Review Question - QID 214311

This patient has a lack of spontaneous micturition within 6 hours of vaginal delivery, as well as bladder distention and overflow incontinence, and therefore likely has postpartum urinary retention. The best next step in management of postpartum urinary retention is intermittent urinary catheterization.

Postpartum urinary retention (PUR) occurs due to pudendal nerve injury during delivery. Women are at increased risk for PUR if it is their first delivery or if they receive epidural anesthesia, instrument-assisted delivery, or episiotomy during delivery. PUR is commonly defined as absence of spontaneous micturition within six hours of vaginal delivery or within six hours of removal of an indwelling catheter after cesarean delivery. Patients may be asymptomatic or experience urinary overflow incontinence, small voiding volumes, urinary frequency or urgency, bladder pain or discomfort, a sense of incomplete emptying, or an absence of the sensation to void. Bladder distension may be palpated on exam or visualized by ultrasound.

Intermittent urinary catheterization is the management of choice for postpartum urinary retention. Ideally, catheterization is performed by the patient herself. Catheterization should be performed every 4-6 hours or whenever the patient has the urge to void but is unable to do so. If the patient voids a small volume, then she should perform self-catheterization afterwards to determine the residual volume. Catheterization can be discontinued when the residual urine volume is < 150 mL, and the patient is no longer experiencing significant symptoms of difficulty voiding. For most patients, urinary retention resolves within 1 week after delivery.

Incorrect Answers:
Answer 1: Oxybutynin is an antimuscarinic agent used for treatment of urinary urgency, incontinence, and overactive bladder in women. Medications, however, have proven ineffective at treating postpartum urinary retention; therefore, oxybutynin should not be used for this patient.

Answer 3: Although some symptoms of postpartum urinary retention may resemble a urinary tract infection, such as bladder pain and increased urinary urgency or frequency, this patient’s lack of spontaneous voiding within 6 hours after vaginal delivery, her distended bladder seen on bladder scan, and her symptoms of overflow incontinence are all consistent with postpartum urinary retention and should be managed with urinary catheterization.

Answer 4: Urodynamic testing involves a set of tests that study the function of the urinary tract. It may be used to evaluate patients who are experiencing urinary urgency or incontinence. Postpartum urinary retention generally resolves on its own within 1 week and does not require urodynamic testing as initial management. If symptoms persist for a longer period, then further evaluation of the urinary tract may be indicated.

Answer 5: Intermittent catheterization is the preferred management for postpartum urinary retention over indwelling Foley catheters, since indwelling catheters have a higher complication rate than intermittent catheterization, including higher risk of subsequent urinary tract infection.

Bullet Summary:
Postpartum urinary retention is a self-resolving condition that often presents after regional analgesia or cesarean section with inability to void, and is best managed with intermittent urinary catheterization.