Vol.

42 (3): 578-584, May - June, 2016

ORIGINAL ARTICLE
doi: 10.1590/S1677-5538.IBJU.2015.0256

Prophylactic effects of alpha-blockers, Tamsulosin and

Alfuzosin, on postoperative urinary retention in male patients
undergoing urologic surgery under spinal anaesthesia
_______________________________________________
Ali Akkoc 1, Cemil Aydin 1, Ramazan Topaktas 1, Mahir Kartalmis 2, Selcuk Altin 1, Kenan Isen 1,
Ahmet Metin 3
1
Department of Urology, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey; 2 Department
of Urology, Selahaddin Eyyubi State Hospital, Diyarbakir, Turkey; 3 Department of Urology, Faculty of
Medicine, Abant Izzet Baysal University, Bolu, Turkey

ABSTRACT ARTICLE INFO

______________________________________________________________ ______________________

Purpose: Postoperative urinary retention (POUR) is one of the most common compli- Keywords:
cations after surgical procedures under spinal anaesthesia. Recent studies have shown Adrenergic alpha-Antagonists;
the beneficial effects of alpha-adrenergic blockers in preventing POUR. The aim of this Postoperative Period; Urinary
prospective study was to investigate and compare the prophylactic effects of tamsulo- Retention; Anesthesia, Spinal
sin and alfuzosin on POUR after urologic surgical procedures under spinal anaesthesia.
Materials and Methods: A total of 180 males who underwent elective urologic surgery
were included in this study. The patients were randomly allocated into three Groups. Int Braz J Urol. 2016; 42: 578-84
The Group I received placebo. Patients in Group II were given 0.4mg of tamsulosin
orally 14 and 2 hours before surgery. Patients in Group III were given 10mg of alfuzo- _____________________
sin ER orally 10 and 2 hours before surgery. All patients were closely followed for 24
hours postoperatively and their episodes of urinary retentions were recorded. Submitted for publication:
Results: There were 60 patients in each Group. Their mean age was 35.95±15.16 years. May 06, 2015
Fifteen patients in Group I (25%), 3 patients in Group II (5%) and 4 patients in Group
_____________________
III (6.7%) required catheterization because of urinary retention. In tamsulosin group
and alfuzosin group, there were a significantly lower proportion of patients with POUR Accepted after revision:
compared with the placebo Group (p=0.002 and p=0.006). The beneficial effects of ta- August 18, 2015
msulosin and alfuzosin on POUR were similar between both Groups (p=0.697).
Conclusion: This study suggests that the use of prophylactic tamsulosin or alfuzosin
can reduce the incidence of urinary retention and the need for catheterization after
urologic surgical procedures under spinal anaesthesia.

INTRODUCTION -vomiting, transient neurologic problems, headache,

pruritus and urinary retention (2).
Spinal anaesthesia is a common regional Postoperative urinary retention (POUR) has
anaesthesia technique performed by anaesthesiolo- generally been defined as the inability to pass any
gists since 1898 (1). It has some complications such urine in the presence of a percussible or palpa-
as hypotension, bradycardia, cardiac arrest, nausea- ble bladder after surgery, but the definition varies

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 IBJU | ALPHA-BLOCKERS ON POSTOPERATIVE URINARY RETENTION AFTER SPINAL ANAESTHESIA

