Immediate Versus 24-hour Removal of Urinary Catheter After Emergency Caesarean Section: A Randomized Controlled Trial

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Oluwole, Emoekpere Hilary, Wakili Israel, Olasunkanmi Samson Coker, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9016682/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Background Routine 24-hour catheterization remains common after caesarean section despite Enhanced Recovery after Surgery (ERAS) protocols recommending early urinary catheter removal, owing in part to concerns about postoperative urinary retention. While evidence supports immediate removal following elective caesarean delivery, data for emergency procedures are limited. Emergency caesarean sections constitute most caesarean deliveries globally and carry higher risks of bladder dysfunction, infection, and delayed recovery. This trial evaluates whether immediate catheter removal after emergency caesarean section improves maternal recovery and reduces infectious morbidity without increasing urinary retention. Methods We conducted an open-label randomized controlled trial at a Nigerian tertiary hospital between June 2021 and February 2022. Two hundred ten women undergoing emergency CS were randomly assigned (1:1) to immediate catheter removal on the operating table (intervention, n = 105) or removal at 24 hours postoperatively (control, n = 105). The primary outcome was acute urinary retention (inability to void within 6 hours requiring recatheterization with drainage ≥ 150 mL). Secondary outcomes included significant bacteriuria (≥ 10⁵ colony-forming units/mL at 48 hours), urinary symptoms, recovery indices (time to ambulation, hospital stay), and catheter-related discomfort. Analysis was by intention-to-treat. Results Baseline characteristics were comparable between groups. Acute urinary retention occurred significantly more frequently in the immediate removal group (7/105, 6.7% vs. 0/105, 0%; P = 0.021). Conversely, the incidence of significant bacteriuria was significantly higher in the 24-hour removal group (19/105, 18.1% vs. 8/105, 7.6%; P = 0.023; RR 2.38, 95% CI 1.09–5.19), with Escherichia coli as the predominant isolate (66.7%). Immediate removal significantly reduced time to ambulation (10.57 ± 2.54 vs. 28.70 ± 2.80 hours; P < 0.001), hospital stay (2.47 ± 0.83 vs. 3.30 ± 0.68 days; P < 0.001), and catheter-related discomfort (mean NRS 0.34 ± 0.96 vs. 4.14 ± 1.47; P < 0.001). No significant differences were observed in voiding difficulties or time to first bowel sounds. Conclusion Immediate urinary catheter removal following emergency caesarean section significantly reduces infectious morbidity, facilitates faster ambulation, and improves patient comfort. While associated with a modest increase in transient urinary retention, the overall benefits to maternal recovery and hospital throughput support its implementation as a standard component of ERAS protocols for emergency caesarean delivery in appropriately screened women. Trial Registration Pan African Clinical Trials Registry (PACTR202203693872412) Registration Date March 2022 caesarean section urinary catheter early removal catheter-associated urinary tract infection postpartum urinary retention enhanced recovery after surgery randomized controlled trial Figures Figure 1 BACKGROUND Caesarean section (CS) is one of the most commonly performed surgical procedures globally, accounting for approximately 21% of all births, with rates continuing to rise [ 1 , 2 ]. While CS is life-saving when medically indicated, it is associated with higher maternal morbidity and longer recovery compared with vaginal delivery [ 3 ]. Historically, indwelling urethral catheterization has been a near-universal perioperative component of CS, intended to prevent intraoperative bladder injury and improve surgical visualization [ 4 ]. However, the global rise in CS rates has necessitated a shift toward evidence-based recovery protocols that prioritize the reduction of complications and the optimization of hospital resources. A critical, yet debated, element of postoperative care is the timing of catheter removal. While catheterization facilitates intraoperative safety and postoperative urine output monitoring, its prolonged use is a primary driver of catheter-associated urinary tract infections (CAUTI), which account for up to 40% of all nosocomial infections [ 5 ]. The risk of significant bacteriuria increases by 3–7% for each day of catheterization, contributing to increased healthcare costs, prolonged hospitalization, and escalating antimicrobial resistance [ 6 ]. Beyond infectious risks, indwelling catheters contribute to non-infectious morbidities, including urethral trauma, bladder spasms, delayed ambulation, and a higher risk of venous thromboembolism [ 7 ]. These factors collectively impair maternal-infant bonding and can negatively impact the overall childbirth experience [ 8 ]. Concerns regarding postpartum urinary retention (PUR) have historically sustained the practice of prolonged catheterization, despite strong evidence favoring early removal. Reported incidence ranges from 1.3% to 24.1% due to inconsistent definitions and study populations, with risk factors including prolonged labour, operative vaginal delivery, nulliparity, epidural analgesia, and emergency CS [ 9 , 10 ]. Several randomized controlled trials have examined optimal catheter removal timing following CS, comparing immediate, early, and delayed removal, and evidence now strongly advocates for minimizing catheter duration. A 2023 network meta-analysis confirmed that catheter removal within 0–6 hours is optimal for preventing UTI and accelerating recovery [ 9 ]. However, optimal duration remains controversial due to persistent concerns regarding PUR following immediate removal [ 11 ]. Critically, a substantial evidence gap exists regarding catheter management in emergency caesarean sections. Most existing randomized controlled trials (RCTs) have focused on elective CS, where patients are typically optimized and not in labor [ 12 , 13 , 42 ]. Women undergoing emergency CS represent a distinct physiological cohort; they are often in active labor, may have experienced prolonged second-stage bladder compression, and are subject to higher rates of surgical trauma and blood loss [ 14 ]. Despite emergency procedures constituting the majority of CS in low-resource settings [ 15 ], dedicated RCTs for this high-risk population are scarce. In Nigeria, emergency CS predominates, yet practices like routine 24-hour catheterization remain unoptimized. At Federal Medical Centre, Makurdi—where 60.4% of CS are emergencies [ 16 ]—we evaluated whether immediate versus 24-hour removal after emergency CS reduces morbidity and accelerates recovery. We hypothesized immediate removal shortens ambulation and reduces infection without significantly increasing urinary retention. METHODS Study Design and Setting This was an open-label, parallel-group randomized controlled trial conducted at the Department of Obstetrics and Gynaecology, Federal Medical Centre, Makurdi, Nigeria, between June 2021 and February 2022. The study adhered to the principles of the Declaration of Helsinki and was reported in accordance with the CONSORT 2010 guidelines [ 17 ]. Participants We included women scheduled for emergency caesarean section (primary or repeat lower segment CS) who provided written informed consent. Emergency CS was defined as delivery indicated by immediate maternal or fetal compromise requiring expedited delivery, consistent with RCOG categories 1 and 2 [ 18 ]. Exclusion criteria were: (1) positive UTI screening; (2) chorioamnionitis; (3) severe hemorrhage; (4) severe preeclampsia/eclampsia; (5) obstructed labor; (6) uterine rupture; (7) general anesthesia; (8) iatrogenic bladder injury. Sample Size Calculation Sample size was calculated for an equivalence trial comparing two proportions [ 19 ]. Based on previous studies reporting PUR incidence of 13.8% [ 10 ], we assumed a non-inferiority margin of 10%. With α = 0.05, power = 80%, and anticipating 10% attrition, the minimum sample size was 97 per group. We enrolled 10 5 per group (total N = 210). Randomization and Allocation Concealment A computer-generated random sequence (1:1 allocation ratio) was created by an independent statistician. Allocation concealment was ensured using sequentially numbered, opaque, sealed envelopes. The microbiologist assessing urine cultures and the data analyst were blinded to group allocation. Interventions All participants underwent standard preoperative preparation. Under aseptic technique, a 16-French Foley catheter was inserted before spinal anesthesia. Antibiotic prophylaxis (ceftriaxone 1g intravenously) was administered within 30 minutes of incision. Group A (Intervention) : Catheter removed immediately after surgery completion. Group B (Control) : Catheter retained and removed at 24 hours postoperatively. Outcome Measures Primary outcome : Acute urinary retention (inability to void within 6 hours of catheter removal with painful palpable bladder, necessitating recatheterization with drainage ≥ 150 mL) [ 20 ] Secondary outcomes : Significant bacteriuria (≥ 10⁵ CFU/mL at 48 hours) [ 6 ]; urinary symptoms; fever; time to first void, ambulation, and discharge; catheter-related pain (Numeric Rating Scale 0–10) [ 21 ] Statistical Analysis Data were analyzed using SPSS version 23.0. Continuous variables were compared using independent t-tests; categorical variables using Chi-square or Fisher's exact test. Relative risks (RR) with 95% CI were calculated. Statistical significance was set at P < 0.05. Ethical Considerations Ethical approval was