Original Article

Obstet Gynecol Sci 2016;59(2):137-143

http://dx.doi.org/10.5468/ogs.2016.59.2.137
pISSN 2287-8572 · eISSN 2287-8580

Risk factors for urinary retention after vaginal

hysterectomy for pelvic organ prolapse
Chul Chong1, Hye Sung Kim1, Dong Hoon Suh2, Byung Chul Jee2,3
Department of Obstetrics and Gynecology, 1Seoul National University Hospital, Seoul, 2Seoul National University Bundang Hospital, Seongnam, 3Seoul National
University College of Medicine, Seoul, Korea

Objective
To evaluate the risk factors for postoperative urinary retention in women who underwent vaginal hysterectomy for
symptomatic pelvic organ prolapse.
Methods
The medical records of 221 women who underwent vaginal hysterectomy with anterior and posterior colporrhapy were
reviewed. Urinary retention after catheter removal was defined as the presence of at least one of the following three
conditions: 1) failure of first voiding trial necessitating catheterization, 2) first residual urine volume after self-voiding
≥150 mL, and 3) Foley catheter re-insertion.
Results
Urinary retention occurred in 60 women (27.1%). Multivariate and receiver operating characteristic curve analysis
revealed that age (>63 years) and early postoperative day of catheter removal (day 1) was independent predictor for
postoperative urinary retention. The incidence of urinary retention was significantly higher in women who removed
indwelling catheter at day 1 (35.2%) than those at day 2 (12.0%, P=0.024), or day 3 (21.3%, P=0.044), but was similar
to those at day 4 (25.0%, P=0.420). In women ≤63 years, urinary retention rate was not associated with the time of
catheter removal after surgery; however, in women >63 years, the rate was significantly higher in day 1 removal
group than day 2 to 4 removal group.
Conclusion
Age and postoperative day of catheter removal appear to be associated with postoperative urinary retention in
women undergoing vaginal hysterectomy for pelvic organ prolapse. Keeping urinary catheter in situ at least for one
day after vaginal prolapse surgery could be recommended, especially, in women older than 63 years.
Keywords: Hysterectomy, vaginal; Pelvic organ prolapse; Postoperative period; Urinary catheterization; Urinary retention

Introduction
Received: 2015.6.1. Revised: 2015.10.7. Accepted: 2015.10.28.
Corresponding author: Byung Chul Jee
Pelvic organ prolapse is a common disease in women’s later Department of Obstetrics and Gynecology, Seoul National
life and surgical procedure is needed for correcting most of University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-
the symptomatic and/or severe prolapse. Vaginal hysterectomy gu, Seongnam 13620, Korea
(VH) with or without colporrhaphy has been one of the most Tel: +82-31-787-7254 Fax: +82-31-787-4054
E-mail: blasto@snubh.org
common surgical procedures for the treatment of symptom-
http://orcid.org/0000-0003-2289-6090
atic pelvic organ prolapse.
Postoperatively, some patients experience voiding difficulty Articles published in Obstet Gynecol Sci are open-access, distributed under the terms of
the Creative Commons Attribution Non-Commercial License (http://creativecommons.
after urinary catheter removal although the exact cause is not org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution,
fully understood yet. In the literatures, the incidence of post- and reproduction in any medium, provided the original work is properly cited.

operative urinary retention (UR) following any type of vaginal Copyright © 2016 Korean Society of Obstetrics and Gynecology

