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

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2 Journal of Cardiovascular Nursing x Month 2017
supine to urinate is foreign and difficult for most people,
and urinary retention is distressing and embarrassing.2
The change of posture from sitting or standing to
urinate to lying supine to urinate is a significant fac-
tor contributing to post-PCI voiding difficulty.9 Re-
search examining the influence of posture on urination
demonstrates the importance of foot support for pelvic
floor relaxation.10Y13 Having the feet supported influences
pelvic position and tone of the pelvic floor muscles.12,13
Voiding without feet resting on the floor also impedes
bladder emptying and increases the delay between feel-
ing the need to void and actually doing so.12Y14 In a study
comparing uroflowmetric parameters and postvoid
residual urine volumes, urinary flow rate decreased
in the supine position.14 Furthermore, bedridden pa-
tients are predisposed to urinary tract infections because
of alterations in voiding dynamics in the recumbent
position.15
Educating patients to urinate in the supine position
is a common method to prevent voiding difficulty after
PCI. This however seems to have limited benefit, with
as many as half of all patients still experiencing im-
paired micturition after PCI.2,5 Lei et al16 taught women
to use a semisquatting position when urinating, none
of whom experienced urinary retention in the postpar-
tum period. Ma et al17 compared the effects of supine
positioning with bent knees and hip lift on micturi-
tion for abdominal surgery patients, finding that this
position could significantly reduce the time to the first
void after surgery and the urinary retention rate.17 The
common feature of these methods is mimicking the
normal micturition posture and using feet support to
facilitate patients" urination.
Because it is necessary to keep the legs straight for
at least 12 hours after PCI to prevent bleeding, we
hypothesized that, for patients undergoing PCI, a
modified supine position with feet support could:
h reduce the rate of impaired micturition;
h reduce residual urinary volume (RUV) after the first
void; and
h preserve normal bladder function.
Method
Design and Sample
A randomized controlled trial was conducted in a
cardiology department in a 1500-bed tertiary hospital
in Beijing, China, between June 2012 and January
2014. The study was approved by the university review
board and the hospital"s Director of Nursing. The re-
search protocol conformed with the provisions of the
Declaration of Helsinki (1995). Medical records of
suitable patients were screened for demographics,
medication, and health history to identify potential
participants.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Patients who met the inclusion criteria were con-
secutively recruited. Inclusion criteria were (1) given
a diagnosis of cardiovascular disease, (2) undergoing
elective inpatient transfemoral PCI, (3) aged 30 to
80 years, (4) able to urinate without problem and ex-
press the intention to urinate, and (5) alert and able
to consent. We focused on patients who underwent
transfemoral PCI because it typically requires 12 to
24 hours bed rest postprocedure, which commonly
results in impaired micturition.
Patients younger than 30 years were excluded be-
cause our pilot study found that many of these patients
were very embarrassed when calling for the research
nurse to assist with urination. Furthermore, people in
this age group do not typically require a PCI. Patients
older than 80 years were excluded because many of
them may have age-related urination problems, which
may have influenced study outcomes.
Exclusion criteria were (1) intraoperative Foley cathe-
terization; (2) history of prostatic hyperplasia, prostatic
carcinoma, urinary tract infection, urologic disorders,
sensory disorders, or neurological problems; (3) spinal
or epidural anesthesia; (4) inability to communicate;
and (5) signs of cognitive impairment.
Patients meeting the inclusion criteria were informed
of the procedure and purpose of the study. Written
informed consent was obtained. All participants had
the right to withdraw at any time. Participants were
reassured that their data would be kept confidential
and that their identity would not be revealed when the
study is published.
All participants received physical assessment by a
physician, including urinary assessment, before the
PCI. All participants could urinate with no difficulty.
Urinary system assessments were normal for all par-
ticipants before PCI.
Procedure
A computer-based random number generator was used
to divide participants into intervention and control
groups. Written allocation of group assignment was
provided in opaque, sealed envelopes, labeled with con-
secutive number ordering. Envelopes were prepared by
an independent research assistant who was blinded to
the group allocation. Envelopes were distributed to
participants by another research assistant who had no
other involvement in the trial.