obtained from the Health Research Ethics Committee of Federal Medical Centre, Makurdi (FMCM/HREC/2021/056). The trial was registered with the Pan African Clinical Trials Registry (PACTR202203693872412); Registration Date: March 2022. RESULTS Participant Flow and Baseline Characteristics A total of 232 women scheduled for emergency CS were assessed for eligibility between June 2021 and February 2022. Twenty-two women were excluded: 5 declined participation, and 17 met exclusion criteria (6 positive UTI screening, 4 obstructed labor, 3 antepartum hemorrhage, 2 pre-eclampsia, 2 general anesthesia). The remaining 210 women were randomized equally (105 per group). All participants received the allocated intervention and completed follow-up; none were lost to follow-up. All 210 were included in the final intention-to-treat analysis (Fig. 1 ). Baseline characteristics were comparable between groups (Table 1 ). The mean age was 28.10 ± 4.93 years in the immediate removal group and 27.08 ± 5.03 years in the 24-hour removal group (P = 0.468). The majority of participants were aged 26–30 years (41.4%), were para 2 (32.4%), and delivered at 37–39 weeks (74.3%). Parity distribution was similar between groups (mean 2.26 ± 1.28 vs. 2.27 ± 1.50; P = 0.087). Table 1 Baseline Characteristics of Study Participants Variable Immediate Removal (n = 105) 24-hour Removal (n = 105) P-value Age (years), mean ± SD 28.10 ± 4.93 27.08 ± 5.03 0.468 Parity, mean ± SD 2.26 ± 1.28 2.27 ± 1.50 0.087 Gestational age (weeks), mean ± SD 37.88 ± 1.21 38.17 ± 1.39 0.165 Age 26–30 years, n (%) 46 (43.8%) 41 (39.0%) 0.561 Primary Outcomes Acute Urinary Retention Acute urinary retention occurred significantly more frequently in the immediate removal group, affecting 7 women (6.7%), compared with no women (0%) in the 24-hour removal group (continuity correction χ²=5.32, P = 0.021; Table 2 ). The mean volume drained at recatheterization for these 7 women was 278.57 ± 24.78 mL (range 150–220 mL). All seven women experienced uneventful subsequent voiding after catheter reinsertion and removal at 24 hours as seen in Table 2 . Table 2 Acute Urinary Retention by Study Group Urinary Retention Immediate Removal (n = 105) 24-hour Removal (n = 105) P-value No 98 (93.3%) 105 (100.0%) Yes 7 (6.7%) 0 (0.0%) 0.021* *Statistically significant Secondary Outcomes Significant Bacteriuria Overall, 27 participants (12.9%) developed significant bacteriuria. The incidence of significant bacteriuria was significantly higher in the 24-hour removal group (19/105, 18.1%) compared with the immediate removal group (8/105, 7.6%; RR 2.38, 95% CI 1.09–5.19; χ²=5.14, P = 0.023; Table 3 ). Escherichia coli was the predominant isolate (18/27, 66.7%), followed by Staphylococcus aureus (6/27, 22.2%) and Pseudomonas aeruginosa (3/27, 11.1%). The distribution of organisms did not differ significantly between groups (Fisher's exact = 1.12, P = 0.676) as seen in Table 4 . Table 3 Significant Bacteriuria by Study Group Significant Bacteriuria Immediate Removal (n = 105) 24-hour Removal (n = 105) P-value No 97 (92.4%) 86 (81.9%) Yes 8 (7.6%) 19 (18.1%) 0.023* RR (95% CI) Reference 2.38 (1.09–5.19) *Statistically significant Table 4 Isolated organisms in significant bacteriuria by study group Organism Immediate Removal (n = 8) 24-hour Removal (n = 19) Total (N = 27) P-value E. coli 6 (75.0) 12 (63.2) 18 (66.7) 0.676 S. aureus 2 (25.0) 4 (21.1) 6 (22.2) Pseudomonas 0 (0.0) 3 (15.8) 3 (11.1) *=Statistically significant, Both = Group A + Group B Urinary Tract Symptoms Although the 24-hour removal group exhibited numerically higher frequencies of fever (3.8% vs. 1.9%), dysuria (7.6% vs. 5.7%), urgency (5.7% vs. 4.8%), suprapubic pain (6.7% vs. 5.7%), and frequency (5.7% vs. 4.8%), none of these differences reached statistical significance (all P > 0.05) as seen in Table 5 . Table 5 Comparison of Urinary Symptoms Outcome Immediate Removal (n = 105) 24-hour Removal (n = 105) Test statistic P-value Fever 2 (1.9) 4 (3.8) Continuity correction = 0.17 0.679 Dysuria 6 (5.7) 8 (7.6) χ²=0.30 0.580 Urgency 5 (4.8) 6 (5.7) χ²=0.09 0.757 Suprapubic pain 6 (5.7) 7 (6.7) χ²=0.08 0.775 Frequency 5 (4.8) 6 (5.7) χ²=0.09 0.757 Straining 1 (1.0) 0 (0.0) Continuity correction = 0.00 1.000 Recovery Indices Women in the immediate removal group ambulated significantly earlier (10.57 ± 2.54 vs. 28.70 ± 2.80 hours; mean difference − 18.13 hours, 95% CI − 18.86 to − 17.40; P < 0.001). Hospital stay was also significantly shorter in the immediate removal group (2.47 ± 0.83 vs. 3.30 ± 0.68 days; mean difference − 0.83 days, 95% CI − 1.03 to − 0.63; P < 0.001). Time to first void (P = 0.351) and time to resumption of bowel sounds (P = 0.198) did not differ significantly between the groups (Table 6 ). Table 6 Comparison of Recovery Indices Outcome Immediate Removal (n = 105) 24-hour Removal (n = 105) Mean Difference (95% CI) t P-value Time to first void (hours) 3.87 ± 1.75 3.45 ± 4.18 0.42 (− 0.46 to 1.30) 0.93 0.351 Time to first ambulation (hours) 10.57 ± 2.54 28.70 ± 2.80 −18.13 (− 18.86 to − 17.40) −49.00 < 0.001* Time to bowel sounds (hours) 4.72 ± 1.29 4.96 ± 1.32 −0.24 (− 0.60 to 0.12) −1.29 0.198 Length of hospital stay (days) 2.47 ± 0.83 3.30 ± 0.68 −0.83 (− 1.03 to − 0.63) −7.98 < 0.001* *Statistically significant Catheter-Related Pain and Discomfort Catheter-related discomfort differed markedly between the groups (Fisher's exact = 212.35, P < 0.001; Table 7 ). In the immediate removal group, 86.7% reported no discomfort, compared with 0% in the 24-hour removal group. Conversely, 73.3% of the 24-hour removal group reported moderate discomfort, and 1.9% reported severe discomfort. The mean NRS score was significantly lower in the immediate removal group (0.34 ± 0.96) versus the 24-hour removal group (4.14 ± 1.47; mean difference − 3.80, 95% CI − 4.14 to − 3.46; t = − 22.04, P < 0.001). Table 7 Catheter-Related Pain and Discomfort Discomfort Category Immediate Removal (n = 105) 24-hour Removal (n = 105) P-value None (NRS 0) 91 (86.7%) 0 (0.0%) Mild (NRS 1–3) 11 (10.5%) 26 (24.8%) Moderate (NRS 4–6) 3 (2.9%) 77 (73.3%) Severe (NRS 7–10) 0 (0.0%) 2 (1.9%) < 0.001* Mean NRS ± SD 0.34 ± 0.96 4.14 ± 1.47 < 0.001* *Statistically significant DISCUSSION This randomized controlled trial provides robust evidence addressing the optimal timing of urinary catheter removal following emergency caesarean section, a clinically important yet previously underexplored aspect of postoperative obstetric care. Our findings demonstrate that while immediate catheter removal is associated with a modest, but manageable, increase in transient acute postpartum urinary retention (PUR), it significantly reduces the incidence of catheter-associated urinary tract infection (CAUTI), accelerates postoperative recovery, shortens hospital stay, and markedly improves patient comfort. Urinary retention The incidence of acute urinary retention observed in the immediate removal group (6.7%) was significantly higher than in the 24-hour removal group, in which no cases occurred. This finding is unsurprising, as prolonged catheterization effectively prevents retention through continuous bladder drainage. Importantly, however, the observed retention rate is clinically acceptable and consistent with existing literature. Reported PUR rates following caesarean section range widely from 1.3% to 24.1%, reflecting heterogeneity in diagnostic criteria, patient populations, anaesthetic techniques, and catheter management practices [ 10 , 11 , 22 ]. The rate observed in this study aligns closely with the 4.7–13.6% reported in trials evaluating early catheter removal following elective caesarean section [ 23 – 26 ] and is substantially lower than the 13.8–39.2% rates reported in earlier studies employing less standardized definitions or intermittent catheterization protocols [ 27 , 28 ]. All women who developed urinary retention responded promptly to re-catheterization and subsequently voided normally within 24 hours, with no evidence of persistent voiding dysfunction. This pattern strongly suggests that PUR associated with immediate catheter removal is functional and reversible rather than indicative of structural bladder injury. The mean bladder volume drained at re-catheterization (278.57 ± 24.78 mL) confirms clinically significant retention and underscores the importance of systematic postoperative monitoring. These findings support the safety of immediate catheter removal when accompanied by clear protocols for early detection and management of retention [ 20 ]. While the absence of retention in the 24-hour removal group may appear advantageous, this benefit must be weighed against the substantial infectious and non-infectious harms associated with prolonged catheterization demonstrated in this and other studies. The pathophysiology underlying this increased PUR risk relates to the persistent effects of regional anesthesia on bladder function. Spinal anesthesia with agents such as bupivacaine and fentanyl can reduce bladder sensation for over 6 hours postoperatively, making immediate voiding difficult despite adequate bladder volume [ 10 , 25 ]. Identification of women at increased risk of PUR may further optimize outcomes. Prolonged labour, epidural analgesia, nulliparity, and operative vaginal delivery have consistently been identified as risk factors for PUR [ 10 , 11 , 20 ], all of which are common in emergency caesarean populations. Future studies should focus on developing validated risk-prediction tools to guide individualized catheter management, allowing most women to benefit from immediate removal while selectively delaying removal in those at highest risk. Catheter-associated urinary tract infection