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Reviews in Gynaecological and Perinatal Practice 6 (2006) 140144

www.elsevier.com/locate/rigapp

Management of postpartum urinary retention


Raheela M. Rizvi *, Javed Rizvi
Aga Khan University Hospital, Pakistan
Received 15 January 2006; accepted 20 February 2006
Available online 19 April 2006

Abstract
There is a large body of literature investigating the mechanism, risk factors, and pathophysiology of postpartum urinary retention; it is
usually a temporary condition where early diagnosis and appropriate management can avoid long term complication. This article reviews the
etiology, prevention, management and long-term implications of retention for bladder functions.
# 2006 Elsevier B.V. All rights reserved.
Keywords: Postpartum urinary retention; Prevention; Management

1. Introduction
Postpartum urinary retention is regarded as a common
event but the reported incidence varies considerably, from
1.7 to 17.9% [1,2]. Literature on this common condition is
relatively exiguous.
In the women voiding difficulties and retention represent
a gradation of failure of bladder emptying. These disorders
are poorly documented mainly because they are frequently
misdiagnosed until symptoms such as recurrent urinary tract
infections or incontinence prevail. Since the condition rarely
progress to upper tract dilatation and renal failure, they are
not associated with mortalitiy, but its morbidity is
significant.
2. Definitions and classification
Although there is no standard definition textbooks define
postpartum urinary retention as the sudden onset of painful
or painless inability to void over 12 h, requiring catheterization with removal of a volume equal to, or greater than the
bladder capacity [3]. Another definition of postpartum
* Correspondence to: Department of Obstetrics & Gynecology, The Aga
Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi 74800,
Pakistan. Tel.: +92 21 4864642; fax: +92 21 4934294/4932095.
E-mail address: raheela.mohsin@aku.edu (R.M. Rizvi).
1871-2320/$ see front matter # 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.rigapp.2006.02.003

urinary retention is the absence of spontaneous micturition


within 6 h of vaginal delivery. After cesarean delivery, if a
catheter is used, retention is defined as no spontaneous
micturition within 6 h after the removal of an indwelling
catheter (more than 24 h after delivery) [4]. The International Continence Society revised definition of acute urinary
retention as painful, palpable or percussable bladder, when
the patient is unable to pass any urine [5]. In postpartum
circumstances pain may not be a presenting feature, for
example, after regional anesthesia.
Postpartum urinary retention has been classified into
covert and overt forms by some investigators [6]. The covert
form can be identified by elevated post-void residual
measurements, either with ultrasound scanning or with
catheterization. Women with post-void residual volumes of
150 ml and no symptoms of urinary retention are in this
category. Clinically overt postpartum urinary retention
refers to the inability to void spontaneously after delivery.
The incidence of postpartum urinary retention depends
on the definition used as well as differences in obstetric
practice. Using the definition of no spontaneous void within
6 h of delivery, retrospective analysis of medical records
showed the incidence of clinically overt type of urinary
retention to be as low as 0.14% [7]. Where protocols and
clinical guidelines are followed for diagnosis and management the incidence of both overt and covert types of
postpartum urinary retention was found to be 0.7% [8].

R.M. Rizvi, J. Rizvi / Reviews in Gynaecological and Perinatal Practice 6 (2006) 140144

3. Aetiology and pathophysiology


In females voiding occurs when there is initial relaxation of
the urethral sphincter and pelvic floor musculature, followed
by contraction of the detrusor muscle and, a rise in
intrabdominal pressure. Voiding disorders result when one
of these mechanisms fail. When the detrusor muscle is unable
to maintain an effective contraction (detrusor hypotonia) and/
or the urethra fails to relax and lower urethral resistance,
voiding becomes restricted. Similarly voiding dysfunction
also occurs if there is a failure in the synchronization of these
two actions such that the detrusor contracts but the urethra
fails to relax, known as detrusor sphincter dyssynergia [3].
Occasionally flow may be prevented altogether. Non-relaxing
urethral obstruction can also occur, after radical pelvic
surgery. As a consequence of voiding dysfunction and urinary
retention, some patients can present with overflow urinary
incontinence which may be mistaken for urinary stress
incontinence unless a good clinical history and/or urodynamics studies are undertaken to distinguish between the two
conditions [5].
Physiological and traumatic events during pregnancy and
child birth such as damage to the nerves, pelvic muscles and
bladder musculature increase the risks of urinary retention in
the postpartum period [9].
Voiding difficulties following delivery have been
recognized for a long time [10]. Further information
regarding etiology and outcome, however, has been limited
by the fact that urodynamic investigations are by and large
invasive [11] and are not always available.
The pathophysiology of postpartum urinary retention is
poorly understood. In pregnancy and few weeks after
delivery, progesterone reduces smooth muscle tone, resulting in dilatation of renal pelvis, the ureter and the bladder
[12]. Beginning in the third month of pregnancy the tone in
the detrusor muscle decreases and the bladder capacity
slowly increases. As a result pregnant women ordinarily
have the first desire to void when the bladder contains 250
400 ml of urine and maximum urinary urge often is not
reached until 8001000 ml in the supine position. When a
pregnant woman stands up the enlarged uterus exerts
pressure on the bladder, this places an added burden on the
bladder and therefore a doubling of bladder pressure has
been observed in the 38th week [8]. This disappears once the
baby is born, without the weight of pregnant uterus to limit
its capacity; the postpartum bladder tends to be hypotonic.

