Hip fractures are a major cause of morbidity, functional decline, institutional care, and mortality in older adults. Operative treatment is generally required to restore mobility and reduce complications related to prolonged immobilization. Despite advances in perioperative pathways, elderly patients with hip fractures remain vulnerable to complications because of frailty, multimorbidity, pain, altered mobility, polypharmacy, and age-related physiological reserve. Urinary dysfunction is particularly relevant in this population because it can interfere with early mobilization and rehabilitation, yet it receives less attention than cardiopulmonary, thromboembolic, infectious, or neurological complications. Postoperative urinary retention (POUR) is commonly defined as inability to void adequately despite a distended bladder after surgery. Reported incidence varies widely because definitions, bladder-volume thresholds, anesthetic techniques, catheter protocols, surgical populations, and monitoring practices differ between studies [1]. In elderly patients treated for hip fracture, clinically important urinary retention has been documented across both acute postoperative and rehabilitation settings [2-8]. Recent prospective evidence indicates that POUR remains frequent after fragility hip fracture surgery and that lower urinary tract symptom burden, medications with anticholinergic effects, opioid exposure, and impaired early mobilization can contribute to risk [2]. Earlier hip-fracture studies have likewise implicated sex, age-related urinary dysfunction, catheter timing, cognitive or functional impairment, and perioperative factors [3-8]. The pathophysiology of POUR is multifactorial. Anesthesia can temporarily suppress sacral reflexes, bladder sensation, and detrusor contractility, while postoperative pain can increase sympathetic outflow and outlet resistance [1]. Opioids further interfere with parasympathetic detrusor activation and can increase sphincter tone, particularly in susceptible older adults [1,14]. Spinal anesthesia has repeatedly been examined as a risk factor in orthopedic populations, although findings vary with local anesthetic duration, intrathecal opioid exposure, and catheter-management protocols [11-13]. In parallel, pre-existing lower urinary tract symptoms (LUTS) can identify reduced baseline urinary reserve, making perioperative bladder dysfunction more likely [2,4,5]. POUR has practical consequences beyond transient discomfort. Bladder overdistension can impair detrusor function, while catheterization undertaken for retention exposes patients to urethral trauma and infection risk [1,9,10]. In hip fracture care, prolonged catheter use has been associated with urinary tract infection, and urinary complications can increase clinical workload and hinder rehabilitation [9]. Recognition of high-risk patients is therefore important for rational bladder scanning, timely catheterization, cautious catheter removal, early mobilization, and individualized analgesic strategies. The present study was undertaken to characterize POUR in an Indian tertiary-care hip fracture population. The primary objective was to determine the incidence of postoperative urinary retention among elderly patients undergoing surgical treatment for hip fractures. The secondary objectives were to examine associations between POUR and age, sex, pre-existing LUTS, type of anesthesia, operative duration, and postoperative opioid use, and to compare selected postoperative outcomes, including length of hospital stay and urinary tract infection, between patients with and without POUR.