Immediate catheter removal was associated with a clinically meaningful 2.4-fold reduction in significant bacteriuria compared with routine 24-hour catheterization (7.6% vs. 18.1%; RR 2.38, 95% CI 1.09–5.19). This finding is biologically plausible given the well-established dose–response relationship between catheter duration and bacteriuria risk, which increases by approximately 3–7% for each day of catheterization [ 6 ]. The overall CAUTI rate observed in this study (12.9%) is comparable to reports from Nigerian settings, including rates of 12.5% (Onile et al.), 9% (Onyegbule et al.), and 26.9% (Kingsley et al.) [ 28 – 30 ], as well as international studies reporting rates ranging from 1.5–5.2% in high-income settings and approximately 13.4% in comparable low-resource contexts [ 12 , 31 ]. Variability across studies likely reflects differences in catheter duration, antibiotic prophylaxis regimens, microbiological thresholds, and patient characteristics. The predominance of Escherichia coli (66.7%) as the causative organism is consistent with the known microbiology of CAUTI and reflects ascending infection from faecal and perineal colonization [ 32 ]. The anatomical proximity of the female urethra to the anus, combined with postpartum perineal contamination, facilitates this route of infection. The presence of Staphylococcus aureus and Pseudomonas aeruginosa mirrors findings from similar settings [ 28 , 33 ] and highlights the contribution of nosocomial organisms in catheter-related infections. Despite marked differences in bacteriuria, urinary symptoms did not differ significantly between groups, confirming that most CAUTIs in postpartum women are asymptomatic. This observation aligns with the findings of Tambyah and Maki, who reported that only 1–4% of catheterized patients with bacteriuria develop clinical symptoms [ 34 ]. The low incidence of fever despite high bacteriuria rates further underscores the limitations of symptom-based surveillance. These findings emphasize the importance of objective microbiological endpoints in CAUTI research, particularly in postoperative populations where symptoms may be masked or attributed to other causes. Although asymptomatic bacteriuria is often considered benign in non-pregnant populations [ 35 ], the puerperium represents a distinct physiological state characterized by altered immunity, risk of ascending infection, and close maternal–neonatal contact [ 36 ]. Evidence suggests that untreated asymptomatic bacteriuria can progress to symptomatic infection and that treatment reduces this risk [ 37 ]. Therefore, prevention through reduced catheter exposure is particularly relevant. The 10.5% absolute reduction in bacteriuria observed in this study would translate into substantial reductions in antibiotic use and antimicrobial resistance pressure if implemented at scale. Enhanced recovery after surgery The findings strongly support incorporation of immediate catheter removal into enhanced recovery after surgery (ERAS) pathways. Women in the immediate removal group ambulated approximately 18 hours earlier and were discharged nearly one day sooner than those managed with routine catheterization. These differences have important implications for patient satisfaction, healthcare costs, and bed utilization, particularly in resource-constrained settings [ 38 ]. Early mobilization is a cornerstone of ERAS and is associated with reduced venous thromboembolism risk [ 7 ]. Early mobility will also facilitates maternal–infant bonding and breastfeeding initiation [ 8 ]. The similar time to first spontaneous void following catheter removal in both groups challenges the traditional rationale for prolonged catheterization as a means of bladder "rest" and aligns with physiological evidence demonstrating rapid recovery of detrusor function after surgery [ 39 ]. These findings reinforce the concept that prolonged catheterization offers little functional advantage while exposing women to avoidable harm [ 12 ]. Patient-centred outcomes A major strength of this trial is the inclusion of patient-reported outcomes. Moderate-to-severe discomfort was reported by three-quarters of women managed with 24-hour catheterization, compared with almost none in the immediate removal group. These findings are consistent with prior reports of catheter-associated pain [ 40 ] and underscore the substantial contribution of indwelling catheters to negative postoperative experiences. Catheter-related discomfort reflects not only physical irritation but also restricted mobility, dependence on staff, and psychological distress [ 41 ]. By substantially reducing this burden, immediate catheter removal offers meaningful improvements in patient experience alongside traditional clinical benefits. Contribution to the evidence base This study extends existing evidence by directly addressing emergency caesarean section, a population that accounts for the majority of caesarean deliveries worldwide yet has been underrepresented in prior trials [ 15 , 16 ]. Demonstrating safety and effectiveness in this higher-risk group strengthens the generalizability of early catheter removal strategies. Second, the study's conduct in a Nigerian tertiary hospital enhances relevance to similar low-resource settings, where the CAUTI burden is most pronounced. Limitations Limitations include the open-label design (though objective outcomes mitigate bias), single-centre setting, and lack of long-term follow-up. The study was conducted in a setting with high background rates of CAUTI; results may differ in populations with lower baseline infection rates. Implications for practice and policy Immediate catheter removal should become the default strategy following emergency caesarean section, replacing routine 24-hour catheterization. This change requires no additional resources—only a willingness to challenge entrenched practice patterns. Implementation should be accompanied by simple protocols for monitoring voiding. Conclusions This randomized controlled trial demonstrates that immediate urinary catheter removal following emergency caesarean section significantly reduces CAUTI, accelerates recovery, shortens hospital stay, and improves patient comfort, with an acceptable and manageable increase in transient urinary retention. Adoption of this simple, low-cost intervention has the potential to improve maternal outcomes and reduce healthcare costs in low-resource settings. Declarations Ethics Approval and Consent to Participate: Ethical approval was obtained from the Health Research Ethics Committee of Federal Medical Centre, Makurdi (approval number: FMCM/HREC/2021/056). All participants provided written informed consent before enrollment. The study was conducted in accordance with the Declaration of Helsinki and Nigerian National Code of Health Research Ethics. Consent for Publication: Not applicable. Competing Interests: The authors declare that they have no competing interests. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution TEO: Conceptualization, methodology, investigation, data curation, formal analysis, writing—original draft, project administration. EH, IW, PA: Conceptualization, methodology, supervision, writing—review and editing. OSC, UA and TT: Methodology, investigation, supervision, writing—review and editing. All authors read and approved the final manuscript. Acknowledgement The authors thank the resident doctors, nursing staff, and laboratory scientists of the Department of Obstetrics and Gynaecology and Microbiology Laboratory, Federal Medical Centre, Makurdi, for their assistance with data collection and specimen processing. We are grateful to all the women who participated in this study. Data Availability The datasets generated and analysed during this study are available from the corresponding author on reasonable request. References Boerma T, Ronsmans C, Melesse DY, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341–8. Betrán AP, Ye J, Moller AB, et al. The increasing trend in caesarean section rates: global, regional and national estimates. PLoS ONE. 2016;11(2):e0148343. Sandall J, Tribe RM, Avery L, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet. 2018;392(10155):1349–57. 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Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319–26. [Duplicate of ref 5]. Onile TG, Kuti O, Orji EO, et al. A randomised controlled trial of immediate versus 6-hour postpartum catheter removal after caesarean section. J Matern Fetal Neonatal Med. 2018;31(6):779–84. Onyegbule OA, Udigwe GO, Ezebialu I, et al. Catheter-associated urinary tract infection following caesarean section in Nnewi, Nigeria: a prospective comparative study. Microbiol Res J Int. 2014;4(9):1025–34. Kingsley OV, Solomon N. Comparative analysis of the duration of urethral catheterization for caesarean delivery. IOSR J Dent Med Sci. 2018;17(4):1–5. [Duplicate of ref 23]. Moulton LJ, Lachiewicz M, Liu X, Goje O. Catheter-associated urinary tract infection (CAUTI) after term cesarean delivery: incidence and risk factors at a multi-centre academic institution. J Matern Fetal Neonatal Med. 2018;31(3):395–400. Mahabubul Islam Majumder M, Ahmed T, Ahmed S, Rahman Khan A. Microbiology of catheter-associated urinary tract infection. In: Behzadi P, editor. Microbiology of urinary tract infections: microbial agents and predisposing factors. London: IntechOpen; 2019. Nicolle LE. Catheter associated urinary tract infections. Antimicrob Resist Infect Control. 2014;3:23. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med. 2000;160(5):678–82. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019;68(10):e83–110. Schnarr J, Smaill F. Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. Eur J Clin Invest. 2008;38(Suppl 2):50–7. Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2019;2019(11):CD000490. Ituk U, Habib AS. Enhanced recovery after cesarean delivery. F1000Res. 2018;7:513. Wein AJ. Pathophysiology and classification of voiding dysfunction. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 11th ed. Philadelphia: Elsevier; 2016. pp. 1868–82. Tabrizi NT, Torabi Z, Bastani P, et al. Assessing the perception of pain and distress of female patients undergoing routine urethral catheterization in cesarean delivery. Int J User-Driven Healthc. 2013;3(4):1–10. Saint S, Trautner BW, Fowler KE, et al. A multicenter study of patient-reported infectious and noninfectious complications associated with indwelling urethral catheters. JAMA Intern Med. 2018;178(8):1078–85. Wang Y, Shan C, Zhao X, Zhang X. Early versus delayed removal of urinary catheter after cesarean section: a systematic review and meta-analysis. J Matern Fetal Neonatal Med. 2021;34(23):3975–83. Additional Declarations No competing interests reported. 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Oluwole","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYFAC5gaGByCanbGBgaECJAAUwQd4GIAqE8BaQVrOwBjEaQFixjYQi4AWe/bGNomEijty8s3MbRIf59VG87cDtfyo2IbbFp6DQC1nnhkzNjO2Sc7cdjx3xmHGBsaeM7dxa5FIbAOiw4nNzIzNxrzbjuU2ALUwM7YR1lLfBtLyd86x3PnEakngYWZsfMzYUJO7gaCWMwebLYB+MZwB1PKw59iB3I1ALQfx+YW9vfngjQ8Vd+Tl29sfHPhRU5c77/zhgw9+VODWAgUHYIzDqFxitNQRoXgUjIJRMApGGgAAZzxclb2DK5YAAAAASUVORK5CYII=","orcid":"","institution":"Federal Medical Centre","correspondingAuthor":true,"prefix":"","firstName":"Tolulope","middleName":"E.","lastName":"Oluwole","suffix":""},{"id":619139253,"identity":"c2718513-1c3c-447a-8a9e-651450332f5a","order_by":1,"name":"Emoekpere Hilary","email":"","orcid":"","institution":"Federal Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Emoekpere","middleName":"","lastName":"Hilary","suffix":""},{"id":619139254,"identity":"9da1da27-6939-4f7a-8d3b-49119f41f87b","order_by":2,"name":"Wakili Israel","email":"","orcid":"","institution":"Federal Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Wakili","middleName":"","lastName":"Israel","suffix":""},{"id":619139255,"identity":"a7cbca5a-5911-4ab0-8735-2b31af3491f2","order_by":3,"name":"Olasunkanmi Samson Coker","email":"","orcid":"","institution":"Federal College of Veterinary and Medical Laboratory Technology","correspondingAuthor":false,"prefix":"","firstName":"Olasunkanmi","middleName":"Samson","lastName":"Coker","suffix":""},{"id":619139257,"identity":"b77868d1-9981-49eb-8f51-ef3c14313b3a","order_by":4,"name":"Paulinus Abu","email":"","orcid":"","institution":"Federal Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Paulinus","middleName":"","lastName":"Abu","suffix":""},{"id":619139259,"identity":"1d2247d3-8f8b-4942-983b-a1986d4fe83c","order_by":5,"name":"Terhile Tyo","email":"","orcid":"","institution":"Federal Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Terhile","middleName":"","lastName":"Tyo","suffix":""},{"id":619139260,"identity":"6e8d095b-57b1-4144-96fd-06c231a43296","order_by":6,"name":"Uche Azuka","email":"","orcid":"","institution":"Federal Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Uche","middleName":"","lastName":"Azuka","suffix":""},{"id":619139261,"identity":"34c0e714-e00d-49d3-97b2-733968fa0044","order_by":7,"name":"Yange Terhemen Gideon","email":"","orcid":"","institution":"Federal Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Yange","middleName":"Terhemen","lastName":"Gideon","suffix":""},{"id":619139262,"identity":"6b57e2ae-3004-4da8-8e2b-bcbc03b201a5","order_by":8,"name":"Ochigbo Ezekiel","email":"","orcid":"","institution":"Federal Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Ochigbo","middleName":"","lastName":"Ezekiel","suffix":""},{"id":619139265,"identity":"bca485f8-8fbc-4056-9153-2f96cbc51900","order_by":9,"name":"Ugboji Jonah","email":"","orcid":"","institution":"Federal Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Ugboji","middleName":"","lastName":"Jonah","suffix":""}],"badges":[],"createdAt":"2026-03-03 06:38:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9016682/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9016682/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106534874,"identity":"493a0002-b2ae-4cbf-bebb-07de0ec2d207","added_by":"auto","created_at":"2026-04-09 15:07:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":321161,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCONSORT Flow Diagram\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9016682/v1/acce0b19bdbed9f4b42f847c.png"},{"id":106726805,"identity":"13b5c94e-73b2-4388-abdf-e038fe5eac60","added_by":"auto","created_at":"2026-04-12 18:37:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1429501,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9016682/v1/164a4ba1-49d5-4649-9244-1027d53bc4b8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eImmediate Versus 24-hour Removal of Urinary Catheter After Emergency Caesarean Section: A Randomized Controlled Trial\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eCaesarean section (CS) is one of the most commonly performed surgical procedures globally, accounting for approximately 21% of all births, with rates continuing to rise [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While CS is life-saving when medically indicated, it is associated with higher maternal morbidity and longer recovery compared with vaginal delivery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Historically, indwelling urethral catheterization has been a near-universal perioperative component of CS, intended to prevent intraoperative bladder injury and improve surgical visualization [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, the global rise in CS rates has necessitated a shift toward evidence-based recovery protocols that prioritize the reduction of complications and the optimization of hospital resources.\u003c/p\u003e \u003cp\u003eA critical, yet debated, element of postoperative care is the timing of catheter removal. While catheterization facilitates intraoperative safety and postoperative urine output monitoring, its prolonged use is a primary driver of catheter-associated urinary tract infections (CAUTI), which account for up to 40% of all nosocomial infections [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The risk of significant bacteriuria increases by 3\u0026ndash;7% for each day of catheterization, contributing to increased healthcare costs, prolonged hospitalization, and escalating antimicrobial resistance [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Beyond infectious risks, indwelling catheters contribute to non-infectious morbidities, including urethral trauma, bladder spasms, delayed ambulation, and a higher risk of venous thromboembolism [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These factors collectively impair maternal-infant bonding and can negatively impact the overall childbirth experience [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConcerns regarding postpartum urinary retention (PUR) have historically sustained the practice of prolonged catheterization, despite strong evidence favoring early removal. Reported incidence ranges from 1.3% to 24.1% due to inconsistent definitions and study populations, with risk factors including prolonged labour, operative vaginal delivery, nulliparity, epidural analgesia, and emergency CS [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Several randomized controlled trials have examined optimal catheter removal timing following CS, comparing immediate, early, and delayed removal, and evidence now strongly advocates for minimizing catheter duration. A 2023 network meta-analysis confirmed that catheter removal within 0\u0026ndash;6 hours is optimal for preventing UTI and accelerating recovery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, optimal duration remains controversial due to persistent concerns regarding PUR following immediate removal [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCritically, a substantial evidence gap exists regarding catheter management in emergency caesarean sections. Most existing randomized controlled trials (RCTs) have focused on elective CS, where patients are typically optimized and not in labor [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Women undergoing emergency CS represent a distinct physiological cohort; they are often in active labor, may have experienced prolonged second-stage bladder compression, and are subject to higher rates of surgical trauma and blood loss [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Despite emergency procedures constituting the majority of CS in low-resource settings [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], dedicated RCTs for this high-risk population are scarce.\u003c/p\u003e \u003cp\u003eIn Nigeria, emergency CS predominates, yet practices like routine 24-hour catheterization remain unoptimized. At Federal Medical Centre, Makurdi\u0026mdash;where 60.4% of CS are emergencies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u0026mdash;we evaluated whether immediate versus 24-hour removal after emergency CS reduces morbidity and accelerates recovery. We hypothesized immediate removal shortens ambulation and reduces infection without significantly increasing urinary retention.