4. Risk factors
General obstetric factors include nulliparity, prolonged
first and second stages of labor, instrumental delivery, and
cesarean sections for lack of progress in the first stage of
labor [4,12,13]. Duration of labor has been found to be a very
significant risk factor. In a recent study labor that exceeded

141

11 h and 40 min was found to have significant association


with postpartum urinary retention [14].
The effect of epidural analgesia on the postpartum
bladder is controversial. Weisman et al. [15] showed that
regional analgesia is not associated with an increased risk for
postpartum urinary retention after vaginal delivery while in a
recent study by Rizvi et al. [7] epidural analgesia was found
to be associated with retention of urine in 24% of their
patients. Differences may be due to lower doses of anesthetic
drugs used or changes in other obstetric practices.

5. Impact of retention on bladder functions


In the short term, retention of urine, if not identified and
relieved, may lead to atony of bladder and infection. It is
generally believed that the risk of harmful effects on urinary
bladder starts at residual volumes between 500 and 800 ml
[16]. Early detection of persistent urinary retention is very
important as irreversible damage may result from bladder
overdistension [17]. It has long been established that a single
episode of bladder over-distention (if not diagnosed and
treated early), may cause persistent postpartum urinary
retention and irreversible damage to the detrusor muscle
with recurrent urinary tract infections and permanent
voiding difficulties [18].
In three large studies of women after delivery, all women
with postpartum urinary retention returned to normal within 2
6 days of diagnosis [12,13,19]. However, although the problem
resolved quickly, there are small case studies of women, who
do not resume normal voiding for several weeks [2].
Yip et al. could not show a higher prevalence of stress
incontinence, fecal incontinence, frequency, nocturia,
urgency and urge incontinence in a 4-year follow-up study
of women who were diagnosed to have postpartum urinary
retention [20].

6. Prevention
Identifying risk factors, monitoring two hourly urinary
output during labor and vigilant early detection of
postpartum urinary retention are considered as the most
important preventive measures. In women unable to void
within 6 h of delivery, ultrasound evaluation or straight
catheterization can identify women who need close
surveillance. Early detection of postpartum urinary retention
especially covert type is possible by measuring the urinary
volume by ultrasound. The reliability of ultrasound
measurement and estimation of post-void residual bladder
volume has been validated in postpartum women by Yip
et al. [21]. Ultrasound measured urinary volume of 99
women with postpartum urinary retention was compared
with immediate collected catheterized volume. The results
of the study have shown that ultrasonic assessment of postvoid residual bladder volume in the postpartum period is

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R.M. Rizvi, J. Rizvi / Reviews in Gynaecological and Perinatal Practice 6 (2006) 140144

Fig. 1. Algorithm of postpartum bladder care.

accurate, and it can be used as a guide to whether


transurethral catheterization is necessary. Although further
research is needed to develop evidence-based guidelines, all
units should be timing and measuring the voided volume and
ideally checking the first post-void residual volume to ensure
that retention does not go unrecognized.

Indwelling catheterization as a management option for


postpartum urinary retention needs to be judicious. Women
who have spinal anesthesia or epidural anesthesia for pain
relief in labor may be at increased risk of retention and
should be offered an indwelling catheter, to be kept in place
for at least 12 h following delivery to prevent asymptomatic
bladder overfilling [22].

