TUC is plugged using a bladder scanning device and least frequently by bladder
with a plastic cap and unplugged by the patient when she has an urge catheterization (77.7% vs 22.3%). However, this difference was
to urinate or at set time intervals. The plug-unplug method is similar not significant when comparing by specialty (P = 0.092). A total
in concept to catheter valves, which allow the intermittent drainage of of 48.6% of participants defined voiding trial failure after 1 mea-
urine from the bladder at the patient's discretion; however, the for- surement directly after the first void, whereas 37.1% performed 2
mer technique has not been evaluated in a controlled setting. measurements after 2 separate voids, and 2.9% defined voiding
Survey respondents were also asked their definition of urinary trial failure by 1 measurement after the patient's second void.
tract infection (UTI) and indications for antibiotic administration. When comparing measurement techniques for PVR and number
Descriptive data analyses included frequencies for nominal of measurements before voiding trial failure, there was no difference by
data and were reported as percentages. The χ2 tests were used for type of catheterization (P = 0.692 and P = 0.423, respectively).
comparison of categorical variables. Statistical significance was When asked to note duration of time until patients underwent a

TABLE 2. Type of Catheterization by Specialty, Hospital Setting, and US Region; n (%)

CD PUP CISC Patient Preference P*

Specialty (n = 69)
- Ob/Gyn 7 (29) 5 (21) 8 (33) 4 (17) 0.026
- FPMRS 9 (28) 0 13 (41) 10 (31)
- Urology 2 (15) 0 9 (60) 2 (15)
Hospital setting (n = 98)
- University affiliated 19 (23) 4 (5) 36 (43) 24 (29) 0.219
- Community based 6 (18) 2 (11) 5 (28) 2 (11)
Region of United States (n = 98)
- Northeast 7 5 18 7
- Midwest 8 1 7 6 0.340
- South 8 0 14 11
- West 2 0 2 2
*Values in bold are significant at less than 0.05.
CD indicates indwelling transurethral catheter to continuous drainage; and PUP, indwelling transurethral catheter to plug-unplug.

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Female Pelvic Medicine & Reconstructive Surgery • Volume 00, Number 00, Month 2017 Preferences in Catheter Management

TABLE 3. Duration of Standard Initial Catheterization by Type of Surgery (%)

Type of Surgical Procedure

No. Postoperative Days AR (n = 103) PR (n = 102) A&P(n = 101) Apical (n = 96) Incontinence (n = 99)
0 45.7 46.7 31.4 18.8 68.7
1 50.5 46.7 62.9 79.2 29.3
2 0 0 0 0 0
3 1.9 1.9 1.9 1 1
Other 0 1.9 0 1 1
A&P indicates combined anterior and posterior repair; AR, anterior repair alone; and PR, posterior repair alone.