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\n\u003cp\u003eThis was an open-label, parallel-group randomized controlled trial conducted at the Department of Obstetrics and Gynaecology, Federal Medical Centre, Makurdi, Nigeria, between June 2021 and February 2022. The study adhered to the principles of the Declaration of Helsinki and was reported in accordance with the CONSORT 2010 guidelines [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eWe included women scheduled for emergency caesarean section (primary or repeat lower segment CS) who provided written informed consent. Emergency CS was defined as delivery indicated by immediate maternal or fetal compromise requiring expedited delivery, consistent with RCOG categories 1 and 2 [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eExclusion criteria were: (1) positive UTI screening; (2) chorioamnionitis; (3) severe hemorrhage; (4) severe preeclampsia/eclampsia; (5) obstructed labor; (6) uterine rupture; (7) general anesthesia; (8) iatrogenic bladder injury.\u003c/p\u003e\n\u003ch3\u003eSample Size Calculation\u003c/h3\u003e\n\u003cp\u003eSample size was calculated for an equivalence trial comparing two proportions [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. Based on previous studies reporting PUR incidence of 13.8% [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e], we assumed a non-inferiority margin of 10%. With \u0026alpha;\u0026thinsp;=\u0026thinsp;0.05, power\u0026thinsp;=\u0026thinsp;80%, and anticipating 10% attrition, the minimum sample size was 97 per group. We enrolled 10\u003csup\u003e5\u003c/sup\u003e per group (total N\u0026thinsp;=\u0026thinsp;210).\u003c/p\u003e\n\u003ch3\u003eRandomization and Allocation Concealment\u003c/h3\u003e\n\u003cp\u003eA computer-generated random sequence (1:1 allocation ratio) was created by an independent statistician. Allocation concealment was ensured using sequentially numbered, opaque, sealed envelopes. The microbiologist assessing urine cultures and the data analyst were blinded to group allocation.\u003c/p\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cp\u003eAll participants underwent standard preoperative preparation. Under aseptic technique, a 16-French Foley catheter was inserted before spinal anesthesia. Antibiotic prophylaxis (ceftriaxone 1g intravenously) was administered within 30 minutes of incision.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003eGroup A (Intervention)\u003c/strong\u003e: Catheter removed immediately after surgery completion.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003eGroup B (Control)\u003c/strong\u003e: Catheter retained and removed at 24 hours postoperatively.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eOutcome Measures\u003c/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary outcome\u003c/strong\u003e: Acute urinary retention (inability to void within 6 hours of catheter removal with painful palpable bladder, necessitating recatheterization with drainage\u0026thinsp;\u0026ge;\u0026thinsp;150 mL) [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary outcomes\u003c/strong\u003e: Significant bacteriuria (\u0026ge;\u0026thinsp;10⁵ CFU/mL at 48 hours) [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]; urinary symptoms; fever; time to first void, ambulation, and discharge; catheter-related pain (Numeric Rating Scale 0\u0026ndash;10) [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n\u003cp\u003eData were analyzed using SPSS version 23.0. Continuous variables were compared using independent t-tests; categorical variables using Chi-square or Fisher's exact test. Relative risks (RR) with 95% CI were calculated. Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eEthical approval\u0026nbsp;was obtained from the Health Research Ethics Committee of Federal Medical Centre, Makurdi (FMCM/HREC/2021/056). The trial was registered with the Pan African Clinical Trials Registry (PACTR202203693872412); Registration Date: March 2022.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipant Flow and Baseline Characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 232 women scheduled for emergency CS were assessed for eligibility between June 2021 and February 2022. Twenty-two women were excluded: 5 declined participation, and 17 met exclusion criteria (6 positive UTI screening, 4 obstructed labor, 3 antepartum hemorrhage, 2 pre-eclampsia, 2 general anesthesia). The remaining 210 women were randomized equally (105 per group). All participants received the allocated intervention and completed follow-up; none were lost to follow-up. All 210 were included in the final intention-to-treat analysis (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eBaseline characteristics were comparable between groups (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The mean age was 28.10\u0026thinsp;\u0026plusmn;\u0026thinsp;4.93 years in the immediate removal group and 27.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03 years in the 24-hour removal group (P\u0026thinsp;=\u0026thinsp;0.468). The majority of participants were aged 26\u0026ndash;30 years (41.4%), were para 2 (32.4%), and delivered at 37\u0026ndash;39 weeks (74.3%). Parity distribution was similar between groups (mean 2.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28 vs. 2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50; P\u0026thinsp;=\u0026thinsp;0.087).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline Characteristics of Study Participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eImmediate Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e24-hour Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.10\u0026thinsp;\u0026plusmn;\u0026thinsp;4.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.468\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParity, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.087\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGestational age (weeks), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.165\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge 26\u0026ndash;30 years, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (43.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.561\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003ePrimary Outcomes\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eAcute Urinary Retention\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAcute urinary retention occurred significantly more frequently in the immediate removal group, affecting 7 women (6.7%), compared with no women (0%) in the 24-hour removal group (continuity correction \u0026chi;\u0026sup2;=5.32, P\u0026thinsp;=\u0026thinsp;0.021; Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The mean volume drained at recatheterization for these 7 women was 278.57\u0026thinsp;\u0026plusmn;\u0026thinsp;24.78 mL (range 150\u0026ndash;220 mL). All seven women experienced uneventful subsequent voiding after catheter reinsertion and removal at 24 hours as seen in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" style=\"width: 531px;\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAcute Urinary Retention by Study Group\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth style=\"width: 109.697px;\" align=\"left\"\u003e\n \u003cp\u003eUrinary Retention\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 183.303px;\" align=\"left\"\u003e\n \u003cp\u003eImmediate Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 167px;\" align=\"left\"\u003e\n \u003cp\u003e24-hour Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 46px;\" align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 109.697px;\" align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183.303px;\" align=\"char\" char=\".\"\u003e\n \u003cp\u003e98 (93.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\" align=\"char\" char=\".\"\u003e\n \u003cp\u003e105 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 109.697px;\" align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 183.303px;\" align=\"char\" char=\".\"\u003e\n \u003cp\u003e7 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 167px;\" align=\"char\" char=\".\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\" align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.021*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 506px;\" colspan=\"4\"\u003e*Statistically significant\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003ch2\u003eSecondary Outcomes\u003c/h2\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eSignificant Bacteriuria\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOverall, 27 participants (12.9%) developed significant bacteriuria. The incidence of significant bacteriuria was significantly higher in the 24-hour removal group (19/105, 18.1%) compared with the immediate removal group (8/105, 7.6%; RR 2.38, 95% CI 1.09\u0026ndash;5.19; \u0026chi;\u0026sup2;=5.14, P\u0026thinsp;=\u0026thinsp;0.023; Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). \u003cem\u003eEscherichia coli\u003c/em\u003e was the predominant isolate (18/27, 66.7%), followed by \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (6/27, 22.2%) and \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (3/27, 11.1%). The distribution of organisms did not differ significantly between groups (Fisher\u0026apos;s exact\u0026thinsp;=\u0026thinsp;1.12, P\u0026thinsp;=\u0026thinsp;0.676) as seen in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSignificant Bacteriuria by Study Group\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSignificant Bacteriuria\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eImmediate Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e24-hour Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97 (92.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e86 (81.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e19 (18.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.023*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e2.38 (1.09\u0026ndash;5.