Effect Of General Anesthesia On The Bladder Muscles
General anesthesia becomes safer with each passing decade. The medicines used to put a patient under do, however, change how your body works. General anesthesia drugs affect brain function and inhibits the autonomic nervous system that triggers urination. The result is that the detrusor contractions are suppressed or decreased. This is an effect of both IV agents and gases used during general anesthesia.
How Is The Cause Of Difficulty Urinating After Surgery Diagnosed
Since symptoms of urinary retention are not always present, the postoperative care team will monitor your ability to urinate. You may have a urine collection pan in the toilet you use to measure how much you are voiding. In general, you should not go for longer than 6 to 7 hours without urinating. If you are unable to urinate, a physical exam may reveal a distended bladder. Sometimes, the care team may use ultrasound to view the bladder. Using a catheter to drain the bladder and measure its contents is useful for both diagnosing and treating POUR.
How Is Chronic Urinary Retention Diagnosed
History and physical exam: During the diagnosis process, your healthcare provider will ask about your signs and symptoms and how long you have had them. He or she will also ask about your medical history and your drug use. A physical exam of the lower abdomen may show the cause or give your provider additional clues. After this, certain tests may be needed. Men may have a rectal exam to check the size of their prostate.
Your urine may be saved and checked to look for infection.
Ultrasound of the bladder: The amount of urine that stays in your bladder after urinating may be measured by doing an ultrasound test of the bladder. This test is called a postvoid residual or bladder scan.
Cystoscopy: Cystoscopy is a test in which a thin tube with a tiny camera on one end is put into your urethra. This lets the doctor look at pictures of the lining of your urethra and bladder. This test may show a stricture of the urethra, blockage caused by a stone, an enlarged prostate or a tumor. It can also be used to remove stones, if found. A computed tomography scan may also help find stones or anything else blocking the flow of urine.
Urodynamic testing: Tests that use a catheter to record pressure within the bladder may be done to tell how well the bladder empties. The rate at which urine flows can also be measured by such tests. This is called urodynamic testing.
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Respiratory Effects Of Spinal Anesthesia
In patients with normal lung physiology, spinal anesthesia has little effect on pulmonary function. Lung volumes, resting minute ventilation, dead space, arterial blood gas tensions, and shunt fraction show minimal change after spinal anesthesia. The main respiratory effect of spinal anesthesia occurs during high spinal block when active exhalation is affected due to paralysis of abdominal and intercostal muscles. During high spinal block, expiratory reserve volume, peak expiratory flow, and maximum minute ventilation are reduced. Patients with obstructive pulmonary disease who rely on accessory muscle use for adequate ventilation should be monitored carefully after spinal block. Patients with normal pulmonary function and a high spinal nerve block may complain of dyspnea, but if they are able to speak clearly in a normal voice, ventilation is usually adequate. The dyspnea is usually due to the inability to feel the chest wall move during respiration, and simple assurance is usually effective in allaying the patients distress.
Medication Causes Of Difficulty Urinating After Surgery
Anesthesia and other medications can also contribute to POUR. With difficulty urinating after anesthesia, the longer the duration of anesthesia, the greater the risk of POUR. Drugs that can lead to urinary retention include:
- Anticholinergic drugs and other drugs doctors may use during surgery, which can lead to decreased bladder activity
- General anesthetics, which relax smooth muscles and lead to decreased bladder tone. General anesthesia also interferes with voluntary control over the sphincter muscle.
- Opioid relievers, which can reduce the sensation of bladder fullness and make it harder to relax the bladder sphincter muscle
- Spinal and epidural anesthetics, which interfere with nerve signals traveling to and from the spinal cord. The risk is highest with spinal anesthesia, followed by epidural anesthesia and general anesthesia.