Consistent with local practice, patients underwent
PCI with local anesthesia using lidocaine. All PCIs were
performed via the TFA. Angio-Seal vascular closure is
not covered by health insurance for Chinese citizens.
Most participants therefore chose manual compression
for hemostatic puncture closure (see Table 1).
Post-PCI care was performed as follows. Patients
in the control group received standard clinical care,
 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
noted when urination ceased (T2). The difference be-
tween T1 and T2 was noted as time to the first void.
Micturition function was divided into 4 levels, de-
pending on the time to the first void as defined previously.
The 4 levels were the following20:
Level 0: urinating within 1 minute
Level 1: urinating within 1 to 30 minutes
Level 2: urinating within 1 to 30 minutes and needing
assistance such as massage or heat pack to do so
Level 3: cannot urinate by self or with other assistance
methods and needs urinary catheterization
Levels 2 to 3 are regarded as impaired micturition.
Secondary outcome variables included RUV, volume
of the first void, and urinary retention rate. Residual
urinary volume was noted by a portable ultrasound
device using a 3.5-MHz probe (Adara SONOLINE
50643406; Siemens, Germany). Bladder scanning was
performed to ensure uniformity of data. Urinary
retention was defined as the need for catheterization
within 24 hours of the procedure.21
The complication rate after PCI was also noted to
assess the safety of the modified supine position. Com-
plications assessed for included back pain, deep venous
thrombosis, and local wound complications (hematoma,
subcutaneous hemorrhage, pseudoaneurysm). Pain was
assessed by a visual analog scale, which has established
validity and reliability.22 Before and immediately after
the procedure, participants were asked whether they
had pain in the puncture site, chest, or back.
Deep venous thrombosis and local wound complica-
tions were identified via documentation in the patient"s
chart. Level of postoperative anxiety and depression
was measured by the Hospital Anxiety and Depression
Scale, which has demonstrated reliability and validity.23,24
Anxiety and depression are risk factors for postoper-
ative urinary retention.25 Baseline data were collected
from medical records. The research nurse received
training for data collection, including how to measure
RUV with the ultrasound device.
Pilot Study
A pilot study was conducted to determine feasibility of
the study. Nineteen patients meeting the inclusion criteria
were recruited and randomly assigned to 2 groups. The
pilot study indicated that the study was feasible, finding
that 30% of the patients in the intervention group and
55% in the control group had abnormal bladder function.
No patients in the pilot study experienced urinary reten-
tion, catheterization, or complications after PCI.
Sample Size
In a previous study, the incidence of abnormal bladder
function in PCI patients was 55% in the control group
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
and 30% in the intervention group.5 We therefore ex-
pected a 25% difference in the incidence of abnormal
bladder function between the intervention and control
groups. Sample size calculation indicated that 260 pa-
tients were required to detect a difference between the
2 groups (2-tailed, ! = .01; power, 0.9). It was decided
to recruit 300 participants to allow for attrition.
Statistical Analysis
Central tendency was described as mean and standard
deviation for continuous data with a normal distribu-
tion and median value with the first and third quartiles
for abnormal distribution. The # 2 test was used to test
the difference between the 2 groups for categorical
data. Mann-Whitney U test or Student t test was used
for continuous data. The distribution of time to the
first void was logarithmically transformed for analy-
ses and standardized. Statistical significance was set at
P G .05. Statistical analyses were conducted using
SPSS 13.0 for Windows (SPSS Inc, Chicago, Illinois).
Two nurses working in the cardiology department
extracted data for analysis.
Results
Baseline Characteristics
Three hundred fifty-seven patients were assessed for
eligibility, with 311 meeting the inclusion criteria
(Figure 2). Three patients declined to participate, and
8 were lost because of transferring to another ward or
because of incomplete data. Three hundred patients were
entered into the final analysis. There were no significant
differences between the 11 patients lost to the study and
the remaining 300 on baseline characteristics.
Among the 300 participants, 150 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 (P G .05;
see Table 1).