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*Statistically significant\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIsolated organisms in significant bacteriuria by study group\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOrganism\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eImmediate Removal (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e24-hour Removal (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eE. coli\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e6 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e12 (63.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e18 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.676\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eS. aureus\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e2 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e4 (21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e6 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePseudomonas\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e3 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e3 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003cp\u003e*=Statistically significant, Both =\u0026thinsp;Group A\u0026thinsp;+\u0026thinsp;Group B\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUrinary Tract Symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAlthough the 24-hour removal group exhibited numerically higher frequencies of fever (3.8% vs. 1.9%), dysuria (7.6% vs. 5.7%), urgency (5.7% vs. 4.8%), suprapubic pain (6.7% vs. 5.7%), and frequency (5.7% vs. 4.8%), none of these differences reached statistical significance (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) as seen in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of Urinary Symptoms\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eImmediate Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e24-hour Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTest statistic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFever\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e2 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e4 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContinuity correction\u0026thinsp;=\u0026thinsp;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDysuria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e6 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e8 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;=0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.580\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrgency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e5 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e6 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;=0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.757\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuprapubic pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e6 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e7 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;=0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e5 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e6 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;=0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.757\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStraining\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e1 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContinuity correction\u0026thinsp;=\u0026thinsp;0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eRecovery Indices\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eWomen in the immediate removal group ambulated significantly earlier (10.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.54 vs. 28.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80 hours; mean difference\u0026thinsp;\u0026minus;\u0026thinsp;18.13 hours, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;18.86 to \u0026minus;\u0026thinsp;17.40; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hospital stay was also significantly shorter in the immediate removal group (2.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83 vs. 3.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68 days; mean difference\u0026thinsp;\u0026minus;\u0026thinsp;0.83 days, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;1.03 to \u0026minus;\u0026thinsp;0.63; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Time to first void (P\u0026thinsp;=\u0026thinsp;0.351) and time to resumption of bowel sounds (P\u0026thinsp;=\u0026thinsp;0.198) did not differ significantly between the groups (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of Recovery Indices\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eImmediate Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e24-hour Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean Difference (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime to first void (hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e3.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e3.45\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.42 (\u0026minus;\u0026thinsp;0.46 to 1.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime to first ambulation (hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e10.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e28.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;18.13 (\u0026minus;\u0026thinsp;18.86 to \u0026minus;\u0026thinsp;17.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e\u0026minus;49.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime to bowel sounds (hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e4.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e4.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.24 (\u0026minus;\u0026thinsp;0.60 to 0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e\u0026minus;1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.198\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of hospital stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e2.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\"\u003e\n \u003cp\u003e3.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;0.83 (\u0026minus;\u0026thinsp;1.03 to \u0026minus;\u0026thinsp;0.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e\u0026minus;7.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e*Statistically significant\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eCatheter-Related Pain and Discomfort\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCatheter-related discomfort differed markedly between the groups (Fisher\u0026apos;s exact\u0026thinsp;=\u0026thinsp;212.35, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e). In the immediate removal group, 86.7% reported no discomfort, compared with 0% in the 24-hour removal group. Conversely, 73.3% of the 24-hour removal group reported moderate discomfort, and 1.9% reported severe discomfort. The mean NRS score was significantly lower in the immediate removal group (0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96) versus the 24-hour removal group (4.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47; mean difference\u0026thinsp;\u0026minus;\u0026thinsp;3.80, 95% CI\u0026thinsp;\u0026minus;\u0026thinsp;4.14 to \u0026minus;\u0026thinsp;3.46; t\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;22.04, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab7\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCatheter-Related Pain and Discomfort\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDiscomfort Category\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eImmediate Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e24-hour Removal (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone (NRS 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e91 (86.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild (NRS 1\u0026ndash;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e11 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e26 (24.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerate (NRS 4\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e3 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e77 (73.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere (NRS 7\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e2 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean NRS\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e4.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*Statistically significant\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis randomized controlled trial provides robust evidence addressing the optimal timing of urinary catheter removal following emergency caesarean section, a clinically important yet previously underexplored aspect of postoperative obstetric care. Our findings demonstrate that while immediate catheter removal is associated with a modest, but manageable, increase in transient acute postpartum urinary retention (PUR), it significantly reduces the incidence of catheter-associated urinary tract infection (CAUTI), accelerates postoperative recovery, shortens hospital stay, and markedly improves patient comfort.