MRS.

YELIZ CULHA (Orcid ID : 0000-0002-5460-5844)

Accepted Article
Article type : Special Issue Article

The Effects of Bladder Training on Bladder Functions after Transurethral Resection of

Prostate

Running Title: The Effects of Bladder Training

Authors:

* Funda Büyükyilmaz, PhD, BSN (Associate Professor); Istanbul University-Cerrahpasa Florence

Nightingale Faculty of Nursing, Fundamentals of Nursing Department, Istanbul, Turkey.

** Yeliz Culha, MSc (Research Assistant); Istanbul University-Cerrahpasa Florence Nightingale Faculty

of Nursing, Fundamentals of Nursing Department, Istanbul, Turkey.

*** Hande Zümreler, (Nurse); University of Health Sciences, Okmeydanı Training and Research

Hospital, Urology Department, Istanbul, Turkey.

**** Murat Özer; MD; University of Health Sciences, Okmeydanı Training and Research Hospital,

Urology Department, Istanbul, Turkey.

***** Mehmet Gökhan Culha, MD; University of Health Sciences, Okmeydanı Training and Research

Hospital, Urology Department, Istanbul, Turkey.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jocn.14939
This article is protected by copyright. All rights reserved.
 ****** Alper Ötünçtemur, MD (Associate Professor); University of Health Sciences, Okmeydanı
Accepted Article Training and Research Hospital, Urology Department, Istanbul, Turkey.

Correspondence: Yeliz Culha, MSc (Research Assistant); Istanbul University Faculty of Nursing,

Istanbul University-Cerrahpasa Faculty of Nursing, Fundamentals of Nursing Department, Istanbul,

Turkey.

Address: Abide-i Hurriyet Cad, Istanbul Universitesi, Florence Nightingale Hemsirelik Fakultesi, 34381

Şişli, Istanbul, Turkey

E mail: [email protected]

Phone: +90 2122242618- 27046

Abstract

Introduction: The aim of this was to examine the effect of bladder training on bladder

functions.

Design and Methods: This quasi-experimental study was conducted in the urology clinic in

Istanbul, Turkey in which 50 males were non-randomly assigned to either a bladder

training(n=28) or control group(n=22). In the bladder training groups, the urinary catheters of

the patients were clamped at 4-hour intervals and then were left open for 5 minutes on the

second postoperative day. This study was created in accordance with TREND Statement

Checklist (See Supplementary File 1).

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 Results: The first urgency time and the first voiding time were longer and the pre-voiding
Accepted Article and the voiding volumes were higher following the removal of the catheter in the training

group (p=0.001).In addition, the evaluation of the patient bladder diaries in the first three

days after the discharge period revealed that the daily frequencies of micturition and nocturia

were lower(p=0.04) the mean duration of intervals between the micturition was longer(p=

0.006) and the mean voided urinary volume was higher(p=0.024) in the training group.

Conclusion: At the end of the study, it is observed that bladder training performed by

clamping the catheter on postoperative day 2 after Transurethral Resection of Prostate(TUR-

P) operation is a significant positive effect on the storage symptoms of the patients.

Relevance to Clinical Practice: Before removing the urinary catheter, bladder training

program affect positively to patients, especially pre-voiding and the voiding volumes, the

daily frequencies of micturition and nocturia on postoperative periods.

Keywords: Bladder Training, Bladder Function, Urinary Catheter, TUR-P.

What does this paper contribute to wider global clinical community?

• Urinary catheterization is frequently performed in order to evaluate the outcomes of

the surgical procedures and to monitor the urine output after urology operations.

• Clinical nurses are responsible for catheter insertion, removal, and routine care

practices.

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 • Bladder training with intermittent urinary catheter clamping after TUR-P had critical
Accepted Article effects especially on the urinary retention symptoms of the patients.