widely. POUR is common and represents betwe- in accordance with the Declaration of Helsinki
en 5% to 70% of all surgeries (3). It occurs more and approved by the local ethics committee of
frequently in lower urinary tract, perineal, in- Diyarbakir Training and Research Hospital. All
guinal, orthopaedic, gynecologic, and anorectal patients provided informed consent.
surgeries after spinal anaesthesia. The exclusion criteria were patients who
Urethral catheterization, a mainstay of ini- had severe lower urinary tract symptoms before
tial management for patients with POUR, is asso- surgery (according to AUA-American Urological
ciated with some complications and increases in Association-symptom score), active urinary tract
cost of care (3, 4). Both the health and financial infection, medications that could affect voiding
costs of retention are considerable, because it can function such as alpha-agonists/antagonists and
cause urinary tract infections and necessitate ca- cholinergic/anti-cholinergic drugs, urinary incon-
theterization, which can in turn result in urethral tinency, previous history of lower urinary tract sur-
strictures, prolonged hospital stays, and additional gery and history of neurological, urological or sys-
operations. Therefore, pharmacological therapy is temic disease (such as multiple sclerosis, prostate
viewed as an interesting option for patients deve- cancer, diabetes mellitus).
loping urinary retention following surgery. The patients were submitted to physical
Urinary retention in the postoperative pe- examination, blood analysis, electrocardiogram,
riod has two main causes. The first is mechanical chest X-ray, urinalysis, uroflowmetry and ultraso-
obstruction of lower urinary tract and the second nographic investigation (measurement of prostatic
is altered neural control of the bladder and detru- volume and postvoid residual urine volume). The
sor mechanism, most commonly due to analgesic patients were randomly allocated into three Groups.
drugs (5). Additionally, high sympathetic activity In Group I (placebo), the patients were given two
increases the risk of urinary retention. Therefore, doses of placebo orally 2 and 12 hours before sur-
inhibition of alpha-adrenergic receptors located gery. The patients in Group II (Tamsulosin) were
on the bladder neck and proximal urethra may given 0.4mg of tamsulosin orally 14 and 2 hours
prevent POUR (3). Tamsulosin and alfuzosin are before surgery. The patients in Group III (Alfuzo-
safe selective alpha1-adrenergic receptor blockers sin) were given 10mg of alfuzosin ER (extended
characterized by their favorable side effect profiles release) orally 10 and 2 hours before surgery. The
(6, 7). There is currently little published data on whole patients voided before transfer to the ope-
the incidence and treatment of urinary retention rating area. Ringer’s lactate solution was infused
after spinal anaesthesia in urologic surgery proce- at a rate of 10mL/kg/h during surgery and 30mL/
dures. We think that prophylactic effects of alpha- kg/24h after operation. Surgery was performed un-
-blockers on POUR after urologic surgical pro- der spinal anesthesia using 14-20mg bupivacaine.
cedures under spinal anaesthesia have not been The patients were followed for 24 hours postopera-
investigated adequately. tively. Nonsteroidal anti-inflammatory drugs were
The aim of the present study was to inves- ordered for postoperative analgesia. Opioid analge-
tigate the prophylactic effects of tamsulosin and sics were not applied to any patient in the posto-
alfuzosin on the prevention of urinary retention in perative period. The diagnosis of POUR was proved
male patients after spinal anaesthesia in urologic when the patient had a painful and palpable mass
surgery procedures. in suprapubic area, and was unable to void during
the first 12 hours after surgery. It was confirmed by
MATERIALS AND METHODS emptying of more than 500mL of urine by cathe-
terization. A 14-French Foley catheter was placed
From January 2010 through October 2014, to decompress the bladder of patients who could
a total of 180 male patients aged 18 to 69 years not urinate after surgery. Operation times, patient’s
who underwent elective inguinal, penile, scrotal age, urinary symptom scores of patients and urina-
and perineal surgery under spinal anesthesia were ry retentions were recorded and parameters were
included in this study. The study was performed compared among three Groups.

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 IBJU | ALPHA-BLOCKERS ON POSTOPERATIVE URINARY RETENTION AFTER SPINAL ANAESTHESIA

