Comprehensive perioperative management: Prevention and treatment strategies for catheter-related bladder discomfort in urological surgery patients

Abstract

Indwelling urinary catheterization, which is widely used in urological surgeries, predisposes patients to complications such as catheter-associated urinary tract infection, urethral trauma, and catheter-related bladder discomfort. Catheter-related bladder discomfort presents as suprapubic burning, dysuria, restlessness, or delirium; however it remains underrecognized in clinical practice, leading to suboptimal management during surgery. This narrative review summarizes the current evidence relating to the pathogenesis of catheter-related bladder discomfort, which is primarily associated with urothelial injury, muscarinic receptor–mediated detrusor overactivity, and neurogenic inflammation. In addition, the review identifies high-risk factors, including male sex, catheter diameter ≥18 Fr, and transurethral procedures. We highlight the need for uniform approaches to perioperative management, including preoperative pharmacoprophylaxis, intraoperative interventions, and postoperative therapies. Implementing these evidence-based approaches is essential to mitigate the incidence of catheter-related bladder discomfort and improve recovery and surgical outcomes in urological patients.

Introduction

With the increasing use of indwelling urinary catheters, catheter-related bladder discomfort (CRBD) has emerged as an important factor affecting postoperative recovery. Studies have reported the incidence of CRBD between 47% and 90% following urological surgery. ¹ The symptoms of CRBD include suprapubic discomfort, a burning sensation in the urethra, and symptoms similar to those of overactive bladder syndrome, including frequent urination and urgency, with or without urge urinary incontinence. ² These symptoms may cause patients to experience pain and restlessness, thereby increasing the risk of postoperative complications such as urinary tract infections and bladder injuries. ³ CRBD not only prolongs recovery period and hospital stay but also reduces the quality of recovery and increases the workload of medical staff. Severe CRBD may cause severe vocal cord reactions and limb tremors, and some patients may attempt to remove the catheter, creating additional safety concerns. Moreover, CRBD may also lead to serious complications including agitation upon waking up and postoperative delirium, among others, further complicating the recovery process. ⁴

Therefore, treatment and intervention of CRBD are of crucial importance. Various pharmacological interventions for CRBD, including anticholinergic drugs, anesthetics, antiepileptic drugs, and analgesics, have been investigated and applied in clinical settings. ⁵ For instance, Singh et al. ⁶ reported that bladder lavage with 0.01% lidocaine (100 mg dissolved in 1 L normal saline) 30 min before the end of surgery reduced the incidence of moderate to severe CRBD by 52%. Kim et al. ⁷ demonstrated that intravenous lidocaine injection reduced the incidence of moderate to severe CRBD by 41%. Furthermore, Lin et al. ⁸ reported that bladder lavage with 0.05% lidocaine (25 mL of 2% lidocaine dissolved in 1000 mL normal saline) within the first 2 hours after surgery reduced the incidence of moderate to severe CRBD by approximately 80%. Based on currently available clinical evidence, although drug treatment for CRBD is effective, clear clinical standards or guidelines regarding optimal dosage and administration routes remain lacking. Notably, current drug regimens primarily focus on specific surgical stages, namely preoperative, intraoperative, and postoperative stages; however they fail to provide comprehensive and continuous perioperative management.

This narrative review addresses the pathogenesis, risk factors, perioperative management, preventive and therapeutic pharmacological approaches, and nonpharmacological strategies for CRBD. It aims to alleviate CRBD symptoms, improve postoperative comfort and satisfaction, shorten hospital stays, and promote early recovery. Furthermore, it provides a reference for integrating comprehensive perioperative management into enhanced recovery after surgery protocols, significantly improving quality of care and optimizing medical resource utilization.

Pathogenesis

Currently, the mechanism of CRBD is not completely understood, and the factors contributing to its occurrence are summarized in Figure 1.

Figure 1.

Pathogenesis and risk factors for CRBD. CRBD: catheter-related bladder discomfort.