Primary and Secondary Outcomes
As shown in Figure 3 and Table 2, patients in the inter-
vention group had significantly better bladder function.
Time to the first void was 5 minutes (Q12,Q310) in the
intervention group, which was significantly shorter
than that in the control group (15 minutes; Q13,Q360).
The intervention group showed better micturition func-
tion with a lower rate of impaired micturition (defined
as micturition function levels 2 and 3) compared with
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).
Time of the first void after returning from the proce-
dural room in the intervention group was significantly
shorter than that in the control group (1.31 T 0.68 vs

FIGURE 2. Patient allocation.
2.07 T 0.91 hours, P G .0001). Nearly all patients in the
intervention group (92%) urinated within 2 hours of
returning from the procedure room, but only 68% in
the control group did so (# 2 = 27.000, P G .0001).
Six patients in the intervention group and 8 patients
in the control group had post-PCI urinary retention (P =
.584). No patients in either group experienced deep venous
thrombosis or local wound complications. Primary and
secondary outcomes are presented in Tables 2 and 3.
Discussion
This study showed that a modified supine position with
foot support can preserve normal bladder function in
patients undergoing PCI. This modified position short-
FIGURE 3. Micturition function between groups (n = 150).
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A Modified Supine Position Facilitates Bladder Function 5
ened the time to first void, improved micturition func-
tion, and reduced RUV.
A trial by Ma et al17 also reported a shorter time to
the first void using a foot support voiding position for
patients after abdominal surgery. The average time to
the first void was 0.84 T 0.22 minutes in the inter-
vention group in Ma et al"s study, which is much shorter
than our results (5 minutes as median). A possible
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
their knees and lift their hips when micturating. In our
study, patients had to lie on a sloped bed elevated at an
angle of 20-. Bed elevation in Ma et al"s regimen may
have been greater than 20-, explaining this difference.
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.

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What’s New and Important
h Standard care after PCI typically involves a period of
bed rest in the supine position, but this position
creates voiding difficulties.
h A modified supine position with foot support can
reduce the incidence of impaired micturition and
preserve normal bladder function post-PCI.
h The maintenance of normal bladder function post-PCI
avoids risks associated with urinary catheterization
and associated prolonged hospital stay.
morbidity.2 Impaired micturition is also poorly de-
fined, and its clinical implications are not immediately
apparent.2 Nonetheless, impaired micturition after
surgery may require catheterization and result in
delayed hospital discharge. Post-PCI, it is not uncom-
mon for patients to develop contrast-induced nephrop-
athy due to the impaired ability to micturate. In
our trail, 92% of patients in the intervention group
urinated within 2 hours after PCI, compared with 68%
in the control group (P G .0001).
Limitations
The trial was not blinded because of the nature of the
intervention, which may have led to observer bias. The
use of randomization may have reduced this risk.
Objective measurements, such as time to the first void,
RUV, and volume of the first void, may have reduced
this bias.29 A portable ultrasound device, the criterion
standard for determining RUV,7 was also used to further
minimize observer bias.
This study was conducted in a cardiovascular unit
and excluded patients with intraoperative Foley cath-
eterization and history of cognitive impairment, pros-
tatic hyperplasia, or urological, sensory, or neurological
problems. Caution is therefore advised when generalizing
the results to other patients with postoperative impaired
micturition, such as those younger than 30 or older than
80 years. Furthermore, this study was conducted in only
1 medical center, although it had a large enough sample
to reach statistical significance. Replications of the trial
in multicenters are recommended for further study.
Conclusions
This study demonstrates that a modified supine posi-
tion with foot support can reduce the incidence of
impaired micturition and preserve normal bladder
function after PCI. Further studies of this position on
other postoperative patients at risk of impaired micturi-
tion are warranted.
Acknowledgments
The authors thank all the study participants for their
time and for providing valuable data. They also thank
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A Modified Supine Position Facilitates Bladder Function 7
the directors of nursing departments of the study hos-
pitals and nursing managers of the participating units
for helping with participant recruitment and all faculty
members from School of Nursing, Capital Medical
University, for their enduring support, assistance, and
valuable comments on the design of this study.
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