All statistical evaluations were perfor- effects at 24 hours follow-up. All three patient’s
med by the Statistical Package for Social Scien- experienced vomiting and dizziness. Side effects
ces (SPSS) software for Windows, version 15.0 were mild and did not lead to exclusion of pa-
(SPSS Inc., Chicago, IL, USA). Statistical analy- tients from the study.
sis was accomplished by use of ANOVA (Analy- There was no statistically significant di-
sis of variance), chi-square and Mann-Whitney fference in age, IPSS (International Prostate
U tests with a p-value of less than 0.05 conside- Symptom Score) and operation time between pa-
red significant. tients who developed urinary retention and those
who did not (Table-2).
RESULTS
DISCUSSION
A total of 180 patients who were assig-
ned to placebo Group (Group I, n=60), tamsulo- POUR is a common complication after
sine Group (Group II, n=60) and alfuzosin Group spinal anaesthesia in urologic and other surgical
(Group III, n=60) were included in the analysis. In- procedures. It is a medical emergency requiring
guinal surgery (especially varicocelectomy, n=89) prompt action. The incidence of urinary reten-
was the most frequent surgery in all Groups. The tion after spinal anaesthesia ranges from 0% to
other types of surgical procedures were hydroce- 69% (8). The data on regional anesthesia and its
lectomy (n=29), spermatocelectomy (n=8), epidi- effect on POUR is more consistent in other fields.
dymal cyst excision (n=6), scrotal orchiectomy Spinal anesthesia has been shown to increase ra-
(n=14), inguinal orchiectomy (n=7), orchiopexy tes of urinary retention in orthopaedic, podiatric,
(n=8), peyronie’s disease and congenital penile and hernia surgery (9). POUR causes pain and
curvature surgery (n=15), perineal ectopic tes- discomfort after surgery and catheterization for
tis surgery (n=1), perineal mass surgery (n=1), resolving it, may lead to urethral injury or stric-
lymphangioma circumscriptum surgery (inguinal ture or urinary tract infection and increase cost
and perineal, n=2). The mean age of patients was and work load and hospitalization period (10).
35.95±15.16. No statistically significant differen- Three methods have been used to diag-
ces were found among three Groups in terms of nose POUR: History and physical examination,
age (p=0.819), duration of surgery (p=0.10) and ultrasonographic imaging of bladder and blad-
severity of preoperative urinary symptom scores der catheterization (11). We used two practical
(p=0.995). In Group one, 15 patients required ca- methods for diagnose of POUR: 1-History and
theterization with a mean urine volume of 670mL physical examination (lower abdominal pain and
at catheterization. In Group two, 3 patients re- discomfort and palpation or percussion of blad-
quired catheterization with a 650mL mean urine der in suprapubic area); 2-Bladder catheteriza-
volume. In Group three, 4 patients required ca- tion. Many studies indicate that urine retention
theterization with a 720mL mean urine volume. can be diagnosed when the patient cannot urina-
Thus, 25% of patients in Group I, 5% of patients te at bladder volumes above 400–600mL (12, 13).
in Group II and 6.7% of patients in Group III had The average urine volumes were above 500mL
urinary retention. In tamsulosin Group, there in all of our patients with POUR. We think that
was a significantly lower proportion of patients diagnosis of POUR by history and physical exa-
with POUR compared with the placebo Group mination instead of ultrasonography was one of
(p=0.002). In alfuzosin Group, there was a signi- the limitation of this study.
ficantly lower proportion of patients with POUR Disturbances of micturition are common
compared with the placebo Group, too (p=0.006). in the first 24 hours after spinal anesthesia. There
The beneficial effects of tamsulosin and alfuzosin is a higher frequency of these disturbances after
on POUR were similar in both Groups (p=0.697) bupivacaine than lidocaine spinal anesthesia (2,
(Table-1). Two patients in tamsulosin Group and 14). After administration of spinal anesthesia
one patient in alfuzosin Group showed some side with bupivacaine or tetracaine, the micturition

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 IBJU | ALPHA-BLOCKERS ON POSTOPERATIVE URINARY RETENTION AFTER SPINAL ANAESTHESIA

Table 1 - Clinical features and demographic characteristics of patients in three groups and comparison of all groups
in term of POUR.

Group I Group II Group III ANOVA F Test (F) or chi- p value

(Placebo) (Tamsulosin) (Alfuzosin) square test (X2)
Number of patients 60 60 60
Mean age±SD (year) 34.95±15.21 36.30±15.22 36.60±15.26 F=0.200 0.819
(18-67) (18-69) (18-68)
Pre-operative urinary X2=0.196 0.995
Symptoms* 37 (61.6%) 38 (63.3%) 39 (65%)
No 16 (26.7%) 15 ( 25%) 15 (25%)
Mild Moderate 7 (11.7%) 7 (11.7%) 6 (10%)
Region of surgery
Inguinal 34 (56.7%) 36 (60%) 34 (56.7%)
Penile 6 (10%) 4 (6.7%) 5 (8.3%)
Scrotal 18 (30%) 19 (31.6%) 20 (33.3%)
Perineal 2 (3.3%) 1 (1.7%) 1 (1.7%)
Mean operation time±SD 48.58±12.69 52.28±13.34 (29- 53.63±13.72 F=2.333 0.100
(minute) (27-78) 85) (28-84)
Number of patients with POUR 15(25%) 3(5%) 4(6.7%)
Comparison of Group I and Group II in term of POUR X2=9.412 0.002
Comparison of Group I and Group III in term of POUR X =7.566
2
0.006
Comparison of Group II and Group III in term of POUR X =1.52
2
0.694

*According to AUA (American Urological Association) symptom score.