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How Is It Managed
If you experience difficulty urinating or completely emptying your bladder after surgery, make sure you let the doctor or nurse know. Chances are, they will ask if you have passed urine or are having difficulty. In the majority of cases, the problem will resolve itself with a bit of time, but if the bladder is full and wont release, a catheter will be inserted, and the urine drained. Patients arent discharged until the matter is satisfactorily resolved.
Choice Of Local Anesthetic Longer Duration Spinal Procedures
Bupivacaine and tetracaine are most common .
Bupivacaine: similar dose and duration as tetracaine , slightly more intense sensory anesthesia than tetracaine.
Tetracaine: similar dose and duration as bupivacaine , slightly more motor blockade than bupivacaine. Duration is more variable than bupivacaine and more profoundly affected by vasoconstrictors.
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Medical Procedures And Devices
Your health care professional may recommend a medical procedure or device to treat your urinary retention, depending on the cause of the retention. Examples of these procedures and devices include
- cystoscopyusing a cystoscope to look inside the urethra and bladder to find and remove blockages such as urinary tract stones
- laser therapytherapy that uses a strong beam of light to treat an area of enlarged prostate tissue by breaking up the blockage and reducing the obstruction
- prostatic urethral lift, or UroLiftusing tiny implants to lift and hold the prostate away from the urethra so urine can flow more freely
- transurethral electrovaporizationa procedure that uses heat to vaporize an area of enlarged prostate tissue
- transurethral water vapor therapy, or Rezumtherapy that uses water vapor, or steam, to shrink an enlarged prostate
- urethral dilationgradually increasing the size of the urethral opening by stretching the scar tissue, to help treat urethral stricture
- vaginal pessarya stiff ring that is inserted into the vagina to help stop urine leakage, such as with cases of a cystocele or rectocele
Transurethral Microwave Thermotherapy Of The Prostate
Because of the risks associated with transurethral prostatectomy, minimally invasive therapies have been developed as alternative strategies to ablate prostatic tissue. Of these strategies, radiofrequency and microwave energy have been the most extensively investigated. In general, these minimally invasive techniques are less effective than transurethral prostatectomy but are associated with fewer significant complications. However, a troublesome consequence of these minimally invasive therapies is postprocedure AUR.
The incidence of AUR following TUMT is related to the amount of energy delivered to the prostate. In a prospective randomized study reported by DAncona and colleagues, the length of catheterization was 4.1 days following transurethral prostatectomy versus 12.7 days with TUMT. Blute and colleagues reported that, following TUMT, 36% of men required catheterization for urinary retention. The rate of AUR following TUNA ranges from 13.3% to 41.6%.
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Comparison With Other Anesthetic Modalities
Only five studies made comparisons with other anesthetic modalities. Schmittner et al. compared intrathecal with general anesthesia and found no difference in time to micturition.56 Casati et al. also found no difference between intrathecal, general, or peripheral nerve block anesthesia in terms of time to micturition.25 Sungurtekin et al. found no difference between intrathecal anesthesia and local infiltration, while van Veen et al., Young et al., and Anannamchareon et al. reported significantly higher rates of urinary retention with intrathecal anesthesia compared with local infiltration.27,58,61,63
Management Of Postoperative Urinary Retention
19 July, 2005By NT Contributor
VOL: 101, ISSUE: 29, PAGE NO: 53
Jackie Williamson, RGN, is senior staff nurse, Stracathro Hospital, Brechin, Angus, Scotland
Clinical governance has been described as the total of all factors that make the National Health Service, and the place in which you work, safe .
The term clinical governance was used for the first time in the White Paper, The New NHS: modern, dependable , in which the government stated its commitment to giving the people of the United Kingdom a quality health service. Clinical governance is the framework for driving this quality service. It encompasses clinical effectiveness, risk management, fitness to practise and a patient-focused culture, all of which are underpinned by an organisation that supports the ethos.
As part of an assignment for the clinical governance module of a degree course, I was asked to look at an area of my practice that needed to be improved and determine how I would implement any changes within the clinical governance framework. I chose to look at the problem of detecting postoperative urinary retention and at how it could be treated.