Introduction

Indwelling urinary catheters are used in patients in order to monitor the urine output

appropriately, to prevent urinary retention in the bladder in the postoperative period or during

the course of their treatment in the hospital (Wood, 2013). Urinary catheterization is

frequently performed in order to evaluate the outcomes of the surgical procedures and to

monitor the urine output after urology operations. Benign prostatic hyperplasia (BPH) is a

common urologic condition and a health issue manifesting with lower urinary tract

complaints in men. The incidence of BPH increases with aging. The incidence reaches 50%

at 60 years of age and it becomes 90% in individuals at 85 years old (Starkman&Santucci,

2005). Transurethral Resection of Prostate (TUR-P) is recognized as “the gold standard

method” in the surgical treatment of BPH (Oelke et al., 2013). However, this widely used

surgical method requires postoperative urinary catheterization, leading to a wide range of

complications such as prolonged catheterization, urinary tract infections, acute urinary

retention, repeated hospitalization, and urinary incontinence (Starkman & Santucci, 2005).

Although the time and strategies for catheter removal after TUR-P have not been established

yet, it has been reported in the literature that the duration of stay of the indwelling urinary

catheters has become significantly shorter over the last 15 years. The benefits of short-term

catheterization are explained with the reduction in the incidence of known complications

(narrowing and infection in the urinary tract) originating from an existing catheter (Das

Bhagia, Mahmud &El Khalid 2010).

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 Background
Accepted Article
Dysfunctional voiding symptoms after TUR-P include problems with retention and emptying

of the urine such as urgency, reduction of urine flow, urge incontinence, nocturia or urinary

retention. In addition, general anaesthetics used during the surgery are thought to contribute

to the impaired bladder functions. These agents may interfere with the autonomic nervous

system and cause bladder atony and retention (Baldini, Bagry, Aprikian, & Carli, 2009).

Bladder dysfunction and postoperative voiding disorder may also be seen after urinary

catheterization practices commonly applied in order to monitor urine output accurately in the

postoperative period (Griffiths & Fernandez, 2007). The incidences of these clinical

conditions are reported to vary from 5 to 35% in the literature (Nitti, Kim, & Combs, 1997).

Therefore, follow-up of the patients with urinary catheters is important as their postoperative

removal in the shortest possible time is critical for the prevention of urinary retention and

normalization of bladder function (Nyman, Joohansson & Gustafsson, 2010). Long-term

catheterization may cause problems such as bladder dysfunction and postoperative voiding

disorder with the potential of leading to urinary tract infections (Griffiths & Fernandez,

2007).Griffiths and Fernandez (2007) reported that these undesired consequences occurred

after 7 to 48 hours following the removal of the indwelling urinary catheters.

While the decision to insert or remove a urinary catheter was given by the physician; clinical

nurses are responsible for its insertion, removal, and routine care practices. It is reported in

the literature that bladder training by intermittent clamping is critical before the urinary

catheter is removed (Fernandez & Griffiths 2005; Zhengyonget al. 2014). It is emphasized

that this method stimulates the normal urinary filling and emptying processes, allowing for a

shorter period of time required for the urinary bladder to restore its normal functions

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 (Fernandez and Griffiths 2005; Zhengyong, Changxiao, Shibing, &Caiwen, 2014). This
Accepted Article training was first proposed in 1936, suggesting thatit would improve the bladder tonus and

voiding sensation (Fernandez &Griffiths2005). Despite the abundance of comprehensive

reports on the urinary catheter practices and its care in the literature, the information about

the bladder training prior to the catheter removal is limited in terms of how and how

frequently it should be performed(Griffiths & Fernandez, 2007). In a Cochrane review,

Griffiths and Fernadez (2007) determined that delayed catheter removal were consistent with

a higher risk of voiding problems. In addition, this review concluded, there is little evidence

on which to judge other aspects of management, such as bladder training (intermittent

clamping). Gong, Zhao, Wang, and Wang (2016) showed residual urine volume was higher

in bladder training group, 24 hours following catheter removal. Other studies were

determined that indwelling urethral catheter clamping did not show any advantage or

disadvantage in stroke and hip fracture patients (Nyman, Joohansson & Gustafsson, 2010;

Moon, Chun, Lee & Kim, 2012; Zhengyong, Changxiao, Shibing, &Caiwen, 2014).

