Urinary Retention in Orthopaedic Surgery: An Evidence-based Algorithm

Postoperative urinary retention (POUR), the inability to urinate spontaneously after surgery, affects up to 43% of orthopaedic patients and can lead to pain, bladder injury, urinary tract infections, increased healthcare costs, and delayed rehabilitation. POUR arises from decreased neurologic signaling, reduced bladder sensation and contractility, or mechanical obstruction. Risk factors include advanced age, prior urinary retention, comorbidities (eg, benign prostatic hyperplasia, diabetes, renal dysfunction), anesthesia type, perioperative opioid use, and catheterization. Despite its prevalence, standardized management approaches for POUR are lacking within orthopaedic literature. We propose a structured, evidence-based protocol to be used by orthopaedic surgeons that is centered on specific time and bladder volume thresholds to guide interventions including noninvasive techniques to promote spontaneous voiding, bladder scans, straight catheterization, placement/removal of indwelling catheters, and urology consultation for persistent POUR. The protocol aims to reduce complications, such as infections and bladder injury, by addressing patient- and procedure-specific risk factors, particularly in high-risk groups such as pediatric patients with neuromuscular conditions and geriatric patients undergoing hip fracture fixation.