According to Rosseland et al , PUR is widespread and is associated with over-distention of the bladder and subsequently lifelong bladder damage. It can lead to an extended stay in hospital .
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What We Found And What This Means
We found factors associated with PO-UR included being older, male, and having previous urinary problems or long-term enlargement of the prostate gland restricting the ability to urinate . Reducing fluids and using a catheter during surgery were associated with a lower risk of PO-UR.
Giving tamsulosin before surgery can reduce the number of people who develop PO-UR. All the studies of tamsulosin were in men and none were in UK settings, so more studies are needed to see if similar effects are found in women and in UK settings.
Replacing or avoiding morphine in the anaesthetic, administering the anaesthetic in certain ways, and getting patients up and moving as soon as possible after their operation reduced the chance of developing PO-UR. For people who developed it, a small number of studies also suggested that a hot pack or warm gauze and a warm coffee could help.
Based on the results of our review, we developed an intervention to reduce the risk of developing PO-UR the PO-UR prevention package. This package involves providing hospital staff with training and advice to:
- Avoid using morphine or reducing the dose, wherever possible
- Change other aspects of the anaesthesia or analgesia
- Get people moving as soon as possible after their operation
- Reduce fluids as far as is safe, before and during the operation
- Provide a hot caffeinated drink and hot pack placed on the abdomen around two hours after the operation
Symptoms That Might Indicate A Serious Condition
Postoperative urinary retention can lead to complications, including permanent bladder damage. Tell your care team if you are struggling in any way to urinate after surgery. You should also let them know if you dont have urinary symptoms, but have a feeling of discomfort or fullness in your pelvis or abdomen.
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Unilateral Spinal Nerve Block
Use of a unilateral spinal nerve block for elderly patients and outpatient surgery has undergone a resurgence. Unilateral spinal anesthesia was described in 1950 by Ruben and Kamsler. Their report concerned 116 patients for surgical reduction of hip fracture performed under unilateral spinal block. No deaths were reported, and no increase in the hazard of operation was found. Recently, attention has returned to the use of unilateral spinal anesthesia in elderly patients326 and for outpatient surgery.
Use of unilateral spinal anesthesia results in decreased changes in systolic, mean and diastolic pressures, or oxygen saturation in elderly trauma patients . Keeping the operative side up and using a hypobaric spinal solution in a low dose for these cases results in excellent anesthesia and remarkable hemostability when the patient is kept in the lateral position for 510 minutes before repositioning supine. When using hyperbaric solutions, the operative side should be dependent.Outpatient surgery using hyperbaric 0.5% bupivacaine takes about 16 minutes for development of surgical anesthesia from time of injection with unilateral spinal anesthesia and 13 minutes with traditional bilateral spinal anesthesia. Less hemodynamic changes are found in the unilateral spinal anesthesia group, with quicker regression of the nerve block and equal time to discharge home.
Obstruction In People With A Penis
Possible causes of obstruction in people with a penis
- Cystocele. Cystocele occurs when the bladder lowers and pushes against your vagina.
- Rectocele. This is when the rectum expands and pushes against your vagina.
- Uterineprolapse. Uterine prolapse occurs when the uterus lowers and pushes against the bladder.
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Mechanism Of Spinal Anesthesia
Injection of local anesthetics into the spinal CSF allows access to sites of action both within the spinal cord and the peripheral nerve roots. The traditional concept of spinal anesthesia causing complete conduction block is simplistic, as studies with somatosensory evoked potentials demonstrate little change in amplitudes or latencies after induction of dense spinal or epidural anesthesia. There are multiple potential actions of local anesthetics within the spinal cord at different sites. For example, within the dorsal and ventral horns, local anesthetics can exert sodium channel block and inhibit generation and propagation of electrical activity. Other spinal cord neuronal ion channels, such as calcium channels, are also important for afferent and efferent neural activity. Spinal administration of N-type calcium channel blockers results in hyperpolarization of cell membranes, resistance to electrical stimulation from nociceptive afferents, and intense analgesia. Local anesthetics may have similar actions on neural calcium channels, which may contribute to analgesic actions of central neuraxially administered local anesthetics.
