Association of Preoperative Sleep Fragmentation with Postoperative Urinary Retention Following Elective Lower-Limb Orthopedic Surgery
Sleep Disruption as a Perioperative Bladder-Risk Factor
DOI:
https://doi.org/10.69750/dmls.03.07.0219Keywords:
actigraphy, lower-limb orthopedic surgery, postoperative urinary retention, preoperative sleep, sleep fragmentation, urinary catheterizationAbstract
Background: Postoperative urinary retention is a complication following lower-limb orthopedic surgery. Conventional risk assessment considers demographic, urological, anesthetic, and perioperative factors, whereas preoperative sleep continuity remains insufficiently investigated. Sleep fragmentation may contribute to autonomic imbalance, pain sensitivity, opioid requirements, delayed mobilization, and impaired bladder function.
Objective: To evaluate the association between preoperative sleep fragmentation and postoperative urinary retention following lower-limb orthopedic surgery.
Methods: This single-center prospective cohort study included 150 adults undergoing elective lower-limb orthopedic procedures at Al-Aleem Medical College affiliated with Gulab Devi hospital, Lahore, Pakistan, from April 2025 to April 2026. Preoperative sleep was assessed using wrist actigraphy for three nights. Participants in the highest tertile of the sleep-fragmentation index were classified as having high fragmentation. The primary outcome was urinary retention within 24 hours, defined as inability to void with a bladder volume ≥500 mL or postvoid residual volume ≥400 mL requiring catheterization. Multivariable logistic regression adjusted for demographic, urinary, anesthetic, and perioperative factors.
Results: Of 150 participants, 78 were female and 72 were male. Postoperative urinary retention occurred in 35 patients (23.3%). Incidence was higher in the high-fragmentation group than in the lower-fragmentation group (40.0% vs. 15.0%; p=0.001). High fragmentation remained independently associated with urinary retention (adjusted odds ratio, 3.21; 95% confidence interval, 1.35–7.63; p=0.008) and was associated with delayed voiding, repeated catheterization, and longer hospitalization.
Conclusion: Preoperative sleep fragmentation was associated with postoperative urinary retention in both sexes. Multicenter studies are required to validate its value for perioperative bladder-risk stratification.
Downloads
References
Tsai CE, Tseng WH, Chang WS, Ho CH, Chien CS. Incidence and clinical predictors of postoperative urinary retention following total hip and total knee arthroplasty: a single-center, prospective study. Jt Dis Relat Surg. 2026;37(1):98-106. doi:10.52312/jdrs.2026.2429.
Powers MJF, Grace ZT, Torre BB, Wakefield DB, Sanzari L, Grosso MJ. Investigating postoperative urinary retention: risk factors and postsurgical outcomes in total joint arthroplasty. Arthroplast Today. 2025;31:101600. doi:10.1016/j.artd.2024.101600.
Niklasson A, Finan PH, Smith MT, Forsberg A, Dietz N, Kander T, et al. The relationship between preoperative sleep disturbance and acute postoperative pain control: a systematic review and meta-analysis. Sleep Med Rev. 2025;79:102014. doi:10.1016/j.smrv.2024.102014.
Azarboo A, Ghaseminejad-Raeini A, Teymoori-Masuleh M, Mousavi SM, Jamalikhah-Gaskarei N, Hoveidaei AH, et al. Risk factors of postoperative urinary retention following total hip and knee arthroplasty: a systematic review and meta-analysis. Bone Jt Open. 2024;5(7):601-611. doi:10.1302/2633-1462.57.BJO-2024-0003.R1.
Magnuson JA, Hobbs JR, Snyder V, Hozack WJ, Krueger CA, Austin MS. Routine use of bladder scans after primary total joint arthroplasty is not necessary: results of a protocol change. J Arthroplasty. 2023;38(6 Suppl):S52-S59. doi:10.1016/j.arth.2023.02.040.
Kołodziej Ł, Jurewicz A, Gębska M. Nursing interventions reduce postoperative urinary retention in fast-track total hip arthroplasty: a pilot study. Adv Clin Exp Med. 2023;32(4):497-500. doi:10.17219/acem/161723.