Study design and setting: This prospective observational study was conducted at RVM Institute of Medical Sciences and Research Centre, Laxmakkapally, Siddipet, Telangana, India, from October 2025 to June 2026. Consecutive eligible elderly patients admitted with hip fractures and planned for operative management were screened during the study period. A pragmatic sample of 50 participants was enrolled and followed prospectively through the postoperative hospital stay. Participants: Patients aged 60 years or older with radiologically confirmed femoral neck, intertrochanteric, or subtrochanteric fractures who underwent surgical fixation or arthroplasty were eligible. Patients with chronic indwelling urinary catheters, documented chronic urinary retention, known neurogenic bladder requiring catheterization, recent major urological surgery, or inability to complete postoperative urinary assessment were excluded. Pre-existing LUTS did not constitute an exclusion criterion because symptom burden was a prespecified exposure of interest. Written informed consent was obtained from participants or legally acceptable representatives. Necessary Permissions were obtained before starting the study. Data collection: Baseline variables included age, sex, fracture pattern, hypertension, diabetes mellitus, ischemic heart disease, chronic kidney disease, and history of LUTS. Perioperative data comprised surgical procedure, type of anesthesia, operative duration, intravenous fluid volume, and postoperative opioid administration. Patients were observed for spontaneous voiding, symptoms of bladder distension, requirement for intermittent or indwelling catheterization, time to POUR diagnosis, urinary tract infection, and postoperative length of stay. Outcome definition and bladder assessment: POUR was defined as failure to achieve satisfactory spontaneous voiding after surgery or catheter removal in the presence of clinically significant bladder filling, supported by bedside bladder-volume assessment. In patients with inability to void or suprapubic discomfort, bladder ultrasonography was used when available; a bladder volume of approximately 400 mL or greater, together with failure to void, was considered clinically significant, consistent with contemporary hip-fracture protocols [2,3]. Catheterization was performed when indicated to prevent prolonged overdistension. This approach reflects evidence supporting structured bladder assessment and selective catheter use in older hip-fracture patients [3,8-10]. Statistical analysis: Data were summarized as mean ± standard deviation for continuous variables and frequency with percentage for categorical variables. POUR incidence was calculated as the number of patients meeting the outcome definition divided by the total sample. Categorical associations were assessed using Pearson’s chi-square test when expected cell counts were adequate and two-sided Fisher’s exact test for sparse tables. Continuous postoperative length of stay was compared using an independent-samples t-test based on the available summary data. A two-sided p-value <0.05 was considered statistically significant. Because only 12 POUR events occurred, multivariable logistic regression was not performed, avoiding an unstable overfitted model in this small observational cohort.

A total of 50 elderly patients undergoing surgery for hip fractures were included in the final analysis. The mean age was 74.8 ± 7.9 years, with a range of 60-91 years. Thirty-two (64.0%) participants were female and 18 (36.0%) were male. Intertrochanteric fracture was the most frequent pattern, occurring in 28 (56.0%) patients, followed by fracture neck of femur in 17 (34.0%) and subtrochanteric fracture in 5 (10.0%). Hypertension was present in 27 (54.0%), diabetes mellitus in 19 (38.0%), and pre-existing LUTS in 9 (18.0%) patients. Baseline characteristics are summarized in Table 1. Table 1. Baseline demographic and clinical characteristics of patients with hip fractures (n=50) Characteristic n (%) / Mean ± SD Age, years, mean ± SD 74.8 ± 7.9 Age group, years 60-69 14 (28.0) 70-79 22 (44.0) ≥80 14 (28.0) Sex Male 18 (36.0) Female 32 (64.0) Type of hip fracture Intertrochanteric fracture 28 (56.0) Neck of femur fracture 17 (34.0) Subtrochanteric fracture 5 (10.0) Hypertension 27 (54.0) Diabetes mellitus 19 (38.0) Ischemic heart disease 8 (16.0) Chronic kidney disease 4 (8.0) Pre-existing lower urinary tract symptoms 9 (18.0) Postoperative urinary retention developed in 12 of 50 patients, giving an incidence of 24.0%; the remaining 38 (76.0%) achieved spontaneous postoperative voiding without clinically significant retention. Among patients with POUR, the mean time from completion of surgery to diagnosis was 8.6 ± 3.1 hours and the mean bladder volume at diagnosis was 612 ± 146 mL. Ten of the 12 patients required temporary indwelling catheterization, while two were managed with intermittent catheterization and observation. Nine cases resolved within 48 hours (Table 2). Table 2. Postoperative urinary outcomes among study participants (n=50) Urinary outcome n (%) / Mean ± SD Postoperative urinary retention 12 (24.0) Spontaneous postoperative voiding 38 (76.0) Time to diagnosis of POUR, hours* 8.6 ± 3.1 Bladder volume at diagnosis, mL* 612 ± 146 Temporary indwelling catheterization* 10 (83.3) Intermittent catheterization/observation* 2 (16.7) Resolution within 48 hours* 9 (75.0) Persistence beyond 48 hours* 3 (25.0) *Calculated among the 12 patients who developed postoperative urinary retention. Spinal anesthesia was used in 38 (76.0%) patients and general anesthesia in 12 (24.0%). The mean operative duration was 86.4 ± 28.7 minutes; 20 (40.0%) operations exceeded 90 minutes. Postoperative opioids were administered to 25 (50.0%) patients. Proximal femoral nail fixation was the most common procedure, performed in 26 (52.0%) participants (Table 3). Table 3. Surgical and perioperative characteristics of patients with hip fractures (n=50) Characteristic n (%) / Mean ± SD Type of surgical procedure Proximal femoral nail fixation 26 (52.0) Hemiarthroplasty 15 (30.0) Dynamic hip screw fixation 6 (12.0) Total hip arthroplasty 3 (6.0) Type of anesthesia Spinal anesthesia 38 (76.0) General anesthesia 12 (24.0) Duration of surgery, minutes 86.4 ± 28.7 Surgery duration >90 minutes 20 (40.0) Postoperative opioid use 25 (50.0) Intravenous fluid volume, mL 1685 ± 524 Univariable comparisons demonstrated a significant association between pre-existing LUTS and POUR: retention occurred in 5 of 9 patients with LUTS (55.6%) compared with 7 of 41 without LUTS (17.1%; p=0.027). POUR was also more frequent when operative duration exceeded 90 minutes (40.0% vs. 13.3%; p=0.044) and among patients receiving postoperative opioids (36.0% vs. 12.0%; p=0.047). Male patients had a higher numerical rate than female patients (38.9% vs. 15.6%; p=0.089), but the difference was not statistically significant. Similarly, POUR was observed in 28.9% after spinal anesthesia and 8.3% after general anesthesia (p=0.248). Age category was not significantly associated with POUR (Table 4). Table 4. Factors associated with postoperative urinary retention among patients with hip fractures (n=50) Variable POUR n/N (%) No POUR n/N (%) p-value Age <75 years 4/26 (15.4) 22/26 (84.6) 0.138† Age ≥75 years 8/24 (33.3) 16/24 (66.7) Male sex 7/18 (38.9) 11/18 (61.1) 0.089‡ Female sex 5/32 (15.6) 27/32 (84.4) Pre-existing LUTS: present 5/9 (55.6) 4/9 (44.4) 0.027‡ Pre-existing LUTS: absent 7/41 (17.1) 34/41 (82.9) Spinal anesthesia 11/38 (28.9) 27/38 (71.1) 0.248‡ General anesthesia 1/12 (8.3) 11/12 (91.7) Surgery duration >90 minutes 8/20 (40.0) 12/20 (60.0) 0.044‡ Surgery duration ≤90 minutes 4/30 (13.3) 26/30 (86.7) Postoperative opioid use: yes 9/25 (36.0) 16/25 (64.0) 0.047† Postoperative opioid use: no 3/25 (12.0) 22/25 (88.0) POUR: postoperative urinary retention; LUTS: lower urinary tract symptoms. †Pearson chi-square test; ‡two-sided Fisher’s exact test. Statistical significance was set at p<0.05. Patients who developed POUR had a longer postoperative hospital stay than those without retention (7.8 ± 2.4 vs. 5.9 ± 1.8 days; p=0.006). Urinary tract infection occurred in 3 of 12 patients with POUR (25.0%) and 2 of 38 without POUR (5.3%). Although the frequency was higher in the POUR group, the difference was not statistically significant on Fisher’s exact testing (p=0.082). No patient required permanent urinary catheterization; urinary retention resolved before discharge in all but one patient, who was advised urological follow-up (Table 5). Table 5. Selected postoperative outcomes according to postoperative urinary retention status Outcome POUR (n=12) No POUR (n=38) p-value Postoperative hospital stay, days, mean ± SD 7.8 ± 2.4 5.9 ± 1.8 0.006† Urinary tract infection, n (%) 3 (25.0) 2 (5.3) 0.082‡ †Independent-samples t-test; ‡two-sided Fisher’s exact test.

