The impact of postoperative pain and pain management following sacrospinous ligament fixation on trial of void failure

Abstract

Postoperative urinary retention (POUR) and the need to be discharged with a urinary catheter after trial of void (TOV) failure are significant sources of distress for patients. These patients may also be at higher risk of postoperative urinary tract infections. Concomitant midurethral sling, anterior repair, and intraoperative blood loss have been shown to increase the risk of TOV failure following surgery for pelvic organ prolapse. Postoperative pain has not been previously investigated as it relates to TOV failure. This study assessed whether pain and pain management affected TOV failure in patients who underwent sacrospinous ligament fixation (SSLF). We hypothesized that patients with greater postoperative pain are more likely to have POUR. This was a retrospective cohort study of patients who underwent SSLF from January 2014 to September 2021 at five hospitals within a health system. Patients were identified using CPT code 57282. They were included if they were over the age of 18 and underwent SSLF; and were excluded if they did not undergo a trial of void on postoperative day 1 and did not have pain scores or pain medications recorded electronically. Demographics and intraoperative characteristics were collected based on previous studies. Our primary outcome was the impact of mean and highest verbal pain score on TOV failure. Secondary outcomes were the impact of oral morphine equivalents, acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) per hour, time from last pain medication, and whether pain medication was scheduled on TOV failure. Statistical significance was set at a p-value of 0.05. Statistical analyses were completed using Mann-Whitney U and Fisher’s Exact tests. Two hundred and eighteen (218) patients were identified. Of those, 29 were duplicates and 47 met exclusion criteria. One hundred and forty-two (142) patients were included in the analysis, of which 26.8% failed TOV on postoperative day 1. Age and concomitant hysterectomy were associated with TOV failure (p=0.05 and p=0.003). Other demographic and intraoperative factors were not significantly different. Mean and highest verbal pain scores were not significantly different (mean: 3.00 vs. 2.70, p=0.24; highest: 6.00 vs. 6.00, p=0.36). NSAID use per hour was higher in patients who passed their TOV (60.15 vs. 0.0, p=0.03), and patients whose NSAIDs were scheduled were more likely to pass their TOV versus those whose NSAIDs were given as needed or were not given at all (p=0.02). All other secondary outcomes were not significantly different. In patients who underwent SSLF, there was no difference in pain scores between the two groups. Scheduled NSAID administration and NSAIDs consumed per hour postoperatively were significantly associated with higher TOV pass rates. This suggests that the anti-inflammatory properties of NSAIDs may help decrease POUR.