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Journal of Cardiovascular Nursing

Vol. 00, No. 0, pp 00Y00 x Copyright B 2017 Wolters Kluwer Health, Inc. All rights reserved.

A Modified Supine Position Facilitates


Bladder Function in Patients Undergoing
Percutaneous Coronary Intervention
A Randomized Controlled Clinical Trial
Yisi Liu, MSc, RN; Ying Zhang, MSc, RN; Ying Wu, PhD, RN; Malcolm Elliott, PhD, RN

Background: Percutaneous coronary intervention (PCI) is currently the most common intervention for cardiovascular
disease. Standard care after PCI typically involves a period of bed rest in the supine position, but this position creates
voiding difficulties. Objective: This study aimed to determine whether a modified supine position could facilitate
bladder emptying after PCI. Method: A randomized controlled trial involving 300 patients was conducted. Patients
in the intervention group were nursed in the supine position with the bed tilted 20- upright and with a pillow
between their feet and the end of the bed. Patients in the control group received standard care, which was supine
positioning. Results: One hundred fifty patients were allocated to the intervention group (100 men, 50 women),
and 150 were allocated to the control group (103 men, 47 women). Baseline data did not differ between the
2 groups. Patients in the intervention group had significantly better bladder function as evidenced by a shorter time
to the first void (5 vs 15 minutes) and fewer patients requiring voiding assistance (8.6% vs 35.3%). Residual urinary
volumes were also much lower in the intervention group (88.71 vs 248.22 mL, P G .001). Conclusions: This study
demonstrates that a modified supine position can reduce the incidence of impaired micturition and the preservation
of normal bladder function after PCI.
KEY WORDS: bladder dysfunction, percutaneous coronary intervention

C ardiovascular disease is a leading cause of death


around the world.1 Percutaneous coronary interven-
tion (PCI) is currently the most common intervention
management of bifurcations. According to recent guide-
line and literature, the bed rest after PCI range from 6 to
24 hours after TFAs to prevent bleeding-associated
for cardiovascular disease and includes the transradial complications.2Y4
and transfemoral (TFA) approaches.1 Although the Impaired micturition, defined as the inability to void
use of the transradial approach is increasing, the TFA despite having the urge to do so, is a common com-
remains an important approach for most PCIs be- plication in the post-PCI bed rest period.5 Research has
cause it allows the passage of larger catheters and easier found that 24% to 56% of patients experience voiding
difficulty after PCI.5 Despite this high incidence, void-
ing difficulties post-PCI are underreported in the litera-
Yisi Liu, MSc, RN
School of Nursing, Capital Medical University, Beijing, China.
ture compared with other adverse outcomes such as
Ying Zhang, MSc, RN pain, length of stay, and mortality.2,6 Voiding difficulty
Beijing Anzhen Hospital, Capital Medical University, China. may subsequently require urinary catheterization and
Ying Wu, PhD, RN result in delayed hospital discharge.2 Impaired mictu-
School of Nursing, Capital Medical University, Beijing, China.
rition may also lead to contrast-induced nephropathy
Malcolm Elliott, PhD, RN
School of Nursing & Midwifery, Monash University, as early voiding post-PCI ensures the elimination of con-
Melbourne, Australia. trast medium.3
This study was sponsored by the Capital Nursing Research Founda- The exact etiology of impaired micturition post-PCI
tion (10ZYH15). is unclear, but it likely involves neurological, physiolog-
The authors have no conflicts of interest to disclose. ical, and psychological factors.6,7 Regional anesthesia,
Correspondence for example, disrupts afferent input and suppresses sen-
Ying Wu, PhD, RN, School of Nursing, Capital Medical University,
Beijing, China (helenywu@vip.163.com); Malcolm Elliott, PhD, RN,
sory stimuli from the bladder to the micturition center.6,7
School of Nursing & Midwifery, Monash University, Melbourne, Atropin use during PCI interferes with detrusor muscle
Australia (malcolm.elliott@monash.edu). contraction and urinary sphincter relaxation and may
DOI: 10.1097/JCN.0000000000000436 also lead to micturition difficulty.8 Importantly, lying

