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Journal of Clinical Medicine Research

Review

Volume 15, Number 4, April 2023, pages 208-215

Predictors of Catheter-Related Bladder Discomfort After Surgery: A Literature Review

Indwelling bladder catheters are routinely used in clinical practice. In the perioperative period, it is used to assess circulatory dynamics, maintain bed rest, and ensure urine drainage. Patients with perioperative indwelling bladder catheters may experience postoperative indwelling catheter-related bladder discomfort (CRBD), including pain and urinary urgency. These symptoms are often experienced after awakening from anesthesia and cause postoperative distress in patients. Patients may experience various types of discomfort other than pain immediately following surgery and anesthesia. A study reported that 43% of discomfort was related to an indwelling bladder catheter that had been inserted intraoperatively [1]. CRBD is unpleasant for patients after surgery, and it decreases patient satisfaction, causes postoperative complications, and significantly affects the patient’s recovery process. Indwelling bladder catheters are an important cause of postoperative agitation. Therefore, it is recommended that indwelling bladder catheters be removed as soon as possible [2]. Severe CRBD with behavioral responses, such as pulling out an indwelling bladder catheter, can also lead to urethral injury. Compared to a placebo drug, muscarinic antagonists, anesthetics, antiepileptics, and analgesics were reported to have greatly improved clinical symptoms and significantly reduced the incidence of CRBD [3]. Although CRBD has been studied extensively, because it is not a serious life-threatening complication, patients’ complaints of distress may not be properly addressed. A literature review has been published on interventions that may reduce the incidence and severity of CRBD; however, none has been published on predictors of CRBD. Therefore, the purpose of this study was to conduct a literature review of the predictors of CRBD and identify the predictors of CRBD. By preoperatively assessing the predictors of CRBD, appropriate interventions can be provided for patients at risk of CRBD.

We searched PubMed for relevant articles published between 2000 and 2020 using search items.

Various algorithms, including the following terms: catheter-related bladder discomfort, risk factor, risk, and predictors were used. The results of the database search are summarized in ENDNOTE. Data from all selected studies were extracted and tabulated by one author and corroborated by another. Discrepancies were resolved by consensus by all authors. Information retrieved included the following: 1) author name and year of publication; 2) details of the study design (number of patients randomized, method of randomization, and duration of observation); 3) characteristics of the recruited patients; 4) details of interventions used (dosage and schedule); and 5) data on primary and secondary outcomes and P-values.

CRBD is defined as urinary urgency and suprapubic discomfort [4, 5].

CRBD was assessed using the four-point scale used by Agarwal et al [5] (Table 1).

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Table 1. Rating Scale for Catether-Related Bladder Discomfort

Using the keywords “CRBD” and “catheter-related bladder discomfort”, we identified 69 published articles. The results were narrowed down by the keyword “prediction”, and five studies that recruited 1,147 patients remained (Fig. 1) (Table 2).

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Figure 1. Flowchart of literature review.

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Table 2. Studies on Predictors of CRBD

The incidence of CRBD in the five extracted studies ranged from 44.3% to 84.5% [4, 6-9]. The incidence of CRBD was the highest (84.5%) in a study that recruited patients who had undergone abdominal laparotomy in urological diseases [7] and the lowest (44.3%) in a study that recruited patients who had undergone obstetrical and gynecological surgery [4].

The predictors of CRBD that were extracted from the five studies are presented in Table 3.

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Table 3. Predictors of Catether-Related Bladder Discomfort

The following patient factors were extracted: male sex, age ≥ 50 years, age < 50 years, history of indwelling bladder catheters, and history of cesarean section.

Binhas et al classified postoperative patients into two groups: with and without CRBD. Male sex (odds ratio (OR) = 3.2; 95% confidence interval (95% CI), 1.0 - 10.5; P < 0.06) was a predictor of CRBD [6].

Lim et al classified postoperative patients into two groups: with a CRBD grade of 1 or less and those with a CRBD grade of 2 or more [4]. Male sex (OR = 7.07; 95% CI, 1.47 - 34.17; P = 0.015) and age < 50 years (OR = 4.79; 95% CI, 1.62 - 14.09; P = 0.005) were predictors of CRBD.