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prolapse surgery was reported 6% to 29% [1-3], which ap- colporrhaphy, suspension surgery, and other anti-incontinence
pears to be higher than that after VH for other benign dis- surgery. Patients with diagnosis of malignancy were also ex-
eases [4]. Old age of the patients undergoing vaginal prolapse cluded. All surgeries performed before 2008 were also exclud-
surgery may be associated with higher incidence of post- ed due to the previous routine practice of longer catheteriza-
operative UR [5]. Other risk factors which has been hitherto tion (maximum 7 days) during that period. Thus, 221 women
known for postoperative UR following vaginal prolapse sur- were finally eligible for the analysis. This study was approved
gery include high grade cystocele, severe intraoperative blood by the institutional review board of Seoul National University
loss, application of levator and Kelly plication, postoperative Bundang Hospital (no. B-1402-240-110).
pelvic hematoma, and short postoperative day of catheter re- Included variables were age, body mass index, degree of
moval [3,6]. However, there is no specific guideline regarding prolapse, diabetes mellitus, type of anesthesia, type of surgery,
the appropriate time for urinary catheter removal after vaginal operation time, surgeon, postoperative day of catheter remov-
prolapse surgery. al, postoperative hemoglobin drop, and postoperative pyuria
Relevant studies indicated that there was no significant dif- (defined as white blood cell 2+ or more at urine analysis).
ference of the incidence of UR in patients of which the uri- Prophylactic antibiotics (usually intravenous cefazolin) were
nary catheter was removed in first day versus third day after administered to all patients at the time of surgical incision. At
vaginal prolapse surgery [7]. However, a randomized study the time of completion of surgery, a sterile transurethral Foley
demonstrated that first-day catheter removal group had a catheter was placed at the operation room. All operations
significantly higher incidence of UR than fifth-day catheter were performed by one of four surgeons.
removal group [8]. Re-catheterization event was significantly Indwelling Foley catheter was removed in the morning of
more frequent in 1-day catheter-use group than 4-day or postoperative day 1 to day 4 as part of routine postoperative
5-day catheter-use group [3,9]. On the other hand, the longer care. The timing of catheter removal solely depended on the
the catheter indwelling time, the higher the incidence of uri- physician’s preference. We did not perform bladder training
nary tract infection and longer duration of hospital stay [10]. routinely before catheter removal. After catheter removal,
Therefore, early catheter removal for preventing urinary tract post-void residual urine volume was routinely measured in
infection has been recommended. Recently, immediate cath- all patients either by catheterization or bladder scanner (Bio-
eter removal has been recommended because the frequency con-700, Mcube Technology, Seoul, Korea). Urinary retention
of complications between immediate and first-day catheter after catheter removal was defined as the presence of at least
removal was similar [11]. Although there are several studies one of the following three conditions: 1) failure of first voiding
evaluating the appropriate time for catheter removal, there are trial necessitating catheterization; 2) first residual urine volume
no consensus on this issue [12]. Moreover, there is no report after self-voiding ≥150 mL, a criterion of incomplete voiding;
regarding the incidence of UR according to the postoperative and 3) Foley catheter re-insertion.
day of catheter removal. Statistical analysis was performed with IBM SPSS ver. 20.0
The aim of the present study was to identify the risk factors (IBM Corp., Armonk, NY, USA). Two-tailed significance was set
for postoperative UR in a retrospective cohort of patients who at 0.05. The means of continuous variables were compared
underwent VH for pelvic organ prolapse. with the Student’s t-test. The chi-square test was used for
comparison of proportions. Variables with P-value in univari-
ate analyses <0.25 were incorporated into multiple regression
Materials and methods analysis for identifying independent risk factors. The odds ra-
tio (OR) estimates and their 95% confidence interval (CI) were
A total of 561 women who underwent VH for symptomatic calculated from the multivariable logistic regression model
pelvic organ prolapse at Seoul National University Bundang with forward conditional selection method. Receiver operat-
Hospital from May 2003 through April 2013 were retrospec- ing characteristic curve analysis was performed using MedCalc
tively reviewed. Inclusion criteria were all patients who under- ver. 15.4 (MedCalc Software, Ostend, Belgium) to yield cut-off
went VH with anterior and posterior colporrhaphy. Exclusion values for each significant predictor.
criteria were VH only, VH with either anterior or posterior

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 Chul Chong, et al. Risk factors for urinary retention

Results gree of prolapse, incidence of UR was similar: 25.9% in mild,

30.4% in moderate, and 24.6% in severe form. There was
Postoperative UR occurred in 27.1% of the study subjects no statistical difference in the incidence of UR according to
(60/221). Patients with postoperative UR (n=60) were older individual surgeon (P=0.105). Multivariate regression analysis
(mean age, 69.5 vs. 66.9 years) and had urinary catheter lon- showed that age and postoperative day of catheter removal
ger postoperatively (day 1 vs. day 2 to 4, P=0.010) than those (day 1 vs. day 2 to 4) were independent predictors for postop-
without postoperative UR (n=161) (Table 1). However, old age erative UR (Table 2).
had no significant correlation with late postoperative day of Receiver operating characteristic curve demonstrated that
catheter removal (Spearman rho 0.011) (Supplemental Table the best cut-off values of age and postoperative day of cath-
1). Most of postoperative catheter removal (81.1%) was per- eter removal to predict occurrence of postoperative UR were
formed at day 1 and 3. In detail, Foley catheter was removed 63 years and postoperative day 1, respectively (Table 3, Fig.
at postoperative day 1, 2, 3, and 4 in 105 (47.3%), 25 (11.3%), 1). Women older than 63 years had a significantly higher inci-
75 (33.8%), and 17 (7.7%), respectively. According to the de- dence of postoperative UR than those of 63 years or younger