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
2 Journal of Cardiovascular Nursing x Month 2017

supine to urinate is foreign and difficult for most people, Patients who met the inclusion criteria were con-
and urinary retention is distressing and embarrassing.2 secutively recruited. Inclusion criteria were (1) given
The change of posture from sitting or standing to a diagnosis of cardiovascular disease, (2) undergoing
urinate to lying supine to urinate is a significant fac- elective inpatient transfemoral PCI, (3) aged 30 to
tor contributing to post-PCI voiding difficulty.9 Re- 80 years, (4) able to urinate without problem and ex-
search examining the influence of posture on urination press the intention to urinate, and (5) alert and able
demonstrates the importance of foot support for pelvic to consent. We focused on patients who underwent
floor relaxation.10Y13 Having the feet supported influences transfemoral PCI because it typically requires 12 to
pelvic position and tone of the pelvic floor muscles.12,13 24 hours bed rest postprocedure, which commonly
Voiding without feet resting on the floor also impedes results in impaired micturition.
bladder emptying and increases the delay between feel- Patients younger than 30 years were excluded be-
ing the need to void and actually doing so.12Y14 In a study cause our pilot study found that many of these patients
comparing uroflowmetric parameters and postvoid were very embarrassed when calling for the research
residual urine volumes, urinary flow rate decreased nurse to assist with urination. Furthermore, people in
in the supine position.14 Furthermore, bedridden pa- this age group do not typically require a PCI. Patients
tients are predisposed to urinary tract infections because older than 80 years were excluded because many of
of alterations in voiding dynamics in the recumbent them may have age-related urination problems, which
position.15 may have influenced study outcomes.
Educating patients to urinate in the supine position Exclusion criteria were (1) intraoperative Foley cathe-
is a common method to prevent voiding difficulty after terization; (2) history of prostatic hyperplasia, prostatic
PCI. This however seems to have limited benefit, with carcinoma, urinary tract infection, urologic disorders,
as many as half of all patients still experiencing im- sensory disorders, or neurological problems; (3) spinal
paired micturition after PCI.2,5 Lei et al16 taught women or epidural anesthesia; (4) inability to communicate;
to use a semisquatting position when urinating, none and (5) signs of cognitive impairment.
of whom experienced urinary retention in the postpar- Patients meeting the inclusion criteria were informed
tum period. Ma et al17 compared the effects of supine of the procedure and purpose of the study. Written
positioning with bent knees and hip lift on micturi- informed consent was obtained. All participants had
tion for abdominal surgery patients, finding that this the right to withdraw at any time. Participants were
position could significantly reduce the time to the first reassured that their data would be kept confidential
void after surgery and the urinary retention rate.17 The and that their identity would not be revealed when the
common feature of these methods is mimicking the study is published.
normal micturition posture and using feet support to All participants received physical assessment by a
facilitate patients" urination. physician, including urinary assessment, before the
Because it is necessary to keep the legs straight for PCI. All participants could urinate with no difficulty.
at least 12 hours after PCI to prevent bleeding, we Urinary system assessments were normal for all par-
hypothesized that, for patients undergoing PCI, a ticipants before PCI.
modified supine position with feet support could:
h reduce the rate of impaired micturition; Procedure
h reduce residual urinary volume (RUV) after the first
A computer-based random number generator was used
void; and
to divide participants into intervention and control
h preserve normal bladder function.
groups. Written allocation of group assignment was
provided in opaque, sealed envelopes, labeled with con-
Method secutive number ordering. Envelopes were prepared by
an independent research assistant who was blinded to
Design and Sample
the group allocation. Envelopes were distributed to
A randomized controlled trial was conducted in a participants by another research assistant who had no
cardiology department in a 1500-bed tertiary hospital other involvement in the trial.
in Beijing, China, between June 2012 and January Consistent with local practice, patients underwent
2014. The study was approved by the university review PCI with local anesthesia using lidocaine. All PCIs were
board and the hospital"s Director of Nursing. The re- performed via the TFA. Angio-Seal vascular closure is
search protocol conformed with the provisions of the not covered by health insurance for Chinese citizens.
Declaration of Helsinki (1995). Medical records of Most participants therefore chose manual compression
suitable patients were screened for demographics, for hemostatic puncture closure (see Table 1).
medication, and health history to identify potential Post-PCI care was performed as follows. Patients
participants. in the control group received standard clinical care,

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
A Modified Supine Position Facilitates Bladder Function 3

