British Journal of Urology (1997), 80, 554–556
A prospective, randomized trial comparing continuous bladder
drainage with catheterization at abdominal hysterectomy
S . P. DO BBS , S .R. JAC KS ON, A .M . WI LS O N, R.P. M APL E THO RPE and R.H . H AM MO ND
Department of Obstetrics and Gynaecology, Queen’s Medical Centre, Nottingham, UK
Objective To compare the infection rate and post-
operative morbidity between in-dwelling urinary cath-
eterization and ‘in-out’ catheterization at the time of
routine total abdominal hysterectomy.
Patients and methods The study comprised 100 patients
who were blindly randomized to have either an
indwelling Foley catheter or an ‘in-out’ catheterization
at the time of surgery. Follow-up data on the retention
of urine, urinary symptoms and infection were
obtained.
Results Of the 95 patients with complete data, 36% of
those undergoing in-out catheterization had urinary
retention after operation, requiring bladder emptying,
Introduction
Total abdominal hysterectomy is the most common
major gynaecological operation performed; 20% of
women will have undergone a hysterectomy by the age
of 50 years [1]. With the advent of minimally invasive
surgery, most common surgical practices have been
re-evaluated, with a greater emphasis on shorter patient
stay after surgery. One of the main concerns about early
discharge after abdominal hysterectomy is bladder func-
tion [2]. Bladder catheterization is traditionally advo-
cated because patients are unable to increase the intra-
abdominal pressure to aid voiding because of the abdomi-
nal wound, thus increasing the risk of bladder atony
from overdistension. Urinary retention, causing bladder
atony, may increase the long-term morbidity through
increased risk of infection, detrusor instability and void-
ing diculties [3]. Prolonged indwelling urinary cath-
eterization may be associated with an increased risk of
urinary tract infection (UTI), increasing patient mor-
bidity and potentially prolonging the hospital stay [4].
Urinary tract infections associated with indwelling cath-
eterization at the time of gynaecological laparotomy are
reportedly as high as 43% [5]. The objective of this study
was to compare the patient morbidity of an indwelling
Accepted for publication 20 May 1997
554
compared with 4% of those receiving an indwelling
catheter (P<0.001). In addition, 29% of the cath-
eterized group had urinary tract bacteriuria compared
with 13% of the uncatheterized group (P<0.025).
Conclusion This randomized controlled trial showed that
in-out urinary catheterization at the time of routine
abdominal hysterectomy was associated with a sig-
nificantly higher incidence of post-operative urinary
retention compared with in-dwelling catheterization,
and may have implications for long-term bladder
function.
Keywords Hysterectomy, catheter, retention of urine
catheter with ‘in-out’ urinary catheterization after rou-
tine total abdominal hysterectomy for benign disease.
Patients and methods
Permission to undertake the study was obtained from
the hospital ethics committee. Patients were randomized
by random allocation of a number before the onset of
the trial; allocated numbers were sealed in an envelope,
which was opened at the time of surgery. Before oper-
ation, 100 women undergoing total abdominal hyster-
ectomy for non-malignant reasons were approached and
consent obtained for participating in the trial. All patients
recruited were under the care of one consultant (R.H.H.).
Before surgery, the patients were specifically asked about
urinary tract symptoms, e.g. frequency of micturition,
urgency and stress incontinence. Patients were then
blindly randomized to either continuous indwelling blad-
der catheterization or an ‘in-out’ catheterization by
selecting a sealed envelope which was opened in the
operating theatre. All patients received intravenous
prophylactic antibiotics at the induction of general
anaesthetic and again 6 h after surgery (augmentin,
1.2 g). Patients allergic to penicillin received alternative
regimens.
Patients were catheterized in theatre under general
anaesthetic using aseptic methods. Patients randomized
to indwelling bladder drainage had a silastic Foley
© 1997 British Journal of Urology
 CO NTI NUO US BL ADD ER DRAI NA GE OR CATHE TE RI ZATIO N AT A BDO MI NAL H YS TE RE CTOM Y
catheter (14 F) inserted and this was removed the night
after surgery (about 36 h after operation). If patients in
this group had urinary retention, an indwelling catheter
was inserted for a further 24 h. Patients randomized to
bladder emptying were ‘in-out’ catheterized with a dis-
posable female catheter; patients in this group who felt
the need to pass urine but were unable to, or had not
passed urine by 12 h after surgery, had a further bladder
quill. This was repeated 12 h later, if required, when a
Foley catheter was inserted for 24 h. All patients had a
MSU checked for culture on the second post-operative
day; if patients had a positive MSU, appropriate anti-
biotics were prescribed.
The outcome was assessed as immediate post-operative
urinary tract symptoms, urinary tract bacteriuria
(defined as a positive culture >105 organisms/mL), post-
operative pyrexia >38°C and urinary retention or the
inability to pass urine 12 h after surgery. These data
were normally distributed and thus compared using the
chi-squared test.
Results
Of the 100 patients recruited, 95 had complete follow-
up data; the patients’ demographic characteristics are
listed in Table 1. There was no statistical di
erence
between patient age, weight, smoking habit and pre-
operative urinary symptoms and the indications for
surgery were similar (Table 1). There were no major
urinary tract or surgical complications after
hysterectomy.
