|Year : 2014 | Volume
| Issue : 2 | Page : 33-37
Preventive effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries
Mir Mujtaba Ahmad1, Hilal A Wani1, Asif Jeelani2, Sajad Thakur1, Malik Waseem3, Irfan Nazir1
1 Department of Surgery, GMC, Srinagar, Jammu and Kashmir, India
2 Medical Surveillance Office, WHO, Geneva, Switzerland
3 Department of SPM, GMC, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||12-Sep-2014|
Mir Mujtaba Ahmad
Department of Surgery, GMC, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Objective: The aim was to study the prophylactic effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries. Background: Acute urinary retention (AUR) after anorectal surgeries is essentially a type of postoperative urinary retention (POUR). It is the most common complication of the procedure. Use of tamsulosin, a super selective alpha 1a adrenergic blocker has been found to reduce the risk of POUR. Patients and Methods: Patients who underwent anorectal surgeries for benign anorectal conditions were included in this study. Patients were randomly assigned into two groups. In one, group (cases), patients were given 0.4 mg of oral tamsulosin only 6 h preoperative and 6-8 h postoperatively. Inability/difficulty to pass urine, which necessitated catheterization after following patient for 24 h was labeled as POUR. Results: A total of 626 patients who underwent surgery for benign anorectal condition were included in the study and grouped into two groups with 313 patients in each group, control and case group. In the control group, 56 patients (17.9%) had inability to pass urine and required catheterization and in the case group, only eight patients (2.5%) needed catheterization following POUR. The difference in the requirement of catheterization following POUR was statistically significant (P = 0.04). Hemorrhoidectomy was the most common anorectal surgery associated with POUR. Conclusion: The use of tamsulosin in preoperative and postoperative period has been found effective to reduce the incidence of POUR following surgeries for benign anorectal pathologies.
Keywords: Acute urinary retention, anorectal surgeries, postoperative urinary retention, tamsulosin
|How to cite this article:|
Ahmad MM, Wani HA, Jeelani A, Thakur S, Waseem M, Nazir I. Preventive effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries
. Saudi Surg J 2014;2:33-7
|How to cite this URL:|
Ahmad MM, Wani HA, Jeelani A, Thakur S, Waseem M, Nazir I. Preventive effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries
. Saudi Surg J [serial online] 2014 [cited 2019 Jan 16];2:33-7. Available from: http://www.saudisurgj.org/text.asp?2014/2/2/33/140687
| Introduction|| |
Acute urinary retention (AUR) is the most common complication after operation for benign anorectal diseases with a range of 1-50%, average of around 15%.  AUR after a surgical procedure is termed as postoperative urinary retention (POUR), which is defined as the inability to pass any urine in the presence of a palpable or percussive bladder after surgery. It is seen in patients of both sexes and all age group and following all types of surgical procedures though it is more common following surgeries on urinary tract, perineal, gynae and anorectal procedures.  The cause of POUR is uncertain though it seems to be multifactorial. In benign anorectal surgeries, there is an adrenergic stimulation following anal distention, swelling and local pain leading to reflex inhibition of detrusor muscle and bladder outlet contraction. POUR has been found to be related to certain risk factors like spinal anesthesia, age, presence of obstructive urinary disease, type of procedure, duration of the procedure, fluids, analgesia. 
Several steps and strategies have been seen for the prevention of POUR, like restricted perioperative fluid intake,  use of parasymphathetic and alpha-adrenergic blockers, , pain control,  sitz bath,  use of local anesthesia, , ambulation  have been advocated. Tamsulosin, being an alpha 1a receptor blocker acts by reducing tone in bladder outlet, thereby decreasing outflow resistance and decreasing POUR. With this background, a study to investigate the role of prophylactic tamsulosin on the development of POUR in patients undergoing surgeries for benign anorectal conditions was carried out.
| Patients and Methods|| |
This study was conducted in Post Graduate Department of Surgery, Government Medical College Srinagar for a period of 18 months spanning February 2011 to August 2012. All patients of either sex and age <70 years who presented with benign pathology in anorectal region and were operated upon for hemorrhoidectomy, fistula surgery, sphincterotomy, maximal anal dilatation, incision and drainage of perianal abscess. A total of 626 patients was included in the study and were randomly allocated into two groups, one group being a case group and the other one control group, equally distributing 313 patients in each group. The exclusion criterion was age >70 years, active urinary tract infection, neurological disorders, history of urinary calculi or stricture, benign hypertrophy of prostate on treatment, previous urological surgery, malignancy patients, h/o incontinence, indwelling catheter, significant comorbidity like chronic kidney disease, medication with effects on kidney.