Table 1. Preoperative and postoperative characteristics between women with and without postoperative UR after vaginal hysterectomy
with anterior posterior colporrhaphy for pelvic organ prolapse
No. (%) UR (+) (n=60) UR (-) (n=161) P-value
Age (yr) 69.5±7.4 66.9±8.6 0.043
2
Body mass index (kg/m ) 25.2±2.6 24.9±2.9 NSa)
Diabetes mellitus NSb)
Yes 31 (14.0) 9 (29.0) 22 (71.0)
No 190 (86.0) 51 (26.8) 139 (73.2)
Degree of prolapse NSb)
Mild 81 (36.7) 21 (25.9) 60 (74.1)
Moderate 79 (35.7) 24 (30.4) 55 (69.6)
Severe 61 (27.6) 15 (24.6) 46 (75.4)
Type of anesthesia NSc)
Spinal 209 (94.6) 56 (26.8) 153 (73.2)
General 12 (5.4) 4 (33.3) 8 (66.7)
Surgeon 0.105b)
A 126 (57.0) 41 (32.5) 85 (67.5)
B 44 (19.9) 11 (25.0) 33 (75.0)
C 34 (15.4) 4 (11.8) 30 (88.2)
D 17 (7.7) 4 (23.5) 13 (76.5)
Postoperative day of catheter removal 1.8±1.1 2.1±1.0 0.052
Day 1 105 (47.5) 37 (35.2) 68 (64.8) 0.010
Day 2 to 4 116 (52.5) 23 (19.8) 93 (80.2)
Operation time (min) 60.6±15.9 59.3±18.1 NSa)
Postoperative Hb drop (g/dL) 1.4±0.9 1.4±1.0 NSa)
WBC ≥2+ at postoperative UA 0 4 NSc)
Duration of hospital stay (day) 3.0±1.6 3.0±1.0 NSa)
Values are presented as number (%) or mean±standard deviation.
UR, urinary retention; NS, not significant as P>0.25; Hb, hemoglobin; WBC, white blood cell; UA, urine analysis.
a)
Student’s t-test; b)Chi-square test; c)Fisher’s exact test.

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(31.9% vs. 15.3%, P<0.05). Table 4 showed the incidence of higher in day 1 removal group than day 2 to 4 removal group.
UR according to age and postoperative day of catheter remov- Because univariate analysis according to the surgeon dem-
al. Overall incidence of UR was significantly higher in women onstrated that several characteristics including body mass
who removed indwelling catheter at day 1 (35.2%) than those index, degree of prolapse, postoperative day of catheter re-
at day 2 (12.0%, P=0.024) or day 3 (21.3%, P=0.044), but moval, operation time, pyuria, and duration of hospital stay
was similar to those at day 4 (25.0%, P=0.420). In women of showed significant difference between surgeons (Supplemen-
63 years old or younger, the incidence of UR was not associ- tal Table 2), we performed a subgroup analysis only for the
ated with the time of catheter removal after surgery; however, patients of surgeon A (n=126) to exclude the possible con-
in women older than 63 years, the incidence was significantly founding effect of surgeon on the postoperative UR incidence.
We still found that old age was associated with postoperative
Table 2. Multivariate logistic regression analysis for prediction of UR (P=0.019). However, the association between postopera-
postoperative urinary retention tive day of catheter removal and UR did not reach a statistical
Characteristics Odds ratio (95% CI)
Age 1.042 (1.002–1.084)a) 100
Surgeon (A vs. others) 1.079 (0.359–3.245)
Postoperative day of catheter removal 0.455 (0.248–0.834)a)
(day 2 to 4 vs. day 1) 80
CI, confidence interval.
a)
P<0.05.
60
Sensitivity