Furthermore, Liu et al. (2015) showed that early bladder training protocol is effective in

facilitating bladder function, reducing dysuria, and making patients feel more comfortable. In

addition, a systematic review and meta-analysis study concluded that intermittent clamping or

unclamping methods did not affect re-catheterization, and urinary retention (Wang, Tsai,

Han, Huang & Liu, 2016).Other methods are also employed to restore the normal bladder

functions, including a change in the usual timing of the removal (removal of the catheter at

night), catheterization for shorter periods, and prophylaxis with alpha-blockers (Griffiths &

Fernandez, 2007). The standard guidelines for care have not been established in the literature

yet. The model of practice based on the preferred methods of the clinical specialists and the

implemented local preferences as recommended by expert communities (Fernandez &

Griffiths, 2005).

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 It is noteworthy that there are no standard methods available yet, aiming to reduce the
Accepted Article occurrence of potential complications, despite the several attempts to develop strategies for

urinary catheter removal. Furthermore, there are few studies about bladder training,

especially investigating the ways of shortening the period required for the recovery of the

bladder functions following the removal of indwelling urinary catheters inserted in patients

who underwent TUR-P.

Purpose of the study

The aim of this study was to evaluate the effect of bladder training on bladder functions in

patients who underwent TUR-P operation for benign prostatic hyperplasia (BPH). Within this

scope, the primary research hypothesis (H1) was to determine the effects of bladder training

on the first urgency time, first voiding time, volume of pre-voiding, voiding volume, and

post-voiding residual volume. Secondary hypothesis (H2) was to determine the effects of

bladder training in the 3-day patient bladder diary results after the hospital discharge.

Accordingly, the research questions were:

1. What were the effects of postoperative bladder training prior to the removal of an

indwelling urinary catheter on the first urgency time and the first voiding time?

2. What were the effects of postoperative bladder training prior to the removal of an

indwelling urinary catheter on the volume of pre-voiding, voiding, and post-voiding

residual volume?

3. What were the effects of postoperative bladder training prior to the removal of an

indwelling urinary catheter on the 3-day patient bladder diary results?

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 Method
Accepted Article
Design, Sample, and Criteria for Participation

This quasi-experimental study was conducted during five months period (March to August,

2018) in the urology clinic of a university hospital in İstanbul, Turkey. The inclusion criteria

were defined as follows: (a) undergoing TUR-P due to BPH (b) 18 years of age or older

males (c) ability to communicate and to read and write Turkish, (d) freedom from cognitive,

affective, or verbal impairment as diagnosed by health care providers, (e) freedom from

another acute illness that caused pain or infection, and (f) lack of complications on

perioperative days.

The power analysis to estimate the sample size was performed based on a previous research

with a large cohort. Assuming a power of 0.80 and α value of 0.05, a sample size of 40 was

determined to be adequate. All eligible patients (N= 50) were invited to participate in the

study after the assessment whether they meet all of the inclusion criteria. The non-

randomized study sample comprised 50malepatients: 28 in the experimental group (received

bladder training) and 22 in the control group. This study was created in accordance with

TREND Statement Checklist(See Supplementary File 1).

Procedure and equipment

A detailed medical history of all study patients was taken by the urologist at the time of the

hospital admission. The urologist and the registered nurse evaluated the physical examination

findings. According to the principles of surgical asepsis, 3-way latex Foley catheters were

inserted, with the specific size for all patients, by the urologist prior to the administration of

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 general anesthesia in the operating room. During the procedure, the registered nurse assisted
Accepted Article the intervention, and ensured the patient safety. Firstly, researchers followed by routine

clinical practice procedures of the clinic (control group), then determined the effects of

bladder training (experimental group).

In the experimental group (bladder training), the urinary catheters of the patients were

clamped at 4-hour intervals and then were left open for 5 minutes on the second postoperative

day by the registered nurse. This bladder training (intermittent clamping procedure) ordered

by the urologist in compliance with the literature (Griffiths & Fernandez, 2007; Nyman,

Joohansson&Gustafsson, 2010; Moon, Chun, Lee & Kim, 2012; Liu et al., 2015; Gong,

Zhao, Wang & Wang, 2016; Wang, Tsai, Han, Huang & Liu, Wei & Elliott, 2015;

Zhengyong, Changxiao, Shibing, &Caiwen, 2014). The clamping of urinary catheters in the

experimental group patients were opened when they reported the sense of urgency before

completing the four-hour intervals. This intermittent clamping procedure was repeated during

a period of 24 hours until the third postoperative day.