The present prospective observational study found that 24.0% of elderly patients undergoing hip fracture surgery developed POUR. This frequency lies within the broad range reported in older orthopedic populations and is clinically plausible given the variability in POUR definitions, catheter protocols, and surveillance methods [1]. In hip-fracture-specific studies, Tantigate et al. reported a 15.2% incidence after catheter removal, whereas Kwak et al. observed POUR in 31.8% of elderly surgical patients [2,3]. Johansson and Christensson reported urinary retention in 38% of older patients recovering after hip fracture surgery [8], while Thomas et al. documented POUR in 16.8% of a large hip fracture cohort [9]. Differences between these estimates emphasize the influence of case mix, bladder scanning, timing of catheter removal, and outcome thresholds. Pre-existing LUTS showed a significant association with POUR in the current cohort. This finding is biologically coherent because baseline voiding symptoms can indicate reduced detrusor reserve, outlet obstruction, or impaired coordination that becomes clinically apparent after anesthesia, pain, immobility, and medication exposure. Tantigate et al. identified higher International Prostate Symptom Scores as a strong predictor of POUR, and earlier studies of hip fracture surgery also highlighted preoperative urinary factors in risk assessment [2,4,5]. Screening for LUTS is therefore a low-cost component of perioperative evaluation. Operative duration exceeding 90 minutes was associated with a higher POUR rate. Longer surgery can reflect greater physiological stress, fluid exposure, analgesic requirement, and prolonged suppression of normal voiding. Orthopedic studies have linked perioperative and anesthetic characteristics with retention, although the strength of individual predictors is inconsistent [11-13]. Spinal anesthesia showed a numerically higher POUR rate in our cohort but did not reach statistical significance. This is compatible with the recognized inhibitory effect of neuraxial anesthesia on bladder sensation and detrusor function while also reflecting limited statistical power in a 50-patient sample [1,11,12]. Postoperative opioid use was associated with POUR in univariable analysis. Opioids can suppress parasympathetic outflow to the detrusor and increase outlet tone, providing a credible mechanism for this observation [1,14]. The result supports opioid-sparing multimodal analgesia where clinically appropriate, without compromising pain control needed for mobilization. Historical hip fracture studies also demonstrate that urinary retention can affect recovery trajectories and functional outcomes [6,7]. Patients with POUR stayed longer in hospital, reinforcing its relevance as more than a transient postoperative event. Urinary tract infection was numerically more frequent among patients with POUR, although the difference was not statistically significant when sparse-cell testing was applied. Catheter exposure and duration remain important because prolonged catheter use has been associated with UTI in hip fracture populations [9], while management studies support structured assessment and selective intermittent or indwelling catheterization rather than prolonged unmonitored bladder distension [10]. Overall, the findings favor early risk recognition, targeted bladder scanning, careful catheter decisions, mobilization, and judicious opioid use. Limitations This study was conducted at a single centre with a small sample of 50 patients and only 12 POUR events, limiting precision and precluding reliable multivariable adjustment. POUR assessment depended on clinically indicated bladder-volume evaluation rather than a rigid universal scanning schedule. Some potential predictors, including frailty, cognitive status, constipation, anticholinergic medication burden, and exact opioid dose, were not captured. These factors restrict causal interpretation and external generalizability.

Postoperative urinary retention was observed in 24.0% of elderly patients undergoing surgical treatment for hip fractures, indicating a relevant postoperative burden. Pre-existing lower urinary tract symptoms, operative duration exceeding 90 minutes, and postoperative opioid administration were associated with a higher occurrence of POUR in univariable analysis. Patients who developed retention also experienced longer hospitalization. These findings support preoperative urinary symptom assessment, early postoperative surveillance, bladder scanning in symptomatic or high-risk patients, careful catheter management, and opioid-sparing analgesic strategies where appropriate. Larger multicentre prospective studies with standardized POUR definitions, scheduled bladder assessment, and multivariable modeling are required to clarify independent predictors and develop risk-stratification protocols for elderly hip fracture patients.

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