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eUrinary retention\u003c/h2\u003e \u003cp\u003eThe incidence of acute urinary retention observed in the immediate removal group (6.7%) was significantly higher than in the 24-hour removal group, in which no cases occurred. This finding is unsurprising, as prolonged catheterization effectively prevents retention through continuous bladder drainage. Importantly, however, the observed retention rate is clinically acceptable and consistent with existing literature. Reported PUR rates following caesarean section range widely from 1.3% to 24.1%, reflecting heterogeneity in diagnostic criteria, patient populations, anaesthetic techniques, and catheter management practices [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The rate observed in this study aligns closely with the 4.7\u0026ndash;13.6% reported in trials evaluating early catheter removal following elective caesarean section [\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and is substantially lower than the 13.8\u0026ndash;39.2% rates reported in earlier studies employing less standardized definitions or intermittent catheterization protocols [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll women who developed urinary retention responded promptly to re-catheterization and subsequently voided normally within 24 hours, with no evidence of persistent voiding dysfunction. This pattern strongly suggests that PUR associated with immediate catheter removal is functional and reversible rather than indicative of structural bladder injury. The mean bladder volume drained at re-catheterization (278.57\u0026thinsp;\u0026plusmn;\u0026thinsp;24.78 mL) confirms clinically significant retention and underscores the importance of systematic postoperative monitoring. These findings support the safety of immediate catheter removal when accompanied by clear protocols for early detection and management of retention [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the absence of retention in the 24-hour removal group may appear advantageous, this benefit must be weighed against the substantial infectious and non-infectious harms associated with prolonged catheterization demonstrated in this and other studies. The pathophysiology underlying this increased PUR risk relates to the persistent effects of regional anesthesia on bladder function. Spinal anesthesia with agents such as bupivacaine and fentanyl can reduce bladder sensation for over 6 hours postoperatively, making immediate voiding difficult despite adequate bladder volume [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Identification of women at increased risk of PUR may further optimize outcomes. Prolonged labour, epidural analgesia, nulliparity, and operative vaginal delivery have consistently been identified as risk factors for PUR [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], all of which are common in emergency caesarean populations. Future studies should focus on developing validated risk-prediction tools to guide individualized catheter management, allowing most women to benefit from immediate removal while selectively delaying removal in those at highest risk.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCatheter-associated urinary tract infection\u003c/h2\u003e \u003cp\u003eImmediate catheter removal was associated with a clinically meaningful 2.4-fold reduction in significant bacteriuria compared with routine 24-hour catheterization (7.6% vs. 18.1%; RR 2.38, 95% CI 1.09\u0026ndash;5.19). This finding is biologically plausible given the well-established dose\u0026ndash;response relationship between catheter duration and bacteriuria risk, which increases by approximately 3\u0026ndash;7% for each day of catheterization [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The overall CAUTI rate observed in this study (12.9%) is comparable to reports from Nigerian settings, including rates of 12.5% (Onile et al.), 9% (Onyegbule et al.), and 26.9% (Kingsley et al.) [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], as well as international studies reporting rates ranging from 1.5\u0026ndash;5.2% in high-income settings and approximately 13.4% in comparable low-resource contexts [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Variability across studies likely reflects differences in catheter duration, antibiotic prophylaxis regimens, microbiological thresholds, and patient characteristics.\u003c/p\u003e \u003cp\u003eThe predominance of \u003cem\u003eEscherichia coli\u003c/em\u003e (66.7%) as the causative organism is consistent with the known microbiology of CAUTI and reflects ascending infection from faecal and perineal colonization [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The anatomical proximity of the female urethra to the anus, combined with postpartum perineal contamination, facilitates this route of infection. The presence of \u003cem\u003eStaphylococcus aureus\u003c/em\u003e and \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e mirrors findings from similar settings [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and highlights the contribution of nosocomial organisms in catheter-related infections.\u003c/p\u003e \u003cp\u003eDespite marked differences in bacteriuria, urinary symptoms did not differ significantly between groups, confirming that most CAUTIs in postpartum women are asymptomatic. This observation aligns with the findings of Tambyah and Maki, who reported that only 1\u0026ndash;4% of catheterized patients with bacteriuria develop clinical symptoms [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The low incidence of fever despite high bacteriuria rates further underscores the limitations of symptom-based surveillance. These findings emphasize the importance of objective microbiological endpoints in CAUTI research, particularly in postoperative populations where symptoms may be masked or attributed to other causes.\u003c/p\u003e \u003cp\u003eAlthough asymptomatic bacteriuria is often considered benign in non-pregnant populations [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], the puerperium represents a distinct physiological state characterized by altered immunity, risk of ascending infection, and close maternal\u0026ndash;neonatal contact [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Evidence suggests that untreated asymptomatic bacteriuria can progress to symptomatic infection and that treatment reduces this risk [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Therefore, prevention through reduced catheter exposure is particularly relevant. The 10.5% absolute reduction in bacteriuria observed in this study would translate into substantial reductions in antibiotic use and antimicrobial resistance pressure if implemented at scale.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEnhanced recovery after surgery\u003c/h2\u003e \u003cp\u003eThe findings strongly support incorporation of immediate catheter removal into enhanced recovery after surgery (ERAS) pathways. Women in the immediate removal group ambulated approximately 18 hours earlier and were discharged nearly one day sooner than those managed with routine catheterization. These differences have important implications for patient satisfaction, healthcare costs, and bed utilization, particularly in resource-constrained settings [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarly mobilization is a cornerstone of ERAS and is associated with reduced venous thromboembolism risk [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Early mobility will also facilitates maternal\u0026ndash;infant bonding and breastfeeding initiation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The similar time to first spontaneous void following catheter removal in both groups challenges the traditional rationale for prolonged catheterization as a means of bladder \"rest\" and aligns with physiological evidence demonstrating rapid recovery of detrusor function after surgery [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. These findings reinforce the concept that prolonged catheterization offers little functional advantage while exposing women to avoidable harm [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003ePatient-centred outcomes\u003c/h2\u003e \u003cp\u003eA major strength of this trial is the inclusion of patient-reported outcomes. Moderate-to-severe discomfort was reported by three-quarters of women managed with 24-hour catheterization, compared with almost none in the immediate removal group. These findings are consistent with prior reports of catheter-associated pain [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and underscore the substantial contribution of indwelling catheters to negative postoperative experiences.\u003c/p\u003e \u003cp\u003eCatheter-related discomfort reflects not only physical irritation but also restricted mobility, dependence on staff, and psychological distress [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. By substantially reducing this burden, immediate catheter removal offers meaningful improvements in patient experience alongside traditional clinical benefits.\u003c/p\u003e \u003cp\u003e \u003cb\u003eContribution to the evidence base\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study extends existing evidence by directly addressing emergency caesarean section, a population that accounts for the majority of caesarean deliveries worldwide yet has been underrepresented in prior trials [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Demonstrating safety and effectiveness in this higher-risk group strengthens the generalizability of early catheter removal strategies. Second, the study's conduct in a Nigerian tertiary hospital enhances relevance to similar low-resource settings, where the CAUTI burden is most pronounced.