repeat voiding trial, participants most frequently reported imple- up to 9% of patients viewed postoperative catheterization as a sur-
mentation within 7 days of initial voiding trial failure (89%). gical complication, and 15% considered catheterization to be the
Table 5 depicts responses regarding antibiotic administration worst aspect of the surgical experience. At 1 year follow-up,
after voiding trial failure. Respondents were allowed to mark all Mahajan et al10 found that 15% of patients from the original co-
that applied to their daily practice. Antibiotics were administered hort continued to cite catheter-associated complaints as the worst
most frequently based on urine culture alone (92.4%), with aspect of the surgical experience. Patient satisfaction with specific
58.1% of antibiotic therapy based on cultures with greater than catheter type is an area of limited study. One recent prospective
100,000 bacterial colony-forming units (CFU). A total of 17.1% trial comparing valve catheters and traditional drainage catheters
of survey participants routinely administered antibiotics during found patients with valve catheters had better satisfaction overall
or after catheterization. compared with drainage catheters and scored more favorably on
quality of life measures, specifically a decreased limitation in so-
DISCUSSION cial activities and less frustration.4 With the current era of health
care quality improvement based largely on patient satisfaction
Postoperative voiding dysfunction is common after pelvic re-
scores regarding hospital stay and interventions coupled with the
constructive surgery, and its management varies widely among
large percentage of patients that consider catheterization to be
practitioners of all training levels.1,3 Commonly used techniques
one of the worst aspects of their hospital stay, further studies eval-
for bladder drainage include CISC, SPC, and TUC managed with
uating patient satisfaction with specific catheterization types are
either continuous drainage or intermittent drainage using catheter
necessary to optimize patient experience.
valves or plugs. Standardizing short-term catheterization tech-
Regarding the rates of UTIs associated with types of cathe-
niques in patients with acute postoperative voiding dysfunction
terization, a recent meta-analysis reported no difference in UTI
is difficult because one must consider factors such as infection
rates between SPC, CISC, and TUC if duration of catheterization
risk, patient satisfaction, invasiveness of the method, impact on
was less than 5 days.7 This analysis identified 14 randomized con-
surgical recovery, and cost. Current evidence to support the use
trolled trials including 1391 patients. Four compared CISC with
of each catheterization method is varied, making a consensus on
TUC, 3 compared SPC with CISC, and 7 studies compared TUC
optimal method difficult to determine.
with SPC.7 There were no randomized controlled trials that directly
When evaluating patient satisfaction with surgical experi-
compared intermittent drainage catheter techniques with the other
ence, the placement of a urinary catheter and use on hospital dis-
methods. Similarly, a recent Cochrane review, including 42 trials
charge is a common area of dissatisfaction.9,10 A study by Elkadry
on short-term bladder catheterization defined as catheterization
et al9 on patients' perceptions of postoperative outcomes reported
for 14 days or less, determined there was not enough evidence
to conclude whether 1 route was superior in reducing UTI.11
TABLE 4. Assessment and Definition of Abnormal PVR The Cochrane review did conclude that SPC decreased the num-
ber of patients with asymptomatic bacteriuria, recatheterization,
Protocol N %
Technique of residual volume measurement
- Bladder scanner 80 76.2 TABLE 5. Antibiotic Administration After Voiding Trial Failure*
- Catheterization 23 21.9
Indication for antibiotic therapy N %
Definition of abnormal residual volume
- 50 mL 2 1.9 Routinely during or after catheterization 18 17.1
- 100 mL 22 21.0 Symptoms without confirmation of urinalysis or culture 20 19.0
- 150 mL 32 30.5 Treatment based on urinalysis alone 70 66.7
- 200 mL 24 22.9 - Leukocyte positive only 4 3.8
- 250 mL 19 18.1 - Nitrite positive only 30 28.6
- Proportion voided > ½ of volume 29 27.6 - Both nitrite and leukocyte positive 36 34.3
instilled in bladder Treatment based on culture alone 97 92.4
- Proportion voided > 2/3 of volume 27 25.7 - 1000 CFU on culture 8 7.6
instilled in bladder - 10,000 CFU on culture 28 26.7
- Patient reported incomplete emptying 9 8.6 - 100,000 CFU on culture 61 58.1
after fluid instilled in bladder
- Other 11 10.5 *Responses are not mutually exclusive.

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Boyd et al Female Pelvic Medicine & Reconstructive Surgery • Volume 00, Number 00, Month 2017

