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

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