Abnormalities in the central and peripheral nerves, particularly bladder afferent nerves, can lead to overactive bladder symptoms. The nerves innervating the bladder are predominantly composed of visceral nerves, including sympathetic and parasympathetic nerves. Among them, the sympathetic nerves are distributed around the bladder wall, whereas the pelvic nerves, composed of parasympathetic nerves, innervate the detrusor muscle of the bladder. The cerebral cortex processes bladder sensory input, stimulating pelvic nerve efferents and suppressing hypogastric and pudendal nerves, thereby resulting in detrusor contraction and urination. The pathogenesis of CRBD is primarily associated with the activation of muscarinic M2 and M3 receptors. ⁹ Indwelling catheters can damage the urothelium, expose sensory nerves to harmful stimuli, and trigger the release of acetylcholine. ¹⁰ Acetylcholine, a neurotransmitter, activates bladder sensory nerves through muscarinic receptors. The M3 receptor promotes direct bladder contraction, whereas the M2 receptor contributes to indirect contraction, ultimately leading to detrusor overactivity. ¹¹ Together, these factors cause the detrusor muscle to become overly active. In addition, prostaglandin E2 (PGE2) is produced in the bladder and acts on smooth muscle, inducing contractions. Another study demonstrated that inflammatory stimulation caused by catheterization increases PGE2 synthesis due to increased activation of cyclooxygenase-2 (COX-2). ¹² PGE2 can directly activate C-type fibers in the bladder, thereby increasing the input impulse. Additionally, PGE2 can increase intracellular Ca²⁺ concentration in bladder smooth muscle cells through its specific receptor, leading to depolarization and generation of action potentials, which ultimately results in the occurrence of CRBD symptoms. ¹³

Detrusor smooth muscle exhibits large spontaneous contractions and enhanced impulse transmission between myocytes, inducing involuntary detrusor contraction and overactive bladder symptoms. When the detrusor muscle begins to contract, it stimulates the stretch receptors within the bladder wall, triggering a reflex that further causes the detrusor muscle to contract. Frequent detrusor contractions can cause emotional disturbances in patients, resulting in a strong sense of discomfort. ¹⁴

In addition, inflammation may contribute to the occurrence of overactive bladder symptoms. The catheter not only damages the urothelium but also triggers an inflammatory response and increases prostaglandin secretion. ¹⁵ Elevated prostaglandin levels further enhance the contraction of the bladder smooth muscle, thereby triggering or aggravating CRBD symptoms. Meanwhile, capsaicin-sensitive C fibers are activated under conditions of inflammation, obstruction, and mucosal damage. These conditions can increase prostaglandin levels in the bladder, inducing detrusor muscle contraction and further aggravating CRBD symptoms.

Additionally, several external factors have been identified as contributors of CRBD.

Physiological factors. The male urethra is longer than that of females and has more physiological stenosis and curvature. In particular, the subpubic curvature is relatively fixed and difficult to straighten, making it more prone to injury during catheterization. Most older patients also have benign prostatic hyperplasia and urethral stricture, which are important contributors to the development of CRBD.

Iatrogenic factors. During catheterization, uneven application of lubricant, nonstandard catheterization techniques, improper selection of catheter models, and adverse stimulation by foreign bodies can disrupt the barrier function of the urethral mucosa. Additionally, surgical procedures can damage the bladder wall barrier, thereby inducing urethral spasms. These factors exacerbate urethral discomfort and increase the incidence and severity of CRBD. Studies have shown that excessive water injection into the balloon of the urinary catheter can cause excessive pressure at the internal urethral orifice, which is another important contributor to the development of CRBD. ⁷

Anesthetic factors. Most patients have no psychological adaptation time following induction of general anesthesia. This increases pain sensitivity after awakening compared with the preoperative state, and the postoperative pain intensity is significantly higher than the preoperative physiological state, thereby exacerbating the severity of postoperative CRBD. ¹⁶

Internal organ diseases. Studies have shown that processing of sensory stimuli from internal organs requires neural pathways linking afferent excitability with the emotional and cognitive centers in the brain. These core neural circuits depend on integration of the neuroendocrine system, immune system, and sensory afferents, typically requiring bidirectional communication to maintain visceral homeostasis through regulation of the brain–bladder axis.

High-risk factors

By understanding the risk factors associated with CRBD, healthcare professionals can identify individuals at elevated risk, optimize catheter selection and management processes, and implement proactive preventive measures. This comprehensive approach has the potential to markedly reduce the incidence of postoperative CRBD as well as the level of patient distress, as illustrated in Figure 1.