Table 3. Receiver operating characteristic curve analysis for age

and postoperative day of catheter removal
Postoperative day of 40
Age catheter removal
Cut-off >63 ≤1
AUC 0.585a) 0.583a) 20
95% CI 0.517–0.651 0.515–0.649
Age
Sensitivity 85.0 61.7 Duration of catheterization
Specificity 32.3 58.0 0
0 20 40 60 80 100
PPV 31.9 35.2
100-Specificity
NPV 85.2 80.2
Fig. 1. Receiver operating characteristics curve to demonstrate the
LR+ 1.26 1.46
predictability of age and postoperative day of catheter removal for
LR- 0.46 0.66 occurrence of postoperative urinary retention after vaginal prolapse
AUC, area under the curve; CI, confidence interval; PPV, positive pre- surgery. Area under the curve (95% confidence interval) of age>63
dictive value; NPV, negative predictive value; LR, likelihood ratio. and postoperative day of catheter removal ≤1 was 0.585 (0.517 to
a)
P<0.05. 0.651) and 0.583 (0.515 to 0.649), respectively.

Table 4. Incidence of postoperative UR according to age group and postoperative day of catheter removal
Postoperative day of catheter Age
Overall UR incidence P-valuea)
removal ≤63 >63
Day 1 35.2% (37/105) 14.3% (4/26) 42.9% (33/77) 0.022
b),c) b) )b),c)
Day 2 12.0% (3/25) 0% (0/8) 17.6% (3/17 NS
)c) c)
Day 3 21.3% (16/75 18.2% (4/22) 22.6% (12/53) NS
Day 4 25.0% (4/16)b) 33.3% (1/3)b) 23.1% (3/13)b),c) NS
UR, urinary retention; NS, not significant.
a)
Comparison of incidence between two age groups; b)Fisher’s exact test; c)P<0.05 when compared with day 1 incidence in each column.

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 Chul Chong, et al. Risk factors for urinary retention

Table 5. Preoperative and postoperative characteristics between women with and without postoperative UR after vaginal hysterectomy
with anterior posterior colporrhaphy for pelvic organ prolapse by surgeon A (n=126)
UR (+) (n=41) UR (-) (n=85) P-value
Age (yr) 69.95±7.30 66.01±9.82 0.019a)
Body mass index (kg/m2) 24.80±2.65 25.15±2.52 NSa)
Diabetes mellitus NSb)
Yes 6 (40.0) 9 (60.0)
No 35 (31.5) 76 (68.5)
Degree of prolapse NSb)
Mild 19 (29.7) 45 (70.3)
Moderate 15 (41.7) 21 (58.3)
Severe 7 (26.9) 19 (73.1)
Type of anesthesia NSc)
Spinal 38 (32.8) 78 (67.2)
General 3 (30.0) 7 (70.0)
Postoperative day of catheter removal 1.2±0.5 1.3±0.7 0.157a)
Day 1 37 (35.9) 66 (64.1) 0.086b)
Day 2 to 3 4 (17.4) 19 (82.6)
Operation time (min) 55.07±12.3 53.71±13.82 NSa)
Postoperative Hb drop (g/dL) 1.35±0.93 1.30±1.01 NSa)
WBC 2+ or more at postoperative UA 0 0 NSc)
Duration of hospital stay (day) 2.39±0.63 2.40±0.79 NSa)
Values are presented as mean±standard deviation or number (%).
UR, urinary retention; NS, not significant as P>0.25; Hb, hemoglobin; WBC, white blood cell; UA, urine analysis.
a)
Student’s t-test; b)Chi-square test; c)Fisher’s exact test.