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLimitations include the open-label design (though objective outcomes mitigate bias), single-centre setting, and lack of long-term follow-up. The study was conducted in a setting with high background rates of CAUTI; results may differ in populations with lower baseline infection rates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eImplications for practice and policy\u003c/h2\u003e \u003cp\u003eImmediate catheter removal should become the default strategy following emergency caesarean section, replacing routine 24-hour catheterization. This change requires no additional resources\u0026mdash;only a willingness to challenge entrenched practice patterns. Implementation should be accompanied by simple protocols for monitoring voiding.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis randomized controlled trial demonstrates that immediate urinary catheter removal following emergency caesarean section significantly reduces CAUTI, accelerates recovery, shortens hospital stay, and improves patient comfort, with an acceptable and manageable increase in transient urinary retention. Adoption of this simple, low-cost intervention has the potential to improve maternal outcomes and reduce healthcare costs in low-resource settings.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e \u003cp\u003e Ethical approval was obtained from the Health Research Ethics Committee of Federal Medical Centre, Makurdi (approval number: FMCM/HREC/2021/056). All participants provided written informed consent before enrollment. The study was conducted in accordance with the Declaration of Helsinki and Nigerian National Code of Health Research Ethics.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTEO: Conceptualization, methodology, investigation, data curation, formal analysis, writing\u0026mdash;original draft, project administration. EH, IW, PA: Conceptualization, methodology, supervision, writing\u0026mdash;review and editing. OSC, UA and TT: Methodology, investigation, supervision, writing\u0026mdash;review and editing. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank the resident doctors, nursing staff, and laboratory scientists of the Department of Obstetrics and Gynaecology and Microbiology Laboratory, Federal Medical Centre, Makurdi, for their assistance with data collection and specimen processing. We are grateful to all the women who participated in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed during this study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBoerma T, Ronsmans C, Melesse DY, et al. 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Eur J Clin Invest. 2008;38(Suppl 2):50\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2019;2019(11):CD000490.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eItuk U, Habib AS. Enhanced recovery after cesarean delivery. F1000Res. 2018;7:513.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWein AJ. Pathophysiology and classification of voiding dysfunction. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 11th ed. Philadelphia: Elsevier; 2016. pp. 1868\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTabrizi NT, Torabi Z, Bastani P, et al. Assessing the perception of pain and distress of female patients undergoing routine urethral catheterization in cesarean delivery. Int J User-Driven Healthc. 2013;3(4):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaint S, Trautner BW, Fowler KE, et al. A multicenter study of patient-reported infectious and noninfectious complications associated with indwelling urethral catheters. JAMA Intern Med. 2018;178(8):1078\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Shan C, Zhao X, Zhang X. Early versus delayed removal of urinary catheter after cesarean section: a systematic review and meta-analysis. J Matern Fetal Neonatal Med. 2021;34(23):3975\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"caesarean section, urinary catheter, early removal, catheter-associated urinary tract infection, postpartum urinary retention, enhanced recovery after surgery, randomized controlled trial","lastPublishedDoi":"10.21203/rs.3.rs-9016682/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9016682/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRoutine 24-hour catheterization remains common after caesarean section despite Enhanced Recovery after Surgery (ERAS) protocols recommending early urinary catheter removal, owing in part to concerns about postoperative urinary retention. While evidence supports immediate removal following elective caesarean delivery, data for emergency procedures are limited. Emergency caesarean sections constitute most caesarean deliveries globally and carry higher risks of bladder dysfunction, infection, and delayed recovery. This trial evaluates whether immediate catheter removal after emergency caesarean section improves maternal recovery and reduces infectious morbidity without increasing urinary retention.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted an open-label randomized controlled trial at a Nigerian tertiary hospital between June 2021 and February 2022. Two hundred ten women undergoing emergency CS were randomly assigned (1:1) to immediate catheter removal on the operating table (intervention, n\u0026thinsp;=\u0026thinsp;105) or removal at 24 hours postoperatively (control, n\u0026thinsp;=\u0026thinsp;105). The primary outcome was acute urinary retention (inability to void within 6 hours requiring recatheterization with drainage\u0026thinsp;\u0026ge;\u0026thinsp;150 mL). Secondary outcomes included significant bacteriuria (\u0026ge;\u0026thinsp;10⁵ colony-forming units/mL at 48 hours), urinary symptoms, recovery indices (time to ambulation, hospital stay), and catheter-related discomfort. Analysis was by intention-to-treat.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBaseline characteristics were comparable between groups. Acute urinary retention occurred significantly more frequently in the immediate removal group (7/105, 6.7% vs. 0/105, 0%; P\u0026thinsp;=\u0026thinsp;0.021). Conversely, the incidence of significant bacteriuria was significantly higher in the 24-hour removal group (19/105, 18.1% vs. 8/105, 7.6%; P\u0026thinsp;=\u0026thinsp;0.023; RR 2.38, 95% CI 1.09\u0026ndash;5.19), with \u003cem\u003eEscherichia coli\u003c/em\u003e as the predominant isolate (66.7%). Immediate removal significantly reduced time to ambulation (10.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.54 vs. 28.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80 hours; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), hospital stay (2.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83 vs. 3.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68 days; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and catheter-related discomfort (mean NRS 0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96 vs. 4.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant differences were observed in voiding difficulties or time to first bowel sounds.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eImmediate urinary catheter removal following emergency caesarean section significantly reduces infectious morbidity, facilitates faster ambulation, and improves patient comfort. While associated with a modest increase in transient urinary retention, the overall benefits to maternal recovery and hospital throughput support its implementation as a standard component of ERAS protocols for emergency caesarean delivery in appropriately screened women.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e \u003cp\u003ePan African Clinical Trials Registry (PACTR202203693872412) Registration Date March 2022\u003c/p\u003e","manuscriptTitle":"Immediate Versus 24-hour Removal of Urinary Catheter After Emergency Caesarean Section: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 15:06:58","doi":"10.21203/rs.3.rs-9016682/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-01T09:25:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-19T14:34:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-18T08:52:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-16T12:17:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-16T07:15:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"112948668402585873927786003988387039740","date":"2026-04-14T08:36:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79973964431901512616119034527228120019","date":"2026-04-12T14:41:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-10T16:06:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50567426082882119895057286893896277295","date":"2026-04-09T16:06:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116722948617427840410500905174206012937","date":"2026-04-09T13:30:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329414484539618942528822921912718829402","date":"2026-04-09T13:29:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76531895465767752082532888149515519741","date":"2026-04-09T12:50:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228276382073676875292032781289694742282","date":"2026-04-07T17:46:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T15:52:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-12T18:16:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-10T10:31:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-10T10:31:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-03-03T06:24:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b0395e76-9da7-4b33-8486-96f52d93eff9","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-01T09:25:15+00:00","index":80,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T15:06:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 15:06:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9016682","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9016682","identity":"rs-9016682","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}