Related to surgery

Given the potential for postoperative irritation of the bladder or adjacent tissues, the inflammatory response to surgery, when superimposed on catheter-induced irritation, represents a significant contributing factor to the development of CRBD. ¹⁷ Studies have shown that patients undergoing lower abdominal, pelvic, and urologic surgeries have a significantly higher risk of developing CRBD, with an incidence rate approximately 30% higher than that observed in patients undergoing nonurologic surgeries. ¹⁵ The incidence of CRBD is significantly increased after transurethral resection of bladder tumor (TURBT), ¹⁸ which may be associated with direct trauma to the bladder tissue, irritation from postoperative chemotherapeutic infusions, and local discomfort and inflammation resulting from prolonged catheterization.

Furthermore, intraoperative maintenance of anesthesia had a significant effect on the incidence of CRBD in male patients. ¹⁴ Total intravenous anesthesia (TIVA) was used significantly more often than other anesthetic techniques. This observation suggests that TIVA maintenance may be a risk factor for CRBD development in male patients under general anesthesia. ¹⁹ Urethral catheterization, as an invasive procedure, may aggravate irritation and damage to the urethral mucosa, thereby increasing the risk of CRBD.

Related to sex

Studies have shown that male patients undergoing urologic surgery have a much higher prevalence of CRBD than female patients, with an incidence approximately 44% higher. ¹⁷ This difference can be attributed to the anatomical features of the male urethra, which is comparatively longer and more constricted, with multiple curvatures and narrowings. ¹⁵ Such anatomical configuration may increase irritation of the urethra during catheterization. In particular, the subpubic curvature is difficult to straighten and likely to be injured during catheterization. In addition, prostatic hyperplasia and urethral strictures, which are common in older patients, are important factors for the development of CRBD. ²⁰ Furthermore, advanced age is an important risk factor for prostate enlargement, which can complicate catheterization and increase the likelihood of CRBD. ²¹ Consequently, older male patients should be recognized as a high-risk group for CRBD.

Urinary catheters

Foley catheters are commonly used in urologic procedures, and a catheter diameter of ≥18 Fr is considered an independent predictor of moderate to severe CRBD. ¹⁷ Catheters with increased thickness are more closely associated with pain and urethral injury. ²² Consequently, patients undergoing such procedures are predisposed to urinary tract infections and have a higher risk of CRBD. Anesthesia induces relaxation of the penile muscles in males, leading to an increase in penile caliber compared with the nonanesthetic state. ²³ To prevent intraoperative urinary leakage, which may impair the surgical field of view, a large urethral catheter is typically used during intubation. However, this approach is associated with a higher risk of postoperative mucosal injury, edema, and development of CRBD. Studies have shown an increased likelihood of moderate or severe CRBD after surgery in patients with 18 Fr catheters, thereby highlighting the need for clinicians to carefully consider catheter size to mitigate risk. ²⁴ Furthermore, catheter overinflation combined with suboptimal external fixation height may increase discomfort and the incidence of catheter-related behaviors such as pulling, which can contribute to the development of postoperative CRBD.

Perioperative management

Medicinal interventions

Preoperative drug management of CRBD has been shown to improve clinical outcomes.

Catheter insertion causes compression of the bladder neck and internal urethral orifice by the catheter balloon, which can trigger bladder spasms presenting as a strong urge to void. These symptoms resemble those of overactive bladder syndrome and are primarily mediated by involuntary detrusor muscle contractions via muscarinic receptors. ⁹ Prophylactic or therapeutic treatment with antimuscarinic agents has demonstrated positive effects in the management of CRBD. These drugs are considered first-line pharmacotherapy for this condition. Nonselective antimuscarinics, such as tolterodine and oxybutynin, are available, whereas selective agents, including solifenacin, target specific receptor subtypes. ¹⁶ However, their use is limited by central anticholinergic adverse effects, including blurred vision, dry mouth, postoperative nausea, and tachycardia. Mirabegron, a β3 agonist, is an alternative to antimuscarinics. It effectively improves overactive bladder symptoms, has a favorable safety profile, and offers a viable therapeutic option for CRBD management. ²⁵

Commonly used muscarinic antagonists in general anesthesia include scopolamine butylbromide, atropine, and penehyclidine hydrochloride. Among these, butylscopolamine exhibits high affinity for the M2 and M3 receptor subtypes and has been clinically proven effective against CRBD. ²⁶