In the control group; the indwelling urinary catheters were removed according to the routine

clinical practice procedures of the clinic. So, urinary catheters were removed on the third

postoperative day without clamping.

In both groups, first urgency time, and voiding time following the catheter removal were

noted by the registered nurse. Voiding volumes were collected in plastic handheld urinals for

male patients and calculated by the registered nurse. The pre-voiding and post-voiding

residual volumes were quantified with ultrasound by the urologist following the removal of

the urinary catheters. The volumes were measured by transabdominal ultrasound. The

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 registered nurse provided the perineal care with disposable washcloths including soap and
Accepted Article warm water twice a day of all the urinary catheters according to Guideline for Prevention of

Catheter associated Urinary Tract Infections (Gould et al. 2009). In addition, the researchers

developed bladder diary according to European Urology Association (Gratzke et al. 2015).

The patient diary included that micturition/day, nocturia/day, time between micturition

(min.), and voiding volumes/day. In regards to keeping the patient diaries, the patients were

trained by two registered nurses at the time of the hospital discharge. The registered nurses

trained to patients about voiding in plastic handheld urinals, and keeping urine volumes in

measured clean cup for 24-hour intervals at home. At the end of the 24-hour period, the

diaries’ data recorded for three days by patients. Then, the follow-up visits were scheduled

for those patients to take place on the third day of the hospital discharge. The patients were

informed about bringing their diaries to the follow-up visits.

Data Collection Instruments

Data were collected by using a Patient Information Form (age, the presence of chronic

illnesses, and the levels of the prostate specific antigen-PSA-) and patients’ physical

assessment data (International Prostate Symptom Score-IPSS, prostate volume). Also

outcome variables (first urgency time, first voiding time, volume of pre-voiding, voiding

volume and post-voiding residual volume) were recorded. All outcome variables were

recorded following the urethral catheter removal. The quantities of micturition/day and

nocturia/day, the time between the micturitions in minutes, and the average voiding volume

in ml were noted according to the diaries of the patient during follow-up visit.

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 Ethical Considerations
Accepted Article
Permission to conduct the study was received from the hospital ethics committee and

institution (Okmeydani Training& Research Hospital Ethical Board, Number: 2018-935).

Prior to this study, the patients were informed of the purpose of the research and signed an

appropriate consent form. Participants were assured of their right to refuse to participate or to

withdraw from the study at any stage and were guaranteed anonymity and confidentiality.

Data Analysis

The data was analyzed using Statistical Package for the Social Sciences® for Windows®

version 21.0 (IBM Corp., Armonk, USA). The demographic and outcome variables were

analyzed using frequency distributions for the categorical variables, mean, median and

standard deviation for the continuous variables. The normality test based on the skewness and

kurtosis value indicated that both group scores were normally distributed; thus, parametric

tests were used. Chi-square was used to examine differences in categorical variables.

Independent samples t-test was used to determine the difference between the groups.

Statistical significance was determined at p < 0.05.

Results

All study patients were males with a mean age of 65.92±9.46 years and with a mean PSA

level of 1.73±0.68. Of the study patients, 40%had histories of chronic diseases. The mean

IPSS was 22.86±2.43 and the mean prostate volume was 57.22±23.58 mL. There were no

differences between the groups in terms of age, the presence of any chronic diseases, the

levels of PSA, the mean IPSS or the mean volume of the prostate gland (p>0.05) (Table 1).

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 Re-catheterizations were not performed or urinary infections did not develop in the patients
Accepted Article during the study period. Only one patient had to open the clamp ones before four hours. This

situation did not affect the statistics.

Research question 1: The first urgency time and the first voiding time

The data on the first urgency time and the first voiding time following the urinary catheter

removal are presented in Table 2. In the experimental group receiving the bladder training,

the means of the first urgency time, and the first voiding time following the removal of the

catheter were longer (152.14±54.73min, 184.29±57.31 min) than the control group

(75.45±31.58, 98.18±42.94 min), respectively. These time scores were showed statistically

significant between the two groups (p<0.01).