TABLE 1 Baseline Demographic Characteristics


Intervention Group Control Group
(n = 150) (n = 150) P
Age, mean (SD), y 62.39 (9.22) 61.73 (10.04) .550
BMI, mean (SD), kg/m2 25.90 (3.38) 25.47 (3.10) .246
Sex, male/female, n (% [male]) 100/50 (66.7) 103/47 (68.7) .711
Diagnosis, n (%)
Angina 120 (80.0) 122 (81.3) .770
MI 30 (20.0) 28 (18.7)
History with diabetes 39 (26.0) 33 (22.0) .417
Previous PCI, n (%) 103 (69.1) 108 (72.0) .586
NYHA, n (%)a
I 103 (85.8) 111(91.0) .446
II 15 (12.5) 10 (8.2)
IIIYIV 2 (1.7) 1 (0.8)
Killip, n (%)b
I 19 (63.3) 17 (60.7) .619
II 7 (23.3) 9 (32.1)
IIIYIV 4 (13.3) 2 (7.1)
Previous experience of urination on bed, n (%) 65 (43.3) 62 (41.3) .726
Preoperative pain (puncture site, chest, or back), n (%) 57 (38.0) 43 (28.7) .086
Postoperative pain (puncture site, chest, or back), n (%) 49 (32.7) 41 (27.3) .313
Duration of PCI, median (range), min 60 (10Y360) 60 (15Y240) .349
Type of contrast media, n (%)
Iopromide 100 (66.7) 106 (70.7) .455
Visipaque/iohexol 50 (33.3) 44 (29.3)
Compression hemostasis method
Angio-Seal vascular closure 8 8 1.000
Manual compression 142 142
Postoperative bed rest time, median (range), min 360 (360Y1440) 360 (360Y1440) .054
Postoperative depression, n (%) 1 (0.7) 7 (4.7) .073
Postoperative anxiety, n (%) 12 (8.0) 18 (12.0) .248
Postoperative water intake time, median (range), min 5 (2Y120) 5 (5Y60) .352
Amount of intraoperative and 4-hr postoperative 1259.13 (599.62) 1283.73 (669.44) .738
fluid intake, mean (SD), mL

Abbreviations: ACS, acute coronary syndrome; BMI, body mass index; MI, myocardial infarction; NYHA, New York Heart Association; PCI,
percutaneous coronary intervention.
a
NYHA classification is for patients given a diagnosis of angina.
b
Killip classification is for patients given a diagnosis of MI.

which involved lying supine. In the intervention group, Outcome Variables and Measurements
patients were in a modified supine position. This in-
Several variables were collected to determine bladder
volved patients lying supine with the bed head elevated
function. The primary outcome measures were time
at an angle of 20- and with a pillow between their feet
to the first void and micturition function. Time to
and the end of the bed (see Figure 1).
the first void was defined as the time interval from
The chosen angle of 20- was based on the recent
when the patient first feels the need to void to when
study by Chang et al.19 In their study, 38 patients
he/she actually does so.20 Patients were told to press
who had undergone digital subtraction angiography
the call bell if they felt the need to void, at which point a
were nursed in a modified position with the bed head
research nurse would come to assist. The measurement
elevated at 20-. The study supported the use of this
of time to the first void started when the bedpan or
modified supine position because patients experienced
less urinary difficulty, shorter time to the first void, and
no adverse effects such as puncture site bleeding.19
For both study groups, patients were required to lie
supine in bed for 6 hours before being allowed to
position themselves as desired and remain in bed for
12 hours before being allowed to ambulate. Patients
were encouraged to drink water and void within 2 hours
post-PCI to facilitate elimination of contrast medium.
Dorsalis pedis pulse and foot skin temperature were FIGURE 1. Modified supine position (reproduced with
assessed to detect thrombosis. permission).18

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4 Journal of Cardiovascular Nursing x Month 2017