Li et al classified postoperative urological surgery patients into two groups: with and without CRBD [7]. History of indwelling bladder catheters (OR = 2.458; 95% CI, 1.1 - 5.9; P < 0.05) was a predictor of CRBD [7].

Li et al classified postoperative gynecological surgery patients into two groups: with a CRBD grade of ≥ 1 point (mild, moderate and severe) and those with a CRBD grade of ≥ 2 points (moderate and severe) [8]. Age ≥ 50 years (OR = 2.106; 95% CI, 1.2 - 3.8; P = 0.013) was a predictor of CRBD [8].

Moataz et al classified postoperative patients into two groups: with a first group (none and mild) and those with a second group (moderate and severe) [9]. Age < 50 years (OR = 0.4; 95% CI, 0.08 - 9.00; P = 0.006), history of indwelling bladder catheters (OR = 0.2; 95% CI, 0.04 - 1.30; P = 0.032), and history of cesarean section (OR = 0.3; 95% CI, 0.06 - 2.10; P = 0.005) were predictors of CRBD.

The following surgical factors were extracted: abdominal laparotomy in urological diseases, uterus-related laparoscopic surgery, and obstetric and gynecological surgery.

Abdominal laparotomy in urological diseases was a predictor of CRBD in the studies by Li et al (OR = 3.074; 95% CI, 1.3 - 7.4; P < 0.05) [7] and Moataz et al [9] (OR = 0.5; 95% CI, 0.1 - 1.9; P = 0.02).

Uterus-related laparoscopic surgery (OR = 1.863; 95% CI, 1.1 - 3.1; P = 0.019) was reported to be a predictor of CRBD [8], and obstetrical and gynecological surgery (OR = 11.07; 95% CI, 1.06 - 115.70; P = 0.045) was a predictor of CRBD [4].

Lack of postoperative analgesics (OR = 0.408; 95% CI, 0.2 - 0.9; P = 0.032) was a predictor of CRBD [8].

The following device and insertion technique factors were extracted: a urinary catheter size of 18 ≥ Fr and lack of lubrication of a catheter.

The studies by Binhas et al [6] and Moataz et al [9] reported that a urinary catheter size of 18 ≥ Fr was a predictor of CRBD (OR = 2.2; 95% CI, 1.0 - 5.1; P = 0.06 and OR = 0.9; 95% CI, 0.08 - 1.1; P = 0.012, respectively). Moataz et al [9] further reported that lack of lubrication of a catheter (OR = 0.1; 95% CI, 0.05 - 1.1; P = 0.008) was a predictor of CRBD.

Four patient factors associated with CRBD had one or two items of overlap among the five studies. Three surgical factors associated with CRBD had one or two items of overlap among the five studies. One anesthetic factor associated with CRBD had one item of overlap among the five studies. Lack of lubrication of a catheter associated with CRBD had one or two items of overlap among the five studies (Table 4).

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Table 4. Overlap Between Each of the Studies on CRBD

We conducted a literature review of five articles on the predictors of CRBD. The predictors of CRBD can be divided into four factors including patient factors, surgical factors, anesthetic factors, and device and insertion technique factors. By identifying the predictors of CRBD, unpleasant patient experiences and decreased patient satisfaction associated with CRBD can be reduced.

According to Bai et al [3], CRBD is frequent and occurs immediately after urological surgeries, especially after transurethral resection of the bladder tumor (TURBT). To date, TURBT is the most refractory surgical procedure among all urological surgical procedures because most patients who undergo TURBT are men and many have large indwelling bladder catheters (≥ 18 Fr) after the procedure. TURBT may increase the incidence of CRBD due to resection of the bladder wall and continued irritation of the bladder wall by reflux fluid.

The male sex was reported as a predictor of CRBD [4, 6] because anatomically, the male urethra is longer than the female urethra and is bent in an S-shape. This is because the indwelling bladder catheter stimulates a larger area of the urethra in men than in women, and the urethra is more strongly stimulated due to its S-shaped bend. In addition, men are more likely than women to complain of pain and use painkillers [10], indicating a lower pain tolerance. Male patients were more dissatisfied than their female counterparts with transurethral catheterization (satisfaction score: 4.18/10 vs. 2.75/10; P = 0.05) [11].