Research question 2: Volume of pre-voiding, voiding volume and post-voiding residual

volume

The data on pre-voiding, voiding, and post-voiding residual urinary volumes following the

urinary catheter removal are presented in Table 2. In the experimental group receiving the

bladder training, these parameters were found to be higher (247.86±108.74, 194.11±107.09,

and 184.29±107.09, and 57.32±32.38) than the control group (110.00±81.99, 66.36±38.85,

and 58.18±33.19) respectively. In the pre-voiding and voiding volumes were showed

statistically significant between the two groups (p=0.001). However, there was not a

difference between the groups in terms of the post-voiding bladder volume(p=0.55).

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 Research question 3: The data in the patient diaries
Accepted Article
The data from the patient diaries collected at the follow-up visits after the hospital discharge

are presented in Table 3. In the experimental group receiving the bladder training; the daily

frequencies of micturition and nocturia were lower (10.68±5.32/day, and 2.29±2.18/day) than

the control group (12.68±6.20/day, and 3.41±2.28/day) respectively. In addition, the intervals

between micturitions, and the mean of voiding volumes were longer/higher (136.79±65.83

min, and 146.79±58.50 ml) than the control group (87.27±40.73 min, and 111.36±44.54 ml),

respectively. There were significant differences between the groups in the daily frequencies

of micturition and nocturia (p=0.04), the intervals between micturition, and the mean of

voided urine volumes (p<0.05).

Discussion

The present study was aim to investigate the effects of the bladder training on the bladder

functions in the patients who underwent TUR-P due to BPH. In this context, the effects of

postoperative bladder training that were implemented prior to the removal of an indwelling

urinary catheter on the first urgency time, first voiding time, volume of pre-voiding, voiding

volume, post-voiding residual volume, and the 3-day patient bladder diary results were

evaluated. TUR-P is “the gold standard method” in the surgical treatment of BPH (Oelke et

al., 2013).Urinary catheterization is frequently preferred in order to reduce the rate of

potential complications and to monitor the urine output accurately after TUR-P (Griffiths

&Fernandez, 2007; Chughtai, Simma-Chiang & Kaplan, 2014).A prolonged catheterization

and failure of the standards for best practices are caused to clinical problems including

bladder and postoperative voiding dysfunction. Therefore, it is reported in the literature that

This article is protected by copyright. All rights reserved.

 bladder training by intermittent clamping is critical before the urinary catheter is removed
Accepted Article (Fernandez &Griffiths 2005; Zhengyong, Changxiao, Shibing, &Caiwen, 2014).

In this study, the first urgency time and the time of the first void following the urinary

catheter removal were longer in the bladder training group. In addition, the pre-voiding and

the voiding volumes after the removal of the catheter were higher in the bladder training

group (p<0.01, Table 2). It is observed that bladder training performed by clamping the

catheter on postoperative day 2 after Transurethral Resection of Prostate (TUR-P) operation

is a significant positive effect on the storage symptoms of the patients. These results have

suggested that the patients not receiving bladder training prior to the urinary catheter removal

may experience more frequent urges to void and smaller volumes of urinary output,

manifesting the symptoms of an overactive bladder. In this context, the study by

Zhengyonget al. (2014), examining the effects of bladder training prior to the removal of the

urinary catheter in the patients with acute urinary retention due to BPH; and the study by

Moon et al. (2012) on stroke patients did not report any significant differences between the

two groups in regards to the first urgency time and the first voiding volume. The study

conducted by Liu et al. (2013) on the patients with neurosurgical problems demonstrated that

the first urgency time was shorter in the experimental group compared to the control group.

However, in these authors determined that the first voiding volumes were larger in the

experimental group. These differences were considered to result from the mucosal alterations

due to the chronic obstruction or they might be caused due to the bladder dysfunction

associated with the insufficient detrusor tonus(Chughtai, Simma-Chiang, & Kaplan, 2014).In

addition, the results of the control group were also acceptable. It is thought that this condition

may be due to the same surgical and clinical procedure follow-up. This statistical difference

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 suggests that the bladder training may also reduce the symptoms of overactive bladder in the
Accepted Article clinical setting because it reduces the frequency attacks.