All patients underwent a baseline assessment and preoperative sonographic scan to quantify post void residual urine. After informed consent, all patients were subjected to surgery under spinal anesthesia. In all cases, tamsulosin was given 0.4 mg orally 6 h before surgery followed by another same dose 6-8 h later. In all patients, administration of Ringer lactate (1.5 ml/kg/h) was done in the operating room before the anesthesia and patient was kept nil per oral with Intravenous fluids for 4-6 h. All the patients were anaesthetized by spinal anesthesia.
The surgeries performed were hemorrhoidectomy, fistula surgery, lateral sphincterectomy, incisional drainage of perianal abscess. Perioperative tramadol as an analgesic, followed by diclofenac for pain control was used. Dosage of analgesia was adjusted until patient reported zero to mild pain on visual analogue scale for pain.
All the patients were followed for 24 h postoperatively, and any difficulty in voiding or urinary retention was recorded.
Urinary retention was diagnosed when a patient had a palpable mass in the suprapubic area, felt discomfort, and failed to pass urine within 24 h after the operation despite a sufficient fluid intake and when conservative efforts such as warming the suprapubic region and encouraging the patient to stand up and walk were unsuccessful and bladder catheterization seemed inevitable. Indwelling Foleys catheter and 2% xylocaine jelly were used for catheterization and catheter was removed after about 24 h postoperatively.
Statistical analysis was accomplished by use of the Chi-square test with a P < 0.05 considered as significant.
| Results|| |
Among a total of 626 patients included in the study, there were 313 patients in group 1 (tamsulosin group) and another 313 patients in group 2 (control group). The patients were having different anorectal benign pathologies and needed hemorrhoidectomy in 280 patients, fistulectomy/fistulotomy in 106 patients, maximal anal dilitation/lateral internal sphincterotomy in 160 and incision and drainage of perianal abscess in nearly 80 patients. The incidence of urinary retention necessitating catheterization was about 22% in hemorrhoidectomy, 6.3% in fistula surgeries, 2.7% in incision and drainage of perianal abscess, 17.2% in maximal anal dilatation or internal sphincterotomy, with overall retention of around 18%.
No statistically significant differences were found between the two groups in terms of age (P = 0.18), severity of preoperative urinary symptoms (P = 0.7), postvoiding residual urine volume (P = 0.7) or duration of surgery (P = 0.6) and hospital stay (P = 0.5). The average nonsteroidal anti-inflammatory drug use in the two groups was similar (200 mg diclofenac) [Table 1].
In group 1 (tamsulosin group), eight patients required catheterization with a mean urine volume of 800 ml at catheterization. In group 2 (controls), 56 patient required catheterization with a 600-ml mean urine volume. Thus, 18% of patients in group 2 and 2.5% of patients in group 1 had urinary retention.
The difference in the requirement for catheterization was statistically significant (P < 0.0001).
Most of the patients who underwent hemorrhoidectomy developed retention, followed by patients who underwent lateral internal sphincterotomy.
| Discussion|| |
The incidence of POUR varies according to the type of surgery. Urinary retention is a common complication after any surgical procedure. Although the incidence of POUR in general surgical population is around 3.8%.  The incidence of POUR after anorectal surgery ranges between 1% and 52% with an average of 18%. ,, Injury to the pelvic nerves and pain evoked reflex increase in the tone of the internal sphincter explains the high incidence of POUR in patients undergoing anorectal surgery. ,,,,, POUR has also been reported after gynecological surgery, but with conflicting results Previous pelvic surgery can increase the risk of POUR, probably as a result of direct damage to the nerves innervating the lower urinary tract.  The widely varying reported incidence of POUR reflects differences in patient characteristics, the lack of uniform defining criteria, and the multifactorial etiology of POUR, including age, gender, inadequate perioperative fluids, type of anesthesia, and type of surgery. 
Urinary retention produces discomfort, and it can lead to prolongation of hospital stay with urethral injury and urinary tract infection at times following catheterization in addition to increasing financial constraints, avoidance of this perioperative complication is particularly important. Although most patients may recover from POUR with a trial without catheter (TWOC) after a few days of catheterization, some patients with POUR can have persistent urinary retention after failure of TWOC, and this prolongs or complicates the postoperative recovery phase. Therefore, efforts should be made to prevent POUR, especially in men at high risk for the condition. The development of POUR is multifactorial. These include the direct effects of anesthetic agents on the bladder, traumatic instrumentation, pelvic dissection, overzealous intravenous hydration resulting in bladder distension, diminished awareness of bladder sensation, increased outlet resistance, immobilization after the procedure, postoperative pain (nociceptive inhibitory reflex), use of narcotics for analgesia, and patient age and sex. 
Toyonaga et al.  showed that female sex, preoperative urinary symptoms, diabetes mellitus, large amounts of intravenous fluid administered perioperatively, and postoperative pain are independent risk factors for urinary retention in selected cases of anorectal surgery such as hemorrhoidectomy and fistulectomy.