After surgery, 17 (36%) of the patients randomized to
‘in-out’ catheterization required further bladder empty-
ing (Table 2); of these, seven (15%) needed an indwelling
Foley catheter for repeated urinary retention, which was
removed 24 h after catheterization in all seven patients
with no subsequent urinary retention. Two (4%) patients
with an indwelling catheter had urinary retention after
catheter removal; both patients were recatheterized for
Table 1 Patient demographics and indications for total abdominal
hysterectomy
Continuous bladder Bladder quill
drainage (n=48) (n=47)
Mean age (years) 45 42.6
Mean weight (kg) 67.1 64.3
Smokers (%) 35 44
Reason for surgery (n [%])
Menorrhagia 32 (66) 29 (62)
Fibroids 5 (10) 6 (13)
Dysmenorrhoea 6 (13) 5 (10)
Other reasons 5 (10) 7 (15)
© 1997 British Journal of Urology 80, 554–556
555
Table 2 Post-operative measurements
Catheterized Not catheterized
(n=48) (n=47) P*
Retention of urine 2 (4) 17 (36) <0.001
Pyrexia >38°C 17 (35) 15 (32) <0.5
Infected MSU 14 (29) 6 (13) <0.025
Post-operative 11 (23) 7 (15) <0.1
urinary symptoms
*Chi-square test.
24 h and had no further urinary retention after catheter
removal. The di
erence in urinary retention between the
groups was significant (P<0.001). Both groups had a
high incidence of post-operative pyrexia (Table 2).
There was also a significantly higher incidence of
bacteriuria in the catheterized compared with the non-
catheterized group (Table 2). The true incidence of symp-
tomatic UTI is unknown, as all patients with significant
bacteriuria were treated with appropriate antibiotics.
Eleven of the 48 patients (23%) in the catheterized group
complained of urinary symptoms immediately after sur-
gery, compared with seven of 47 (15%) in the non-
catheterized group (P<0.1).
Discussion
Of patients in the in-out catheterization group, 36% had
urinary retention in the first 12 h after surgery, requiring
a bladder quill, and seven (41%) had further urinary
retention requiring an indwelling catheter. If this group
of patients had not been identified early, chronic overdis-
tension of the bladder could have occurred, resulting in
dysfunctional bladder activity with a long-term increase
in morbidity from urinary infection and voiding di-
culties. It has been suggested that post-operative urinary
retention is influenced by post-operative analgesia, par-
ticularly the use of patient-controlled analgesia [6], as
this may remove the normal desire for micturition. In
our institution, most patients undergoing routine total
abdominal hysterectomy are given patient-controlled
analgesia. Studies have shown that continuous bladder
drainage at the time of routine vaginal hysterectomy
has no benefit over bladder emptying [7], but in abdomi-
nal surgery there is the additional problem of abdominal
muscular pain when the intra-abdominal pressure is
increased during voiding. This factor, coupled with the
decreased sensation for voiding due to analgesia, suggests
that an indwelling catheter in the immediate post-
operative period will help to prevent long-term morbidity
from bladder atony.
It has been estimated that the risk of UTI associated
with indwelling catheterization is 5–10% per day of
556 S. P. DO BBS et al.
catheterization [4] and that the commonest cause of UTI
in hospital is urinary catheterization [8]. By instituting
a protocol of catheterization for the immediate post-
operative period (about 36 h), we aim to overcome the
immediate danger of post-operative urinary distension
whilst minimizing the risk of developing a UTI. Although
there is no comparable study, a retrospective study of
949 pelvic laparotomies in which there was no cath-
eterization reported a UTI rate of 4.1% [9]. Studies
examining at post-operative UTI vary in diagnostic cri-
teria and patient selection, and are thus dicult to
interpret, but in the published trials the infection rates
vary from 5% to 43% [5,10–12].
Indwelling urinary catheterization for total abdominal
hysterectomies are not associated with any increase in
long-term urinary symptoms [2]. Although the incidence
of bacteriuria was significantly higher in the indwelling
catheter group than in the ‘in-out’ group, all patients
routinely received prophylactic antibiotics at surgery.
This would decrease the overall incidence of UTI from
contamination at the time of catheterization; a post-
operative UTI when adequately managed is unlikely to
lead to a long-term increase in patient morbidity.
In conclusion, this study illustrates that for total
abdominal hysterectomy, short-term, indwelling urinary
catheterization carries a low risk of patient morbidity
compared to ‘in-out’ urinary catheterization, which
incurs a significantly higher incidence of post-operative
urinary retention.
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Authors
S.P. Dobbs, MRCOG, Registrar.
S.R. Jackson, MRCOG, Registrar.
A.M. Wilson, Senior House Ocer.
R.P. Maplethorpe, Senior House Ocer.
R.H. Hammond, FRCS(Ed), MRCOG, Consultant.
Correspondence: Mr S.P. Dobbs, Department of Obstetrics and
Gynaecology, Leicester Royal Infirmary, Leicester LE1 5WW,
UK.
© 1997 British Journal of Urology 80, 554–556