significance (P=0.086) (Table 5). Multivariate analysis showed vary depending on the definition.
that old age was an independent risk factor for postoperative In the present study, indwelling catheter for no longer than
UR (OR, 1.059; 95% CI, 1.008 to 1.112; P=0.022), but post- one day led to a significant increase of UR compared to those
operative day of catheter removal was not. More frequent UR with catheterization for two and three days. Our results are
in patients of early catheter removal ≤day 1 than in those of discordant with the findings of previous reports, in which no
delayed removal >day 1 was found in older age >65 years, a significant difference of UR was found between day 1 and day
new cut-off value of surgeon A subgroup (42.0% vs. 8.3%, 3 catheter removal after vaginal prolapse surgery [7]. However,
P=0.027) (data not shown). our results are consistent with those of Kamilya et al. [9], in
which a significant increase of UR incidence was demonstrated
in 1-day catheter group than 4-day catheter group.
Discussion In some studies [9,14,15], age does not appear to be a risk
factor for perioperative complications. In the present study,
Postoperative UR is defined as the inability to void with a full however, age was an independent risk factor. In women of
bladder during the postoperative period, but the definition in 63 years old or less, the incidence of UR was not associated
terms of residual urine volume is inconsistent. In several stud- with the day of catheter removal; however, in women older
ies, UR was defined as the failure of first voiding or residual than 63 years, the incidence was significantly higher in day 1
urine volume exceeding 100 to 200 mL. In an another report, removal group. Our results support that early catheter removal
residual urine volume >500 mL by portable ultrasound device (i.e., one-day) in older women result in a higher incidence of
was defined as UR [13]. Therefore, the incidence of UR may UR.

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Prolonged catheterization may increase the risk of urinary colporrhaphy, incidence of postoperative UR after VH without
tract infection [8]. For either short- or long-term catheteriza- colporrhaphy should be further investigated. Lastly, the poten-
tion, urinary tract infection rate has been reported to be ap- tial surgeon factor, if any, might make the generalization of
proximately 5% [10]. Such infection prolongs hospital stay; the results difficult. Statistical insignificance of the association
therefore, earlier removal of catheter may be reasonable after of early postoperative day of catheter removal with UR in a
vaginal prolapse surgery. However, day 1 removal appears to single surgeon group may be ascribed to the small number of
increase the risk of UR. Thus, appropriate time of catheter surgeon A patients keeping the catheter ≥2 days.
removal should be decided based on the balance between In conclusion, the present study demonstrated that age and
the incidence of UR and urinary tract infection. Bacteriuria postoperative day of catheter removal are significant risk fac-
can arise from contamination of a urine specimen during col- tors to predict the occurrence of postoperative UR in women
lection, colonization of the urine, or urinary tract infection. who underwent VH with anterior and posterior colporrhaphy
We did not perform a routine urine culture, but pyuria can be for the treatment of pelvic organ prolapse. Women older than
used as the surrogate for urinary tract infection. Fortunately, 63 years had higher incidence of postoperative UR than those
no urinary tract infection was observed in our study subjects of 63 years or less, and day 1 catheter removal could put older
and the incidence of significant pyuria was quite low (1.8%). patients at higher risk of postoperative UR.
In the present study, we identified two independent risk
factors for postoperative UR: age and duration of indwell-
ing catheter. The results might be a guideline for surgeons to Conflict of interest
decide when to remove Foley catheters after vaginal prolapse
surgery. In two randomized studies, no association was found No potential conflict of interest relevant to this article was
between age and perioperative complications after pelvic re- reported.
constructive surgery [3,15]. Strength of our study is to reveal
that age is an independent risk factor for postoperative UR af-
ter VH with anterior and posterior colporrhaphy. Plausible ex- Supplementary materials
planation for the association of old age with postoperative UR
is age-related progressive neuronal degeneration leading to Supplemental Table 1. Correlation analysis of age, opera-
bladder dysfunction. The aging process can increase urethral tion time, postoperative day of catheter removal and dura-
rigidity and decrease detrusor contractility, thus more prone to tion of hospital stay (Spearman rho: ρ)
postoperative UR [5,16,17]. This material can be found via http://ogscience.org/src/sm/
We found that postoperative UR happened quite frequently ogs-59-137-s001.pdf.
(42.9%) in women older than 63 years when indwelling cath- Supplemental Table 2. Comparisons of clinicopathologic
eter was removed as early as one day after VH with anterior characteristics between surgeons for the patients undergoing
and posterior colporrhaphy. Additional multivariate analysis in vaginal hysterectomy with anterior posterior colporrhaphy
women of which indwelling catheter was removed at day 1 for pelvic organ prolapse
(n=105) showed that age was the only independent risk fac- This material can be found via http://ogscience.org/src/sm/
tor (OR, 0.002; 95% CI, 1.015 to 1.165). Therefore, it could ogs-59-137-s002.pdf.
be recommended that indwelling catheter is removed later
than first postoperative day in women older than 63 years.
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