The contractility of the detrusor decreases with advancing age. Accordingly, in light of previous studies, it was generally assumed that POUR increases with age, with the risk increasing by 2.4-2.8 times in patients over 50 years of age.  Age is an independent factor predicting successful TWOC for POUR and patients older than 70 years are at a 1.8 times higher risk of failure of TWOC than are those younger than 70 years.
Many different methods have been tried to prevent this complication, including the use of parasympathomimetic agents, use of alpha-adrenergic blockers, use of anxiolytic agents, restriction of perioperative fluid intake, avoidance of anal packing, sitz baths, use of local anesthesia, use of short-acting anesthesia, and outpatient surgery.
Some precautions, such as limitation of fluid intake, early mobilization, warm compress to the suprapubic area, and the use of short-acting local or spinal anesthesia, have been reported to prevent this complication. ,,
The overwhelming majority of procedures for benign anorectal pathologies are performed as elective outpatient procedures except perianal abcesses without intra-operative catheterization. Therefore, limiting the perioperative volume of fluids and controlling pain are reasonable measures to reduce POUR. 
In a randomized prospective study of perioperative fluid restriction in anorectal surgery, Bailey and Ferguson were able to reduce urinary retention from 14.9% to 3.5%. 
Efforts toward the pharmacological prevention and treatment of POUR have focused on increasing detrusor muscle activity or decreasing the opening pressure of the internal sphincter at the bladder neck.
It is well-documented that adrenergic receptors are present throughout the bladder. Beta-adrenergic receptors are predominantly in the body and dome, and alpha-adrenergic receptors are in the base and neck of the bladder.
In the acute postoperative setting, sympathetic nerve discharge causes catecholamine release and alpha- adrenergic-mediated contraction of the bladder neck, resulting in functional obstruction of the bladder outlet.
Administration of sympathomimetic and anticholinergic agents (for example, phenylephrine and atropine) during anesthesia can inhibit contraction of the detrusor muscle in the bladder. This relaxes the bladder and decreases the urge to void and the recognition that the bladder is full.
The pain in the perineal area can stimulate the alpha-receptors in the bladder neck and proximal urethra, thereby increasing urethral resistance and bladder outlet tone. The end result is that attempts to void encounter increased output resistance. 
Alpha-adrenergic blockade with phenoxybenzamine historically has seemed effective prophylactically in decreasing the incidence of postoperative retention. Analysis on the use of phenoxybenzamine and concluded that this agent reduced the occurrence of POUR. ,
Prazosin, a selective alpha 1-adrenoceptor antagonist, produces clinical effects similar to those of phenoxybenzamine with less significant side effects. 
Tamsulosin is a superselective adrenoceptor antagonist (alpha-1a). Its preventive effect has not been previously studied in reducing the risk of POUR after anorectal surgeries for benign pathologies in the same region. Patel et al.  investigated the potential efficacy of alpha-blockers for facilitating early removal of the urinary catheter following radical prostatectomy. A consecutive group of 250 men undergoing radical prostatectomy received tamsulosin, 0.4 mg, 3 days before a cystography planned for postoperative day 8. Tamsulosin was administered for an additional 4 days following the catheter removal. The incidence of POUR in the men who received tamsulosin was only 2.6% compared with 10% in the control group.
In the present study, 8 of 313 patients (2.5%) in the tamsulosin group developed urinary retention. In the control group, 56 of 313 patients (18%) had urinary retention and required catheterization. The incidence of AUR was significantly greater in men who did not receive tamsulosin before and after surgery.
The incidence of urinary retention showed no statistically significant difference when we considered the basic pathology in anorectal region, the type of surgery, the type of anesthesia, or the duration of the surgery. The difference was also insignificant when preoperative urinary symptoms were compared between the two groups. Therefore, the use of tamsulosin can be recommended in adult male patients over 50 years of age who undergo surgery in anorectal region, regardless of their baseline characteristics.
The current study is a prospective evaluation of tamsulosin as a means of avoiding urinary retention after anorectal surgeries for benign conditions. This protocol resulted in the reduction of urinary retention from 18% in the controls to 2.5% in the treatment group.
| Conclusions|| |
To the best of our knowledge, the effect of prophylactic tamsulosin has not been investigated on urinary retention in anorectal surgeries. Our data suggest that tamsulosin significantly reduces the incidence of AUR after surgery. Therefore, consideration should be made to give a perioperative course of tamsulosin therapy when performing anorectal surgeries so as to pass benefits to the patients.
| Ethical Approval|| |
Since there was no Ethical Committee at the time of study in GMC, Srinagar and the fact that Tamsulosin being a novel drug with minimal adverse effects and no serious drug toxicity, drug reaction and teratogenic properties has been afflicted with this drug, an ethical approval was given by Dean/Principal GMC, Srinagar for the study.
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