7. Management
8. Helping measures
There are two types of patients
1. Overt urinary retention with urgency and stranguria.
2. Covert urinary retention with a residual volume more
than 150 ml.
Covert urinary retention is self-limiting phenomenon and
the residual volume usually returns to normal in 4 days [20].

There are strategies based on clinical management


principles that help women with postpartum urinary
retention. These helping measures include oral
analgesia, helping patients to stand and walk, providing
privacy, assisting the patient into a warm bath, and
immersing the womens hands into a basin of cold water.
These measures helped voiding in 60% of patients with

R.M. Rizvi, J. Rizvi / Reviews in Gynaecological and Perinatal Practice 6 (2006) 140144

postoperative urinary retention after surgical operations


[23].

143

anticholinestrases, cholinomimetic agents, alpha adrenergic


blocking drugs, prostaglandin F2 alpha and diazepam. Their
use in breastfeeding women is limited [18] and there is no
evidence-based study regarding their usefulness.

9. Catheterization
Retention without obstruction can be dealt with by
intermittent catheterization and resorting to indwelling
catheter only if it becomes necessary. Indwelling catheterization is associated with an increased risk of developing
bacteriuria, cystitis, and pyelonephritis and gram negative
septicemia. The incidence of urinary tract infections
increases with the duration of indwelling catheterization,
varying from 3 to 33%, reflecting a wide variation [16].
Indwelling catheterization is also associated with maternal
discomfort, infection, mucosal irritation and subsequent
urethral scarring.
The effects of long-term catheterization are very well
known but there is a lack of guidelines regarding initial
management of postpartum urinary retention by a Nelaton
(in and out) catheter or by clean intermittent selfcatheterization. Recently, Yip et al. recommended that for
hospitalized women intermittent catheterization should be
performed every 46 h until women void with residual
<150 ml [24]. If the amount of residual urine, after
spontaneous voiding, is persistently >150 ml, continuous
bladder drainage would be required. The duration of
catheterization is empirical, and no standard has been
agreed to. The volume of urine drained initially may predict
the need for repeat catheterization. Bladder should be
drained for 24 or 48 h, if the residual urine is less than
400 ml or more than 400 ml, respectively. In one study, no
postpartum patient with a residual urine volume less than
700 ml required repeat catheterization, but repeat catheterization was necessary for 14% of patients with 700999 ml
of residual urine and 20% patients with 1000 ml or more of
residual urine [25]. After 48 h of catheterization, most can
void with normal bladder residual volumes [13]. Supra pubic
catheterization is considered in only those cases where
residual urine is persistently more than 300 ml; these
patients require strict follow-up.
In women who require catheterization, prophylactic
antibiotics are recommended to reduce the likelihood of
urinary tract infection [14]. Suitable antibiotics include
nitrofurantoin, ampicillin or trimethoprim-sulphamethiazole (contraindicated if breastfeeding). In one study
antibiotics were recommended only if the bladder contained
more than 700 ml [3]. This is in contrast to Glavind and
Bjorks study where prophylactic antibiotics were not used
and only 1.6% had urinary tract infection [8].

10. Pharmacological treatment


Many pharmacologic treatments for urinary retention
have been advocated, but few are of much use. These include

11. Recommendations for postpartum urinary


retention (Fig. 1)
Attention to bladder care during labor and vigilant
postpartum early detection of urinary retention are the two
most important preventive factors. Bladder volume can be
assessed by ultrasound (bladder scanner) or by catheterization. After delivery bladder volume should be assessed if:
 The uterus is high and deviated, especially if there is
heavy lochia.
 The bladder is palpable and patient is unable to void.
 There is frequency, urgency and inability to void or if
voiding is in only small amounts.

If a woman is unable to void, Helping measures should


first be tried along with good analgesia to reduce perineal/
peri-urethral edema; NSAIDS are most effective. In
hospitalized women we recommend intermittent catheterization every 46 h until the woman is able to void and then
until the first residual volume is <150 ml. If she is still
unable to void then the ideal strategy is to teach her
intermittent self-catheterization so that she can do it at home
until residuals are less than 150 ml.
Suprapubic catheter is used when repeated catheterizations have been required or it is anticipated that bladder
drainage will be required for more than 48 h. It is more
comfortable for the women, there is less risk of infection and
it allows repeated trails of voiding. Urine culture should be
requested and oral antibiotic cover is recommended.
Removal of catheter is usually performed in the morning
and normal oral fluid intake should be encouraged. Women
with postpartum retention should be reviewed in out-patient
clinic 68-weeks postpartum

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