The evaluation of the patients’ outcomes by the diaries in the first to three days after the

discharge period revealed that the daily frequencies of micturition and nocturia were lower in

the bladder training group (p<0.05). In addition, the mean duration of intervals between the

micturitions was longer (p<0.01) and the mean voided urinary volume was higher(p<0.05) in

this group (Table 3). This results are supportive in the sense that bladder training by

intermittent clamping procedure in the patients with indwelling urinary catheters improves

the bladder retention capacity. The tension in the detrusor muscle causes a degree of strain as

it occurs in all smooth muscles, allowing for developing the bladder tonus. As the detrusor

muscle responsible for the bladder tonus is not innervated by a specific neural network, direct

muscle fibre reactions will still be possible even if it is denervated completely (Crowe, Clift,

Duggan, Bolton, & Costello, 1994).

Limitations

There are some limitations to the study. First, the long-term results are not available.

Secondly, the data in the patients’ bladder diaries are self-reports.

Conclusion

Before removing the urinary catheter, bladder training program affect positively to patients,

for reaching normal bladder functions on postoperative periods. It is concluded that bladder

training allows for the rehabilitation of the normal bladder functions properly after the

urinary catheterizations applied to monitor the urine output.

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 Relevance to Clinical Practice
Accepted Article
Before removing the urinary catheter, bladder training program affect positively to patients,

especially pre-voiding and the voiding volumes, the daily frequencies of micturition and

nocturia on postoperative periods.

Funding:

None.

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 Table 1. Characteristics of Patients (n=50)
Accepted Article
Characteristics ExperimentalGroup Control Group Total Statistical test
and p value
(Bladder Training) (n=22) Groups

(n=28) (N=50)

Age,yrs, mean (SD) 66.27 (10.13) 64.07 (8.64) 65.92 (9.46) t= 1.582

p=0.12

Presence chronic disease, n (%)

Yes 11 (39.3) 9 (40.9) 20 (40.0) χ2= 2.451

No 17(60.7) 13 (59.1) 30 (60.0) p= 0.52

PSA, Prostate-Specific Antigen 1.78 (0.56) 1.61 (0.88) 1.73 (0.68) t= 1.851
levels, mean (SD)
p=0.49

IPSS, International Prostate 22.00 (1.63) 21.96 (2.60) 22.86 (2.43) t= 3.202
Symptom Score, mean (SD)
p=0.63

Prostate volume (mL), mean (SD) 59.09 (27.10) 55.75 (20.79) 57.22 (23.58) t= 0.494

p=0.62

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 Table 2.Time of first urgency and voiding volumesafter catheter removal(n=50)
Accepted Article ExperimentalGroup Control Group Statistical test and
p value
Measurements (Bladder Training) (n=22)
(n=28)

Time of first urgency (min), 152.14 (54.73) 75.45 (31.58) t= 5.84

mean (SD)
p= 0.001

First voiding time (min), 184.29 (57.31) 98.18 (42.94) t= 5.86

mean (SD)
p= 0.001

Pre-voiding urine volume 247.86 (108.74) 110.00 (81.99) t= 4.91

(ml), mean (SD)
p= 0.001

Voiding urine volume (ml), 194.11 (107.09) 66.36 (38.85) t= 5.32

mean (SD)
p= 0.001

Post-voiding residual urine 57.32 (32.38) 58.18 (33.19) t= 5.40

volume (ml), mean (SD)
p=0.55
*p≤0.001

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 Table 3.The data in the patient diaries(n=50)
Accepted Article
ExperimentalGroup Control Group Statistical test and
p value
Patient diaries (Bladder Training) (n=22)
(n=28)

Micturition/day, mean (SD) 10.68 (5.32) 12.68 (6.20) t= 1.23

p= 0.04*

Nocturia/day, mean (SD) 2.29 (2.18) 3.41 (2.28) t= 1.77

p= 0.04*

Time betweenmicturition 136.79 (65.83) 87.27 (40.73) t= 3.09

(min), mean (SD)
p= 0.006**

Voiding volumes(ml), mean 146.79 (58.50) 111.36 (44.54) t= 2.35

(SD)
p= 0.024*

*p≤0.05 **p≤0.01

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