urine bottle was in position (T1). The research nurse then and 30% in the intervention group.5 We therefore ex-
noted when urination ceased (T2). The difference be- pected a 25% difference in the incidence of abnormal
tween T1 and T2 was noted as time to the first void. bladder function between the intervention and control
Micturition function was divided into 4 levels, de- groups. Sample size calculation indicated that 260 pa-
pending on the time to the first void as defined previously. tients were required to detect a difference between the
The 4 levels were the following20: 2 groups (2-tailed, ! = .01; power, 0.9). It was decided
to recruit 300 participants to allow for attrition.
Level 0: urinating within 1 minute
Level 1: urinating within 1 to 30 minutes
Level 2: urinating within 1 to 30 minutes and needing Statistical Analysis
assistance such as massage or heat pack to do so Central tendency was described as mean and standard
Level 3: cannot urinate by self or with other assistance deviation for continuous data with a normal distribu-
methods and needs urinary catheterization tion and median value with the first and third quartiles
Levels 2 to 3 are regarded as impaired micturition. for abnormal distribution. The # 2 test was used to test
Secondary outcome variables included RUV, volume the difference between the 2 groups for categorical
of the first void, and urinary retention rate. Residual data. Mann-Whitney U test or Student t test was used
urinary volume was noted by a portable ultrasound for continuous data. The distribution of time to the
device using a 3.5-MHz probe (Adara SONOLINE first void was logarithmically transformed for analy-
50643406; Siemens, Germany). Bladder scanning was ses and standardized. Statistical significance was set at
performed to ensure uniformity of data. Urinary P G .05. Statistical analyses were conducted using
retention was defined as the need for catheterization SPSS 13.0 for Windows (SPSS Inc, Chicago, Illinois).
within 24 hours of the procedure.21 Two nurses working in the cardiology department
The complication rate after PCI was also noted to extracted data for analysis.
assess the safety of the modified supine position. Com-
plications assessed for included back pain, deep venous Results
thrombosis, and local wound complications (hematoma, Baseline Characteristics
subcutaneous hemorrhage, pseudoaneurysm). Pain was
assessed by a visual analog scale, which has established Three hundred fifty-seven patients were assessed for
validity and reliability.22 Before and immediately after eligibility, with 311 meeting the inclusion criteria
the procedure, participants were asked whether they (Figure 2). Three patients declined to participate, and
had pain in the puncture site, chest, or back. 8 were lost because of transferring to another ward or
Deep venous thrombosis and local wound complica- because of incomplete data. Three hundred patients were
tions were identified via documentation in the patient"s entered into the final analysis. There were no significant
chart. Level of postoperative anxiety and depression differences between the 11 patients lost to the study and
was measured by the Hospital Anxiety and Depression the remaining 300 on baseline characteristics.
Scale, which has demonstrated reliability and validity.23,24 Among the 300 participants, 150 were allocated to
Anxiety and depression are risk factors for postoper- the intervention group (100 men, 50 women), and 150
ative urinary retention.25 Baseline data were collected were allocated to the control group (103 men, 47 women).
from medical records. The research nurse received Baseline data did not differ between the 2 groups (P G .05;
training for data collection, including how to measure see Table 1).
RUV with the ultrasound device.
Primary and Secondary Outcomes
Pilot Study As shown in Figure 3 and Table 2, patients in the inter-
A pilot study was conducted to determine feasibility of vention group had significantly better bladder function.
the study. Nineteen patients meeting the inclusion criteria Time to the first void was 5 minutes (Q12,Q310) in the
were recruited and randomly assigned to 2 groups. The intervention group, which was significantly shorter
pilot study indicated that the study was feasible, finding than that in the control group (15 minutes; Q13,Q360).
that 30% of the patients in the intervention group and The intervention group showed better micturition func-
55% in the control group had abnormal bladder function. tion with a lower rate of impaired micturition (defined
No patients in the pilot study experienced urinary reten- as micturition function levels 2 and 3) compared with
tion, catheterization, or complications after PCI. the control group (8.6% vs 35.3%, # 2 = 34.839, P G
.0001). Residual urinary volume was also much lower
in the intervention group (4% vs 5.33%, P G .001).
Sample Size
Time of the first void after returning from the proce-
In a previous study, the incidence of abnormal bladder dural room in the intervention group was significantly
function in PCI patients was 55% in the control group shorter than that in the control group (1.31 T 0.68 vs

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A Modified Supine Position Facilitates Bladder Function 5

FIGURE 2. Patient allocation.

2.07 T 0.91 hours, P G .0001). Nearly all patients in the ened the time to first void, improved micturition func-
intervention group (92%) urinated within 2 hours of tion, and reduced RUV.
returning from the procedure room, but only 68% in A trial by Ma et al17 also reported a shorter time to
the control group did so (# 2 = 27.000, P G .0001). the first void using a foot support voiding position for
Six patients in the intervention group and 8 patients patients after abdominal surgery. The average time to
in the control group had post-PCI urinary retention (P = the first void was 0.84 T 0.22 minutes in the inter-
.584). No patients in either group experienced deep venous vention group in Ma et al"s study, which is much shorter
thrombosis or local wound complications. Primary and than our results (5 minutes as median). A possible
secondary outcomes are presented in Tables 2 and 3. explanation is that the intervention regimens are dif-
ferent between the study groups. In Ma et al"s trial,
patients in the intervention group were told to bend
Discussion their knees and lift their hips when micturating. In our
This study showed that a modified supine position with study, patients had to lie on a sloped bed elevated at an
foot support can preserve normal bladder function in angle of 20-. Bed elevation in Ma et al"s regimen may
patients undergoing PCI. This modified position short- have been greater than 20-, explaining this difference.