Table 2 - Demographic data and clinical features of the all patients who developed POUR and those who did not.

POUR (+) (n=22) POUR (-) (n=158) Z Score p Value

Mean Age±SD (years) 38.86±14.558 35.54±15.243 -1.137 0.256

Mean IPSS±SD 3.23±3.161 2.80±4.638 -1.499 0.134

Mean Operation Time±SD (minute) 49.23±11.467 51.82±13±597 -0.798 0.425

reflex is very rapidly eliminated. Detrusor muscle Many factors contribute to the develop-
contraction is restored to normal 7-8 hours ment of POUR. These include history of under-
after the spinal injection. On average, patients lying disease, the direct effects of anesthetic
recover enough motor function to be mobilized agents on the bladder, excessive perioperative
1–2 hours before the micturition reflex returns fluid intake, traumatic instrumentation, pelvic
(2). Kamphius et al. found that motor blockade dissection, diminished awareness of bladder sen-
following bupivicaine spinals lasted 148±76 sation, increased outlet resistance, immobilization
minutes compared to detrusor blockade of after the surgery, postoperative pain and use of
462±61 minutes (15). narcotics, type of anesthesia, duration of surgery,

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 IBJU | ALPHA-BLOCKERS ON POSTOPERATIVE URINARY RETENTION AFTER SPINAL ANAESTHESIA

gender and age (3, 11). The stress response to sur- ment or any other outcome and alpha-blockers,
gery and especially postoperative pain increase cholinergic agents and sedatives as monothera-
sympathetic tone. When ephinephrine is injected pies. A statistically significant association betwe-
intraperitoneally in rats, the intravesical pressure en intravesically administered prostaglandin and
increases without raising urine output, sugges- successful voiding was detected. A statistically
ting that ephinephrine increases internal urethral significant association was detected between
sphincter tone by acting on alpha receptors in cholinergic agents combined with sedative and
the bladder neck (16). So, the sympathetic sti- an improved likelihood of spontaneous voiding
mulation influence the relaxation of the detru- compared with placebo (20).
sor and close the internal urethral sphincter. The The purpose of pharmacologic preven-
resultant stimulation of the alpha receptors in tion of POUR is the increase of detrusor con-
the internal urethral sphincter leads to increased tractility or bladder neck and proximal ure-
pressure on the bladder neck and potentially to thral relaxation. Alpha-adrenergic receptors are
POUR (3). Micturition reflex might be inhibited found in trigone, prostatic urethra and ureters.
by the high sympathetic activity after surgery. These receptors cause contraction of the smooth
Alpha-blocker premedication might have inhibi- muscles in these regions (21). Alpha-adrenergic
tory effect on the elevated sympathetic activity blockers decrease bladder outlet resistance and
and therefore, prevent acute urinary retention facilitate micturation. Several studies found
after surgery. that prophylactic administration of alpha-blo-
Petros and colleagues reviewed 295 in- ckers such as phenoxybenzamine and prazosin
guinal herniorrhaphies in men. They found use significantly decreases the incidence of POUR
of spinal anesthesia, age less than 53 years, and (10). Although all alpha-blocking compounds
perioperative fluid less than 1200mL all signifi- show similar levels of efficacy for lower urina-
cantly reduced the incidence of POUR (17). Lee ry tract symptoms treatment, third generation
and colleagues declared that POUR increases alpha-blockers such as alfuzosin and tamsulosin
with age, with the risk increasing by 2.4 to 2.8 tend to demonstrate improved selectivity for the
times in patients over 50 years of age (18). Al- prostate and bladder (22). Another advantage of
though some studies have reported higher inci- tamsulosin and alfuzosin in the management of
dence of POUR in men compared with women, acute urinary retention is that a therapeutic dose
some studies have reported that there isn’t sig- can be administered at the onset of acute urina-
nificant difference between men and women (3, ry retention (23). The mean time to peak serum
19). In our study, only men were included due to concentration (Tmax) of alfuzosin and tamsulo-
type of surgeries and limited number of female sin are 8 hours and 4-5 hours after an oral dose,
patients. The other limitation of our study was respectively. Alfuzosin and tamsulosin have a
that we did not record perioperative fluid intakes serum half-life (T1/2) of 5 hours and 14-15 hours
of the patient’s. after oral administration, respectively (24). Ma-
There are various methods for prevention dani et al. assessed preventive effect of tamsu-
of POUR, such as induction of local instead of losin on POUR after spinal anesthesia. In this
regional or general anesthesia, restriction of pre- randomized study, 118 patients received 0.4mg
operative fluid intake, use of short acting anes- tamsulosin 14 and 2 hours before and 10 hours
thesia agent, early ambulation of patient’s after after surgery and 114 patients received placebo.
surgery, use of warm compress in suprapubic area They concluded perioperative administration
and use of parasympathomimetic or α-adrenergic of tamsulosin reduced the risk of POUR from
blockers (3, 4). In a review article published in 21.1% to 5.9% (10). In our study, tamsulosin
2010 to investigate the most effective drug for 0.4mg were given orally 14 and 2 hours before
the treatment of POUR in adults, the authors surgery and alfuzosin 10mg were given orally
concluded that no statistically significant asso- 10 and 2 hours before surgery. The effectiveness
ciations were reported between successful treat- of both of them on POUR had equal degree.