Lidocaine is an amide-type local anesthetic with multiple pharmacological properties, including analgesic, antimuscarinic, anti-inflammatory, and antihyperalgesic effects. Its proposed mechanisms for CRBD suppression involve antagonism of the N-methyl-D-aspartate (NMDA) receptor; anti-inflammatory actions on histamine, prostaglandins, and bradykinin; inhibition of C-fiber activity and dorsal horn neuronal excitability; and suppression of spinal visceral motor neurons.^6,8

Notably, studies in renal transplant recipients have found that intrathecal morphine significantly reduces the incidence of CRBD within 24 h postoperatively compared with erector spinae plane block. ²⁷ Although all opiate analgesics can reduce symptoms of CRBD, agents such as fentanyl and sufentanil are commonly used. However, their usefulness is limited by adverse effects mediated by mu-opioid receptor, including nausea, vomiting, and respiratory depression, particularly during anesthetic recovery, where they have suboptimal safety profiles.

In conclusion, preoperative medication is effective for the prevention and management of CRBD in urological patients. Although clinicians should be aware of potential drug-related side effects, the primary objective of preoperative medication is to achieve the greatest possible therapeutic efficacy and minimize adverse reactions. Furthermore, information regarding the postoperative medication regimen, including repeated dosing and dosage adjustments, is essential for assessing the effectiveness of continuous treatment, as shown in Figures 2 and 3.

Figure 2.

Evidence-based perioperative management strategies.

Figure 3.

Mechanisms of pharmacologic agents.

Nonpharmacological measures

Studies have shown that nonpharmacological measures are feasible for the intraoperative management of CRBD in patients undergoing urological surgery. Bilateral ultrasound-guided pudendal nerve block at the entrance of the vaginal (Alcock) canal has been found to significantly reduce the incidence of moderate to severe CRBD 4 h after transurethral holmium laser prostatectomy. ²⁸ Pudendal nerve block is effective in reducing CRBD in urological surgery; however, it requires specialized skills and postoperative monitoring to minimize the risk of complications. Although downsizing catheter balloons improves cost-effectiveness and ease of use, it has been associated with an increased risk of leakage and accidental extubation. ²⁹ Therefore, a full assessment of the advantages and disadvantages is imperative. Integrating patient preferences with guidance from healthcare professionals has been shown to improve the management of CRBD, as presented in Figure 2.

Postoperative management

Postoperative management of CRBD focuses on reducing the severity of the condition. Optimizing various catheter-related parameters has emerged as a promising nonpharmacological approach to mitigate CRBD. ²⁹ Decreasing balloon volume has been shown to significantly reduce CRBD symptoms and pain. This simple, noninvasive adjustment improves patient comfort and maintains catheter function. Transcutaneous electrical nerve stimulation (TENS) and acupuncture have been shown to improve CRBD symptoms through neuromodulatory effects. TENS delivers mild electrical impulses to specific nerve pathways, thereby inhibiting bladder-injurious sensory afferents and reducing discomfort. Studies have demonstrated that acupoint-based TENS therapy can effectively relieve CRBD symptoms and reduce the need for analgesic and anticholinergic medications. ³⁰ This technique is particularly suitable as a complementary intervention for patients at high risk of postoperative CRBD because it is noninvasive and lacks systemic adverse effects. Furthermore, pudendal nerve block has emerged as a promising therapeutic modality for CRBD management, especially in patients with severe CRBD who do not respond to conventional medications. ³¹

Conclusion

Urinary catheters are widely used in urological surgeries; however, their use may lead to CRBD. This review evaluated the pathogenesis, risk factors, perioperative management, preventive and therapeutic drugs, and nonpharmacological strategies for CRBD. Although current studies mainly focus on specific stages of treatment, such as preoperative, intraoperative, or postoperative period, further exploration of comprehensive perioperative management is needed. Many studies have focused on high-risk surgeries, such as transurethral resection of the prostate (TURP) and TURBT, as these surgeries are closely associated with CRBD. This emphasis may obscure the impact of other urological surgeries. To effectively manage CRBD in urological patients, future studies should adopt a comprehensive perioperative management strategy, spanning preoperative preparation to postoperative recovery, to more effectively reduce CRBD and improve surgical quality and recovery outcomes.