FIGURE 3. Micturition function between groups (n = 150).

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6 Journal of Cardiovascular Nursing x Month 2017

TABLE 2 Primary Outcomes Between the 2 Groups Rane and Iyer12 used 3-dimensional translabial ultra-
sound to image the dimensions of the levator hiatus in
Intervention Control
Group Group the supine and squatting positions. The study found
Primary Outcomes (n = 150) (n = 150) P that the levator hiatus in the squatting position is 9.5 cm2
greater than that in the supine position (95% confidence
Time to the first void, 5 (2, 10) 15 (3, 60) G.0001ab
median (quartiles), min interval, 9.0Y10.0).12 Other similar studies have reached
Micturition function, n (%) G.0001c the same conclusion.10,13,26
Level 0 32 (21.3) 21 (14.0) Research supports the benefits of feet support when
Level 1 105 (70.0) 76 (50.7) voiding in healthy subjects10,11,14 and hospitalized
Level 2 5 (3.3) 39 (26.0)
patients.19 Our trial showed that a modified supine
Level 3 8 (5.3) 14 (9.3)
position with foot support can facilitate post-PCI
a
b
P value for Student t test. micturition. These results could be due to the foot
The distribution of time to the first void was slightly skewed and
support relaxing the puborectalis sling, which leads to
logarithmically transformed for standardized and Student t test analyses.
c
P value for # 2 test. pelvic floor relaxation, a necessary component of normal
voiding.11,27 Wennergren et al11 reported that optimal
However, consistent with our local policy, patients post- relaxation of the pelvic floor muscles could be achieved
PCI are not allowed to bend their knee for at least in the supine position with legs supported by pillows. In
24 hours to prevent wound bleeding. Furthermore, their study, 20 healthy girls were allocated to 2 groups,
patients in Ma et al"s trial underwent abdominal sur- legs either supported or unsupported.11 In the group
gery, whereas in our trial, they had a PCI. Differences with supported legs, relaxation of the pelvic floor
in the time to first void between the studies might also muscles was observed in 94% of the subjects, but only
reflect differing surgical or anesthesia protocols. in 5% without leg support (P G .05).
The debate on whether the traditional squatting Another important factor influencing voiding is that
position in east culture is superior to the sitting pos- foot support may increase abdominal and detrusor
ture in western cultures dates back thousands of years.12 pressures, resulting in a change in urethral diameter,
Few studies have examined position-related changes in thus contributing to better bladder emptying.13,27,28
voiding dynamics in healthy subjects, and none are Moreover, in the supine position, the longitudinal axis
current. Wennergren et al11 reported that children of the bladder is practically 90- different compared
whose feet dangled while on the toilet had less than with the sitting or standing positions.14 The speed of
optimal pelvic floor relaxation compared with those bladder emptying may also be reduced in the recumbent
who had feet supported. This suggests that, in healthy position because of inefficient detrusor contractions due
subjects, feet support might facilitate more efficient to altered shape and geometry of the contracting
voiding. Riehmann et al14 investigated the effect of bladder, although this has only been a finding in male
position on uroflowmetry and post-void residual urine patients.14 The slope position of 20- in our trial may
volumes in 55 male nursing home residents. Significant have helped the bladder regain a similar normal shape
decreases were noted in mean peak urine flow rates relative to the gravitational vector and thus increased
from the upright to recumbent positions (14.5 T 8.6 vs peak flow urination rate.
12.4 T 6.7 mL/s, P = .008), with an increase in post- Management of postoperative micturition can be
void residual urine volumes (P = .049). In the supine challenging. Impaired micturition, as a common post-
position, the bladder empties at a lower contraction operative outcome, is often underreported compared with
velocity and to a lesser extent.14 In a more recent study, other more serious outcomes such as pain, bleeding, or