and pain compared with indwelling catheters. However, evidence surveys completed by practitioners in the western United States
regarding SPC compared with intermittent catheterization was was low. Furthermore, surveys were distributed only to practitioners
lacking.11 Furthermore, evidence was inconclusive regarding in ACGME-accredited programs. Therefore, we cannot comment
symptomatic UTI in the setting of SPC compared with indwelling on the practice of clinicians in nonteaching practices, which also
or intermittent urethral catheters. This review did not have suf- decreases the generalizability of our findings.
ficient data to compare intermittent catheterization with in- Postoperative catheter management among practicing physi-
dwelling catheterization directly.7,11 Future high-quality studies cians in the fields of Urology, FPMRS, and Ob/Gyn widely vary.
evaluating infection rates in the setting of intermittent drainage Our findings show consistency with national guidelines of cathe-
catheters such as catheter valves, the plug-unplug technique, and ter management including the emphasis on shortened duration of
CISC are warranted. postoperative catheterization and limited use of antibiotic therapy
The CISC was the most prevalent technique reported by all during catheterization unless urine culture results in growth of a
respondents surveyed in the current study. Although evidence is large volume of UTI-associated bacterium. In addition, the study
inconclusive regarding optimal short-term catheterization tech- shows significant differences in distribution of responses in regards
niques, both CISC and SPC have been shown to have lower rates to the type of catheterization after failed voiding trial. Clean-
of UTI in patients requiring long-term catheterization compared intermittent straight catheterization was more prevalent among
with indwelling transurethral catheters.7,12 In addition, CISC has all survey respondents and had the highest percentage of use
the advantage of decreased surgical complications compared with among urologists compared with other catheterization techniques.
SPC.12 Although respondents were not queried on reason behind The reason behind this choice for short-term catheterization is un-
their choice of catheterization in patients who failed inpatient clear considering the inconclusive evidence available regarding
voiding trials, CISC may have been more commonly chosen for superiority of a specific short-term catheterization technique. The
these reasons. plug-unplug technique of catheter management has never been
Hakvoort et al3 performed a similar survey of perioperative studied in a clinical setting, and thus, future studies are necessary
catheter management across hospital systems within the Netherlands to evaluate its efficacy in the management of patients with acute
in 2008. Surveys were distributed to entire hospital systems rather postoperative voiding dysfunction. The optimal method of post-
than individual practitioners to assess presence of bladder cathe- operative catheterization has yet to be determined, and future stud-
terization protocols, assessment, and management of abnormal ies to determine a superior method are necessary to reveal an
PVR. Whereas the current study assessment of individual practi- underlying clinical impact or improved patient satisfaction.
tioners across the United States showed CISC to be the most com-
mon catheterization for postoperative voiding dysfunction, Hakvoort
et al3 found 57% of hospitals within the Netherlands preferred in- REFERENCES
dwelling transurethral catheters. In addition, all respondents in our 1. Baessler K, Maher C. Pelvic organ prolapse surgery and bladder function.
study reported removing postsurgical urethral catheters by postop- Int Urogynecol J 2013;24(11):1843–1852.
erative day 1 regardless of the procedure performed, which is in 2. Kowalik U, Plante MK. Urinary retention in surgical patients. Surg Clin
contrast to Hakvoort et al,3 who noted initial catheterization for North Am 2016;96(3):453–467.
up to 3 days after anterior repair alone. A recent Cochrane review 3. Hakvoort RA, Burger MP, Emanuel MH, et al. A nationwide survey to
stated a 5% cumulative daily risk of developing bacteriuria in the measure practice variation of catheterisation management in patients
setting of catheterization, with up to 20% of these patients devel- undergoing vaginal prolapse surgery. Int Urogynecol J Pelvic Floor
oping symptomatic UTI.13 Limiting duration of catheterization to Dysfunct 2009;20(7):813–818.
no more than 24 hours greatly decreases the risk of symptomatic 4. Kandadai P, Duenas-Garcia OF, Pilzeck AL, et al. A randomized
UTI in this patient population, and our findings are consistent controlled trial of patient-controlled valve catheter and indwelling foley
with this recommendation.13,14 catheter for short-term bladder drainage. Female Pelvic Med Reconstr Surg
Similarities between the current study and that by Hakvoort 2016;22(2):88–92.
et al3 include the heterogeneity of responses regarding abnormal
5. Sabbuba NA, Stickler DJ, Long MJ, et al. Does the valve regulated
PVR and routine administration of antibiotics during prolonged
release of urine from the bladder decrease encrustation and blockage of
catheterization by 20% of respondents in the Netherlands study indwelling catheters by crystalline proteus mirabilis biofilms? J Urol 2005;
compared with 17% of respondents in the current study. The Cen- 173(1):262–266.
ters for Disease Control (CDC) has strict definitions for symptom-
atic UTI, catheter-associated UTI and non–catheter-associated 6. Jannelli ML, Wu JM, Plunkett LW, et al. A randomized controlled trial of
clean intermittent self-catheterization versus suprapubic catheterization after
UTI with the requirement in all definitions of “urine culture with
urogynecologic surgery. Am J Obstet Gynecol 2007;197(1):72.e1–72.e4.
no more than 2 species of organisms identified, at least 1 of which
is a bacterium of greater than or equal to 105 CFU/mL”.15 It is 7. Han CS, Kim S, Radadia KD, et al. Comparison of urinary tract infection
reassuring to note that whereas the majority of hospitals in the rates associated with transurethral catheterization, suprapubic tube and
Netherlands study diagnosed UTI by the presence of symptoms clean intermittent catheterization in the postoperative setting: a network
alone, individual practitioners surveyed in the current study diag- meta-analysis. J Urol 2017;198(6):1353–1358.
nosed and treated UTIs by urine culture (74% vs 92%), and 58.1% 8. Tunitsky-Bitton E, Murphy A, Barber MD, et al. Assessment of voiding
of respondents diagnosed UTI by urine culture with presence of after sling: a randomized trial of 2 methods of postoperative catheter
greater than 105 CFU/mL of bacterium. management after midurethral sling surgery for stress urinary incontinence
Strengths of our study include the even distribution of respon- in women. Am J Obstet Gynecol 2015;212(5):597.e1–597.e9.
dents across all clinical training levels, individual responses, and the 9. Eman AA, Kenton KS, Fitzgerald MP, et al. Patient-selected goals:
evaluation of practice characteristics in 3 specialties that commonly a new perspective on surgical outcome. Am J Obstet Gynecol 2003;
perform pelvic reconstructive and incontinence procedures. 189(6):1551–1557.
Response bias is an important limitation inherent to survey 10. Mahajan ST, Elkadry EA, Kenton KS, et al. Patient-centered surgical
studies and is reflected in the complete survey response total outcomes: the impact of goal achievement and urge incontinence on
and may affect generalizability. Although surveys were completed patient satisfaction one year after surgery. Am J Obstet Gynecol
by respondents in all regions of the United States, the number of 2006;194(3):722–728.