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In the present study, 15 of 60 patients 8. Kreutziger J, Frankenberger B, Luger TJ, Richard S, Zbinden
(25%) in the placebo Group had urinary retention. S. Urinary retention after spinal anaesthesia with hyperbaric
3 of 60 patients (5%) in the tamsulosin Group and prilocaine 2% in an ambulatory setting. Br J Anaesth.
4 of 60 patients (6.7%) in the alfuzosin Group had 2010;104:582-6.
9. Wohlrab KJ, Erekson EA, Korbly NB, Drimbarean CD, Rardin
urinary retention and required catheterization.
CR, Sung VW. The association between regional anesthesia
The incidence of POUR was significantly greater
and acute postoperative urinary retention in women
in men who did not receive tamsulosin or undergoing outpatient midurethral sling procedures. Am J
alfuzosin before surgery. The beneficial effects of Obstet Gynecol. 2009;200:571.e1-5.
tamsulosin and alfuzosin on POUR were similar. 10. Madani AH, Aval HB, Mokhtari G, Nasseh H, Esmaeili S,
Shakiba M, et al. Effectiveness of tamsulosin in prevention of
CONCLUSIONS post-operative urinary retention: a randomized double-blind
placebo-controlled study. Int Braz J Urol. 2014;40:30-6.
This study suggests that preoperative ta- 11. Chen J, Matzkin H, Lazauskas T, Lelcuk S, Braf Z.
msulosin or alfuzosin administration reduces the Posthernioplasty urinary retention: a noninvasive work-up
incidence of postoperative urinary retention and for prediction. Urol Int. 1993;51:243-5.
the need for catheterization after surgeries under 12. Pavlin DJ, Pavlin EG, Gunn HC, Taraday JK, Koerschgen
ME. Voiding in patients managed with or without ultrasound
spinal anaesthesia. Therefore, the use of preope-
monitoring of bladder volume after outpatient surgery.
rative tamsulosin or alfuzosin can be recommen-
Anesth Analg. 1999;89:90-7.
ded in adult male patients who will undergo uro- 13. Mulroy MF, Salinas FV, Larkin KL, Polissar NL. Ambulatory
logic surgery under spinal anaesthesia. surgery patients may be discharged before voiding after
short-acting spinal and epidural anesthesia. Anesthesiology.
2002;97:315-9.
CONFLICT OF INTEREST 14. Lanz E, Grab BM. Micturition disorders following spinal
anesthesia of different durations of action (lidocaine 2%
None declared. versus bupivacaine 0.5%). Anaesthesist. 1992;41:231-4.
15. Kamphuis ET, Ionescu TI, Kuipers PW, de Gier J, van Venrooij
GE, Boon TA. Recovery of storage and emptying functions of
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22. Agrawal MS, Yadav A, Yadav H, Singh AK, Lavania P, Jaiman 24. Lee M. Alfuzosin hydrochloride for the treatment of
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23. Altarac S. Alpha-adrenergic blockers as a support in Correspondence address:
the treatment of acute urinary retention. Lijec Vjesn. Ali Akkoc, MD
2006;128:233-7. Department of Urology
Gazi Yasargil Training and Research Hospital
Diyarbakir, Turkey
Fax: + 90 412 258-0070
E-mail: [email protected]

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