Vitale JA, Banfi G, Viganò M, Negrini F. How do patients sleep after orthopaedic surgery? Changes in objective sleep parameters and pain in hospitalized patients undergoing hip and knee arthroplasty. Int Orthop. 2023;47(8):1929-1938. doi:10.1007/s00264-023-05862-2.
Bracey DN, Barry K, Khanuja HS, Hegde V. Postoperative urinary retention in modern rapid recovery total joint arthroplasty. J Am Acad Orthop Surg. 2022;30(10):443-447. doi:10.5435/JAAOS-D-21-00963.
Magaldi RJ, Strecker SE, Nissen CW, Carangelo RJ, Grady-Benson J. Preoperative factors to assess risk for postoperative urinary retention in total joint arthroplasty: a retrospective analysis. Arthroplast Today. 2022;13:181-187. doi:10.1016/j.artd.2021.10.009.
Varallo G, Giusti EM, Manna C, Castelnuovo G, Pizza F, Franceschini C, et al. Sleep disturbances and sleep disorders as risk factors for chronic postsurgical pain: a systematic review and meta-analysis. Sleep Med Rev. 2022;63:101630. doi:10.1016/j.smrv.2022.101630.
Bracey DN, Hegde V, Pollet AK, Johnson RM, Jennings JM, Miner TM. Incidence and predictive risk factors of postoperative urinary retention after primary total knee arthroplasty. J Arthroplasty. 2021;36(7 Suppl):S345-S350. doi:10.1016/j.arth.2021.02.043.
Brouwer TA, van Roon EN, Rosier PFWM, Kalkman CJ, Veeger N. Postoperative urinary retention: risk factors, bladder filling rate and time to catheterization: an observational study as part of a randomized controlled trial. Perioper Med (Lond). 2021;10(1):2. doi:10.1186/s13741-020-00167-z.
Møller T, Engedal MS, Plum LM, Aasvang EK. Reduced need for urinary bladder catheterization in the postanesthesia care unit after implementation of an evidence-based protocol: a prospective cohort comparison study. Eur Urol Open Sci. 2021;26:27-34. doi:10.1016/j.euros.2021.01.013.
Wang Y, Liu Y, Li X, Lv Q, Xia Q, Wang X, et al. Prospective assessment and risk factors of sleep disturbances in total hip and knee arthroplasty based on an Enhanced Recovery After Surgery concept. Sleep Breath. 2021;25(3):1231-1237. doi:10.1007/s11325-020-02213-y.
Cha YH, Lee YK, Won SH, Park JW, Ha YC, Koo KH. Urinary retention after total joint arthroplasty of hip and knee: systematic review. J Orthop Surg (Hong Kong). 2020;28(1):2309499020905134. doi:10.1177/2309499020905134.
Abdul-Muhsin HM, Jakob N, Cha S, Zhang N, Schwartz A, Navaratnam A, et al. Incidence, outcomes, and prediction of postoperative urinary retention after a nonurologic procedure. J Am Acad Orthop Surg Glob Res Rev. 2020;4(5):e19.00149. doi:10.5435/JAAOSGlobal-D-19-00149.
Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery Society recommendations. Acta Orthop. 2020;91(1):3-19. doi:10.1080/17453674.2019.1683790.
Luo ZY, Li LL, Wang D, Wang HY, Pei FX, Zhou ZK. Preoperative sleep quality affects postoperative pain and function after total joint arthroplasty: a prospective cohort study. J Orthop Surg Res. 2019;14(1):378. doi:10.1186/s13018-019-1446-9.
Scholten R, Kremers K, van de Groes SAW, Somford DM, Koëter S. Incidence and risk factors of postoperative urinary retention and bladder catheterization in patients undergoing fast-track total joint arthroplasty: a prospective observational study on 371 patients. J Arthroplasty. 2018;33(5):1546-1551. doi:10.1016/j.arth.2017.12.001.
Smith MT, McCrae CS, Cheung J, Martin JL, Harrod CG, Heald JL, et al. Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2018;14(7):1231-1237. doi:10.5664/jcsm.7230.
Downloads
PlumX Metrics
Published
Issue
Section
License
© The Author(s) 2026. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License , which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third-party material in this article are included in the article’s Creative Commons license unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you must obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
How to Cite