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Female Pelvic Medicine & Reconstructive Surgery • Volume 00, Number 00, Month 2017 Preferences in Catheter Management

11. Kidd EA, Stewart F, Kassis NC, et al. Urethral (indwelling or intermittent) 14. Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of
or suprapubic routes for short-term catheterisation in hospitalised adults. catheter-associated urinary tract infections 2009. Infect Control Hosp
Cochrane database Syst Rev 2015;12:CD004203. Epidemiol 2010;31(4):319–326.
12. Healy EF, Walsh CA, Cotter AM, et al. Suprapubic compared with 15. Centers for Disease Control and Prevention. Urinary tract infection
transurethral bladder catheterization for gynecologic surgery: a systematic (catheter-associated urinary tract infection [CAUTI] and
review and meta-analysis. Obstet Gynecol 2012;120(3):678–687. non-catheter-associated urinary tract infection [UTI]) and other
13. Lam TB, Omar MI, Fisher E, et al. Types of indwelling urethral catheters urinary system infection [USI]) events. 2016 NHSN Patient Saf
for short-term catheterisation in hospitalised adults. Cochrane Database Compon Man 2016:1–16. http://www.cdc.gov/nhsn/pdfs/pscmanual/
Syst Rev 2014;9(9):CD004013. 7psccauticurrent.pdf.

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