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Urinary problems and inguinal hernia surgery

INGUINAL HERNIA SURGERY

Over 60 000 primary inguinal hernia repairs are carried out in England each year. Most of these are in men. Urinary retention, that is the inability to pass urine, after groin hernia surgery is not uncommon. The reported incidence varies from less than 5% to nearly 25%. The risk of urinary retention increases with age. It is also more if patients have any urinary symptoms already.

Why is it important?

Urinary retention may result in some patients requiring catheterisation and spending longer in the hospital. In some cases, patients may require further surgical procedures to allow them to pass urine again.Urinary retention is one of the most common causes of delayed discharge after groin hernia surgery.

Why do patients get urinary retention after hernia surgery?

Patients may develop urinary problems after inguinal hernia surgery as a result of overstimulation of muscle in the bladder neck and prostate causing an obstruction.There are some drugs that can block stimulation of these muscles.
These drugs are already used for treating urinary symptoms in men. They are known as alpha-blockers and the commonest used one in use in the UK is Tamsulosin.

 

Can drugs help prevent urinary retention?

A study published in the American Journal of Surgery last year by Clancy and colleagues, from Ireland, has suggested drugs might help.

They conducted a meta-analysis which involved pooling data from 5 previous studies that had compared treatment with an alpha-blocking drug to no treatment at all for patients undergoing open groin hernia surgery under general and spinal anaesthetic.

Their study concluded that the use of the alpha-blocking drug reduced the risk of postoperative urinary retention by just over 20%. There were limitations to this study, not all the blocking drugs were the same in each study. The studies included were quite small and comprised only 456 patients it total. The techniques of hernia repair differed between some of the studies. The type of anaesthetic used also differed between some of the studies.

 Alpha-blocking drugs can have side effects. The commonest side effect is low blood pressure on standing or a headache. These side effects were found to be uncommon.

Despite the shortcomings, this is an interesting study. A larger study in older men needs to be carried out before any definitive recommendation can be made about the routine use of alpha-blockers in patients undergoing hernia surgery.

All patients should certainly be warned of the risks of urinary retention after hernia surgery.

 

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Preventing risk in hernia surgery

In a recent article published in the Daily Telegraph, the president of the Royal College of Surgeons has stirred up a mini-controversy. He suggested that policies of not operating on patients for planned procedures who have problems such as obesity and/or who smoke were “draconian and discriminatory”. This drew a response from Mr Windsor on behalf of the British Hernia Society. Mr Windsor stated that “The key to good surgical outcomes is to understand patients and tailor surgery to their needs. Part of that process involves optimizing their health and clinical condition”

What are the risk factors?

There is plenty of evidence about risk factors for hernia surgery. Smoking, obesity, and diabetes are probably the most significant.

Many UK plastic surgeons had a policy not to carry out elective, non-cancer operations in patients who continue to smoke because of the increased risk of complications. Most other surgical specialties have not taken the same stance despite there being evidence of poorer outcomes in those patients who do continue to smoke.

Obesity is also associated with poorer surgical outcomes in hernia patients. The surgery can be more challenging. There are also greater risks of general postoperative complications such as wound infection or breakdown as well as recurrent herniation.

The numbers of patients suffering from diabetes are increasing. For many, the development of diabetes is directly related to diet and obesity. There is good evidence that dietary control leading to weight loss can improve diabetes and diabetic control. Patients with diabetes are more likely to develop complications following hernia surgery. Better control of diabetes before an operation is associated with fewer risks of complications.

Reducing risk

Nobody would deny a patient an urgent or emergency operation based on whether or not they smoke, are overweight or have diabetes. These patients need an operation often to save life or prevent a more serious complication. In these circumstances, we can accept the additional risks that their smoking habits, obesity or diabetes may bring.

But if we have the chance to reduce those risks before an elective or planned hernia operation we should do so. The burden of a potentially preventable complication from a planned operation may be considerable not only for the patient but for their surgeon as well.

Is it fair for us to simply say “go away, lose weight or stop smoking before we operate”?.
If we do so we must also give advice to patients about the issues and the risks that may ensue. We should also help patients with achieving weight loss, stopping smoking and getting tight diabetic control. This could be through a targeted weight reduction program, a smoking cessation program or with the help of GP. There’s a lot that can be achieved. If followed the effects should go beyond reducing the immediate risk of postoperative complication. They will be translated into a longer and healthier life too.

The Birmingham Hernia Clinic

BMI The Priory Hospital, Priory Road, Edgbaston, Birmingham B5 7UG

0845 903 7833
info@thebirminghamherniaclinic.com

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