TABLE 3 Secondary Outcomes Between the 2 Groups


Secondary Outcomes Intervention Group (n = 150) Control Group (n = 150) P
RUV, median (quartile), mL 88.71 (31.18, 179.42) 248.22 (83.47, 438.46) G.0001a
Time of the first void post-PCI, hr 1.31 (0.68) 2.07 (0.91) G.0001b
Micturition within 2 hr of returning from the operation 138 (92) 102 (68) G.0001c
room, n (%)
Volume of the first void, mean (SD), mL 379.27 (179.94) 351.93 (185.17) .196c
Urinary retention rate, n (%) 6 (4.00) 8 (5.33) .584c
Back pain rate 11 13 .670c
Deep venous thrombosis rate 0 0 V
Local wound complications 0 0 V

Abbreviations: PCI, percutaneous coronary intervention; RUV, residual urinary volume.


a
P value for Mann-Whitney U test.
b
P value for Student t test.
c
P value for # 2 test.

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
A Modified Supine Position Facilitates Bladder Function 7

the directors of nursing departments of the study hos-


What’s New and Important pitals and nursing managers of the participating units
h Standard care after PCI typically involves a period of for helping with participant recruitment and all faculty
bed rest in the supine position, but this position members from School of Nursing, Capital Medical
creates voiding difficulties. University, for their enduring support, assistance, and
h A modified supine position with foot support can
valuable comments on the design of this study.
reduce the incidence of impaired micturition and
preserve normal bladder function post-PCI.
h The maintenance of normal bladder function post-PCI REFERENCES
avoids risks associated with urinary catheterization
1. Franchi E, Marino P, Biondi-Zoccai GG, De Luca G,
and associated prolonged hospital stay.
Vassanelli C, Agostoni P. Transradial versus transfemoral
approach for percutaneous coronary procedures. Curr Cardiol
Rep. 2009;11(5):391Y397.
morbidity.2 Impaired micturition is also poorly de- 2. Choi S, Awad I. Maintaining micturition in the periopera-
fined, and its clinical implications are not immediately tive period: strategies to avoid urinary retention. Curr Opin
apparent.2 Nonetheless, impaired micturition after Anaesthesiol. 2013;26(3):361Y367.
3. Rolley JX, Salamonson Y, Wensley C, Dennison CR,
surgery may require catheterization and result in
Davidson PM. Nursing clinical practice guidelines to improve
delayed hospital discharge. Post-PCI, it is not uncom- care for people undergoing percutaneous coronary interven-
mon for patients to develop contrast-induced nephrop- tions. Aust Crit Care. 2011;24(1):18Y38.
athy due to the impaired ability to micturate. In 4. Tongsai S, Thamlikitkul V. The safety of early versus late
our trail, 92% of patients in the intervention group ambulation in the management of patients after percutaneous
coronary interventions: a meta-analysis. Int J Nurs Stud. 2012;
urinated within 2 hours after PCI, compared with 68%
49(9):1084Y1090.
in the control group (P G .0001). 5. Zhang Y, Liu Y, Han Y. Influence of clinical pathway on
postoperative urination of patients undergoing coronary
Limitations intervention. Chinese Nurs Res. 2013;15:1474Y1476.
6. Lim JL. Post-partum voiding dysfunction and urinary
The trial was not blinded because of the nature of the retention. Aust N Z J Obstet Gynaecol. 2010;50(6):502Y505.
intervention, which may have led to observer bias. The 7. Steggall M, Treacy C, Jones M. Post-operative urinary
use of randomization may have reduced this risk. retention. Nurs Stand. 2013;28(5):43Y48.
8. Elsamra SE, Ellsworth P. Effects of analgesic and anesthetic
Objective measurements, such as time to the first void,
medications on lower urinary tract function. Urol Nurs. 2012;
RUV, and volume of the first void, may have reduced 32(2):60Y67.
this bias.29 A portable ultrasound device, the criterion 9. Zhang Y, Liu Y, Qin Y, Gao R, Li Z. Modified position
standard for determining RUV,7 was also used to further could improve difficulty micturition in patients after per-
minimize observer bias. cutaneous coronary intervention. Chinese Gen Pract Nurs.
2015;9:794Y796.
This study was conducted in a cardiovascular unit
10. Rane A, Corstiaans A. Does micturition improve in the squat-
and excluded patients with intraoperative Foley cath- ting position? J Obstet Gynaecol. 2008;28(3):317Y319.
eterization and history of cognitive impairment, pros- 11. Wennergren HM, Oberg BE, Sandstedt P. The importance
tatic hyperplasia, or urological, sensory, or neurological of leg support for relaxation of the pelvic floor muscles. A
problems. Caution is therefore advised when generalizing surface electromyograph study in healthy girls. Scand J Urol
Nephrol. 1991;25(3):205Y213.
the results to other patients with postoperative impaired
12. Rane A, Iyer J. Posture and micturition: does it really
micturition, such as those younger than 30 or older than matter how a woman sits on the toilet? Int Urogynecol J.
80 years. Furthermore, this study was conducted in only 2014;25(8):1015Y1021.
1 medical center, although it had a large enough sample 13. Bush MB, Liedl B, Wagenlehner F, Yassouridis A, Petros PE.
to reach statistical significance. Replications of the trial Effects of posture and squatting on the dynamics of micturi-
tion. Int Urogynecol J. 2015;26(5):779Y780.
in multicenters are recommended for further study.
14. Riehmann M, Bayer WH, Drinka PJ, et al. Position-related
changes in voiding dynamics in men. Urology. 1998;52(4):
Conclusions 625Y630.
15. El-Bahnasawy MS, Fadl FA. Uroflowmetric differences
This study demonstrates that a modified supine posi-
between standing and sitting positions for men used to void
tion with foot support can reduce the incidence of in the sitting position. Urology. 2008;71(3):465Y468.
impaired micturition and preserve normal bladder 16. Lei M, Tang F, Zhang L. The influence of time and posture
function after PCI. Further studies of this position on on postpartum urinary retention. J Nurse Train. 2010;1:60Y61.
other postoperative patients at risk of impaired micturi- 17. Ma W, Su J, Li G. The effect of improved supine position
on urination. J Binzhou Med Coll. 2007;2:159Y160.
tion are warranted.
18. Li X, Shang S. Fundamentals of Nursing 5th ed. Beijing,
Acknowledgments China: People"s Medical Publishing House; 2012:41.
19. Chang H, FU QN, Yue P. Influence of modified postural
urination trainning on postoperative urination function
The authors thank all the study participants for their and vital signs of patients with DSA. Chinese Nurs Res. 2012;
time and for providing valuable data. They also thank 26(23):2166Y2167.