The controversies surround age factor of CRBD. Age ≥ 50 years and < 50 years were reported as predictors of CRBD [4, 8, 9]. Gynecological surgery studies have reported that an age of ≥ 50 years is a predictor of CRBD [8]. In gynecological surgery, the older the patient, the higher the possibility of that patient undergoing hysterectomy due to malignancy, and since hysterectomy, which irritates the bladder, is performed for patients ≥ 50 years, an age of ≥ 50 years is a predictor of CRBD. As we age, our pain threshold increases [12], we become more insensitive to pain stimuli, and we are less likely to complain of CRBD. In a study of female patients, higher pain scores with indwelling bladder catheters were recorded for younger women, which could be explain by better urethral sphincter muscle tone compared to that of older women [13]. Different studies have reported different results [4, 8, 9], and further research is needed.

History of indwelling bladder catheters was reported as a predictor of CRBD [7, 9]. Emotional distress and anxiety have been shown to be associated with severe acute pain [14]. Patients’ past experience with placement of a retained catheter might psychologically mitigate the fear of urinary catheters, thereby lowering the incidence of CRBD [7]. Preoperative education can effectively reduce anxiety regarding catheterization [15], and preoperative education on CRBD using illustrations, which is simple and inexpensive, is effective in reducing both the incidence and severity of CRBD [16].

History of cesarean section was a predictor of CRBD [9]. Compared with patients with a history of vaginal delivery, patients with a history of cesarean section were significantly more likely to develop CRBD. To date, no study has established an association between CRBD and the method of delivery.

Obstetrical and gynecological surgery and, specifically, uterus-related laparoscopic surgery were reported as predictors of CRBD [4, 8]. This is because uterine contraction or irritation during laparoscopic surgery may irritate the bladder. Furthermore, postoperative neuropathy can induce bladder paralysis.

Lack of postoperative analgesics was reported as a predictor of CRBD [8]. Inadequate postoperative analgesia increases incidence of CRBD. CRBD is similar to overactive bladder and is caused by involuntary contraction of the bladder smooth muscle due to muscarinic receptor stimulation. There are five subtypes of muscarinic receptors, M1 to M5. Bladder smooth muscle assembles M2 (70-80%) and M3 (20-30%) receptors, and M3 receptors are responsible for the contraction of bladder smooth muscle [17]. Therefore, muscarinic receptor antagonists such as tolterodine, oxybutynin, and butyl scopolamine are effective in preventing CRBD [4]. Tramadol and ketamine are centrally acting opioid analgesics with antimuscarinic effects that effectively prevent CRBD when administered intravenously [3]. Intravenous paracetamol has been shown to be effective in the prevention of CRBD [18]. The mechanism of CRBD is related to prostaglandin E2 (PGE2) in urine. PGE2 is produced in the bladder and acts on bladder smooth muscle contraction. Stimulation of bladder smooth muscles by indwelling bladder catheters promotes PGE2 synthesis and induces contraction of the bladder smooth muscles, resulting in CRBD. Paracetamol, an inhibitor of PG synthesis and cyclooxygenase-2, reduces the incidence and symptoms of CRBD [3].

In a study that compared the effects of sevoflurane and desflurane inhalant anesthetics on CRBD, sevoflurane, when compared with desflurane, reduced the incidence of CRBD in patients who underwent TURBT. CRBD in the first 24 h postoperatively occurred in 34/45 (76%) patients receiving sevoflurane compared to 41/44 (93%) patients receiving desflurane [19]. In another study that compared the effects of sevoflurane and propofol on CRBD, CRBD in the first 1 h postoperatively was lower in the sevoflurane group than in the propofol group (59% vs. 85%; P = 0.007) [20]. This is thought to be due to the ability of sevoflurane to block M3 receptors, which cause CRBD [21].

A study examining the effects of magnesium’s smooth muscle relaxant effects on CRBD reported that magnesium reduced the incidence of CRBD grade of ≥ 2 points (above a moderate grade) and increased patient satisfaction after TURBT [22].