Data Extraction And Study Appraisal
Data were extracted using a standard form developed in Microsoft Access® 2010 to include: eligibility criteria, study characteristics, participant characteristics, intervention, comparator, outcome definitions and outcome data for incidence of PO-UR. Data were also extracted for: rates of urinary tract infection , duration of hospital stay, patient acceptability, adverse events and pain scores. Data extraction was performed by one reviewer and checked by a second disagreements were resolved by discussion with a third reviewer. Where PO-UR was reported at multiple time points, data for the initial time point were extracted.
Included studies were assessed independently for risk of bias by two reviewers, using the Cochrane Risk of Bias tool ,. This includes assessment criteria covering selection bias , performance bias , detection bias , attrition bias and reporting bias .
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Effects Of The Volume Of The Lumbar Cistern On Nerve Block Height
Cerebrospinal fluid is produced in the brain at 0.35 mL/min and fills the subarachnoid space. This clear, colorless fluid has an approximate adult volume of 150 mL, half of which is in the cranium and half in the spinal canal. However, CSF volume varies considerably, and decreased CSF volume can result from obesity, pregnancy, or any other cause of increased abdominal pressure. This is partly due to compression of the intervertebral foramen, which displaces the CSF.
Diagnosing Postoperative Urinary Retention
A patient will be diagnosed as having PUR when her/his bladder has a capacity of approximately 500ml Kitada et al, 1989).
Pavlin et al identified that a transient over-distension of the bladder caused by a volume of urine between 500 and 1000ml will not cause damage if it is detected and treated within one to two hours. This is in contrast to a study by Tammela et al , which showed an increase in the prevalence of persistent urinary retention in patients who initially had 500ml of urine drained from their bladder following surgery. However, this may be because 51 per cent of patients in the study were not catheterised until 12 hours after their operation and that in 38 per cent of the subjects the volume drained exceeded 1000ml. If PUR had been detected and treated earlier, complications could have been avoided .
PUR occurs in four to thirty-eight per cent of patients, depending on the type of surgery they have had, their gender, age and preoperative history of urinary dysfunction . It has been identified as a particular problem following hernia repair and anal surgery, and it has been reported that spinal/epidural anaesthesia increases the likelihood of a patient developing PUR .
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Physiology Of Spinal Anesthesia
Spinal anesthesia blocks small, unmyelinated sympathetic fibers first, after which it blocks myelinated fibers. The sympathetic block can exceed motor/sensory by two dermatomes. Spinal anesthesia has little effect on ventilation but high spinals can affect abdominal/intercostal muscles and the ability to cough. Patients may complain of dyspnea because they cant feel themselves breathing. Anything above T5 inhibits SNS to the GI tract. Some operations may bleed less during neuraxial blockade due to decrease systemic blood pressure. Some procedures may suffer less VTE due to increased blood flow to the lower extremities.
Healthy Bladder Function After Anesthesia
Structure of the Urinary Bladder .
A healthy bladder is a fairly complex, sac-like organ. Composed of a body and a neck, the bladder is made of different types of muscle fibers and nerves that interact to allow micturition, or the passage of urine. Emptying the bladder requires input and action from the bladder, surrounding muscles, spinal cord, brainstem, and brain.
The bladder’s body holds the urine. There are stretch receptors in the walls of the bladder body that indicate the level of fullness of the bladder. These special sensors send signals to the brain when the bladder should be emptied. The neck of the bladder has sphincters or valves that open to allow urine to be expelled.
- The internal urethral sphincter, located inside the neck of the bladder, is made of smooth muscle fibers and is not under voluntary control.
- The external urethral sphincter is a ring formed by the pelvic floor muscles and is under voluntary control.
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