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
8 Journal of Cardiovascular Nursing x Month 2017

20. Liu YS, Wei S, Elliott M. The effects of a catheter clamping vidual patient data meta-analyses. BMJ Open. 2016;6(4):
protocol on bladder function in neurosurgical patients: a e011913.
controlled trial. Int J Nurs Pract. 2015;21(1):29Y36. 25. Juma S. Urinary retention in women. Curr Opin Urol. 2014;
21. Toyonaga T, Matsushima M, Sogawa N, et al. Postoperative 24(4):375Y379.
urinary retention after surgery for benign anorectal disease: 26. Gupta NP, Kumar A, Kumar R. Does position affect
potential risk factors and strategy for prevention. Int J uroflowmetry parameters in women? Urol Int. 2008;80(1):
Colorectal Dis. 2006;21(7):676Y682. 37Y40.
22. Lee SH, Lim SM. Acupuncture for poststroke shoulder 27. Yazici CM, Turker P, Dogan C. Effect of voiding position
pain: a systematic review and meta-analysis. Evid Based on uroflowmetric parameters in healthy and obstructed male
Complement Alternat Med. 2016;2016:3549878. patients. Urol J. 2014;10(4):1106Y1113.
23. Nikayin S, Rabiee A, Hashem MD, et al. Anxiety symptoms 28. de Jong Y, Pinckaers JH, ten Brinck RM, Lycklama (
in survivors of critical illness: a systematic review and meta- Nijeholt AA, Dekkers OM. Urinating standing versus
analysis. Gen Hosp Psychiatry. 2016;43:23Y29. sitting: position is of influence in men with prostate enlarge-
24. Thombs BD, Benedetti A, Kloda LA, et al. Diagnos- ment. A systematic review and meta-analysis. PLoS One.
tic accuracy of the Depression subscale of the Hospital 2014;9(7):e101320.
Anxiety and Depression Scale (HADS-D) for detecting 29. Altman D. Practical Statistics for Medical Research. 2nd ed.
major depression: protocol for a systematic review and indi- London, England: Chapman & Hall; 2006.

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