To prevent CRBD, intraoperative and postoperative pain management are important. Each drug has complications, such as anticholinergic effects, sedation, nausea and vomiting, and respiratory depression; however, multimodal pain management can reduce the incidence of these complications.

A urinary catheter size of 18 ≥ Fr was reported as a predictor of CRBD [6, 9]. The incidence of CRBD is less in nonurological postoperative patients with indwelling bladder catheters of 12 - 14 Fr [23]. Reducing the size of the indwelling bladder catheter reduces mechanical irritation to the urethra, leading to a reduction in the CRBD.

Lack of lubrication of a catheter was reported as a predictor of CRBD [9]. If an indwelling bladder catheter is inserted without lubrication, the urethral mucosa is damaged by friction during insertion [13]. When lubricants containing local anesthetics are used, they can reduce trauma to the urethra and minimize pain and discomfort. Local anesthetics, such as lidocaine or prilocaine cream injected into the urethra or applied to the catheter as a lubricant, have been shown to reduce the incidence and severity of CRBD [24]. In addition, indwelling bladder catheters coated with analgesics are effective in preventing CRBD [25], and some indwelling bladder catheters for men are made such that they can be used to inject a local anesthetic into the urethra, which provides surface anesthesia for the urethral mucosa [26].

The balloon volume of an indwelling bladder catheter affects the occurrence of CRBD. In a study of patients who underwent urological surgery, a 50% reduction in the balloon volume of the indwelling bladder catheter reduced CRBD incidence [27]. The pain was mostly reported when the balloon of the urinary catheter contacts the bladder triangle or when the balloon volume of the indwelling bladder catheter is too large. Balloon catheters of 5 - 10 mL should be selected [28]. Reducing the balloon volume reduces the stimulation of the bladder induced by the balloon, thereby reducing the symptoms of CRBD. A comparison of the effects of indwelling bladder catheter insertion and suprapubic bladder drainage on CRBD after robot-assisted laparoscopic radical prostatectomy showed a decrease in postoperative CRBD in patients who underwent suprapubic bladder drainage [29]. The use of appropriate devices and insertion methods can help to reduce the incidence of CRBD.

In this study, a literature review was conducted to identify patient factors associated with the occurrence of CRBDs: surgical factors, anesthetic factors, device and insertion technique factors and patient-related factors. However, these factors were not independent of each other, but combined to cause CRBD. However, it was not clear how many of these factors combined to cause CRBD and whether the combination of factors affected the severity and duration of CRBD. In addition, it was not clear if patient factors were responsible for causing POST or if they affected severity and duration. The current review found no reports related to CRBD or patient factors. Therefore, further research on CRBD and patient factors is warranted. There were few studies on CRBD, and thus only 1 - 2 studies overlapped items for each factor. Therefore, a meta-analysis could not be performed.

Predictors of CRBD included: 1) patient factors (male sex, age ≥ 50 years, age < 50 years, history of indwelling bladder catheters, and history of cesarean section); 2) surgical factors (abdominal laparotomy in urological diseases, uterus-related laparoscopic surgery, and obstetrical and gynecological surgery); 3) anesthetic factors (lack of postoperative analgesics); and 4) device and insertion technique factors (a urinary catheter size of ≥ 18 Fr, lack of lubrication of a catheter, and urinary catheter-related pain (UCRP) ≥ 4).

Our study suggests that patients with predictors of CRBD should be closely monitored to reduce postoperative patient suffering, and their quality of life should be improved after anesthesia.

Acknowledgments

None to declare.

Financial Disclosure

This work was supported by JSPS KAKENHI grant (number: 21K21204).

Conflict of Interest

The authors declare no conflict of interest.

Author Contributions

TY designed the study. KN, TI, and YY participated in data acquisition, extraction, and analysis, and drafted the final work. KK, YM and YB supervised this manuscript’s preparation and writing. The authors reviewed the final version of the manuscript and approved it for publication.

Data Availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

CRBD: catheter-related bladder discomfort; UCRP: urinary catheter-related pain; TURBT: transurethral resection of the bladder tumor; PG: prostaglandin

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