Immediate versus 24-hour removal of urinary catheter after emergency caesarean section: a randomized controlled trial

Background Enhanced Recovery After Surgery (ERAS) protocols recommend early removal of urinary catheters after caesarean section, but most supporting evidence derives from elective procedures, and emergency caesarean section, which carries distinct risks of bladder dysfunction, infection and delayed recovery, remains comparatively understudied. This trial compares immediate versus 24-hour catheter removal after emergency caesarean section. Methods We conducted an open-label, parallel-group, randomized controlled superiority trial at a Nigerian tertiary hospital between June 2021 and February 2022. Two hundred and ten women undergoing emergency caesarean section were randomly assigned (1:1) to immediate catheter removal on the operating table ( n = 105) or removal at 24 h postoperatively ( n = 105). The primary outcome was acute urinary retention (inability to void within 6 h of catheter removal, with a palpable bladder, requiring recatheterization with drainage ≥ 150 mL). Secondary outcomes included significant bacteriuria (≥ 10⁵ colony-forming units/mL at 48 h), urinary symptoms, recovery indices (time to first void, time to ambulation, time to bowel sounds, and length of hospital stay), and catheter-related discomfort. Analysis was by intention-to-treat, using appropriate parametric and non-parametric statistical tests, with effect estimates and 95% confidence intervals reported. Results Baseline characteristics were comparable between groups. Acute urinary retention occurred in 7/105 (6.7%) women in the immediate removal group versus 0/105 (0%) in the 24-hour removal group (risk difference 6.7%, 95% CI 1.9 to 11.4%; Fisher’s exact P = 0.014); all seven women responded promptly to brief recatheterization and voided normally thereafter. The incidence of significant bacteriuria was higher in the 24-hour removal group (19/105, 18.1%) than the immediate removal group (8/105, 7.6%; RR 2.38, 95% CI 1.09–5.19; P = 0.023, an association that persisted after adjustment for maternal age, parity and gestational age (adjusted OR 2.92, 95% CI 1.20–7.12; P = 0.018)), with Escherichia coli as the predominant isolate (66.7%); however, no significant differences were observed between groups in symptomatic urinary tract infection, fever, dysuria, urgency, or suprapubic pain, indicating that the bacteriuria identified was predominantly asymptomatic. Immediate removal was associated with significantly earlier ambulation (median 10 vs. 28 h; Mann-Whitney U, P < 0.001), shorter hospital stay (median 2 vs. 3 days; P < 0.001), and lower catheter-related discomfort (mean NRS 0.34 ± 0.96 vs. 4.14 ± 1.47; P < 0.001). Conclusion In this single-centre trial, immediate urinary catheter removal after emergency caesarean section was associated with faster recovery, shorter hospital stay, improved comfort, and lower asymptomatic bacteriuria, at the cost of a modest increase in transient clinically detected urinary retention (per the study definition) that resolved promptly with recatheterization. These findings support consideration of immediate catheter removal as an option within ERAS pathways for appropriately selected women, pending confirmation in multicentre trials. Trial registration Pan African Clinical Trials Registry (PACTR202607883695641, retrospectively registered, registration date 17 July 2026).