The Obstetrician & Gynaecologist

10.1576/toag.10.2.071.27393 www.rcog.org.uk/togonline

2008;10:7174

Review

Review Postpartum voiding dysfunction

Authors Rohna Kearney / Alfred Cutner

Key content:
The postpartum bladder is vulnerable to urinary retention; if undetected, this can lead to bladder underactivity, recurrent urinary tract infection and incontinence. The aim of intrapartum bladder care is to prevent bladder overdistension. Following delivery or catheter removal, no woman should be allowed to go longer than 6 hours without voiding. All units should have a guideline for bladder care and the management of postpartum voiding dysfunction.

Learning objectives:
To be aware of the risk factors for the development of postpartum voiding dysfunction and the symptoms indicating voiding problems. To learn about the management of postpartum voiding dysfunction.

Ethical issues:
Is it acceptable to catheterise a woman to estimate the volume of residual urine when this can be estimated by ultrasound scanning of the bladder?
Keywords intermittent self catheterisation / postpartum urinary retention / postvoid residual urine volume
Please cite this article as: Kearney R, Cutner A. Postpartum voiding dysfunction. The Obstetrician & Gynaecologist 2008;10:7174.

Author details
Rohna Kearney MD MRCOG MRCPI Consultant Gynaecologist and Subspecialist in Urogynaecology Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK Email: rkearney@doctors.net.uk Alfred Cutner MD FRCOG Consultant Gynaecologist Elizabeth Garrett Anderson and Obstetric Hospital, University College London Hospitals NHS Trust, Huntley Street, London WC1E 6DH, UK

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Introduction
Postpartum voiding dysfunctionif defined as failure to pass urine spontaneously within 6 hours of vaginal delivery or catheter removal after deliveryoccurs in 0.74% of deliveries.1,2 The postpartum bladder has a tendency to be underactive and is, therefore, vulnerable to the retention of urine following trauma to the bladder, pelvic floor muscles and nerves during delivery. If postpartum voiding dysfunction is unrecognised, it can lead to bladder underactivity and prolonged voiding dysfunction, with sequelae such as recurrent urinary tract infection and incontinence.3 In the immediate postpartum period, abnormal voiding parameters were identified in 43% of women in a prospective study of 184 women4 using uroflowmetry and measuring postvoid residual urine volume on ultrasound. All women had daily measurements taken, from the first day following vaginal delivery until discharge. The authors defined abnormal voiding parameters as a mean flow rate 10 ml/second when a volume 150 ml was voided and a residual urine volume was 100 ml. Women with abnormal voiding parameters upon discharge were asked to return weekly until normal voiding parameters were recorded. High residual urine volume was recorded in 37 women, 9 had a low flow rate and in 33 both parameters were abnormal. Only 21 of the 79 women with abnormal voiding parameters were symptomatic. Four required catheterisation for urinary retention. At discharge, normal voiding parameters were recorded in 68% and, of the 25 women discharged with abnormal voiding parameters, 7 returned for testing and all voided normally. The majority of women classified as having abnormal voiding parameters had a high residual urine volume and the addition of uroflowmetry did not provide any beneficial information compared to ultrasound.

without voiding or catheterisation postpartum. In a postal questionnaire survey of 189 maternity units in England and Wales, however, Zaki et al.6 found that there was no consensus of opinion about the diagnosis and management of postpartum voiding dysfunction. Of the 156 units (83%) that returned the questionnaire, only 23% followed the RCOG recommendation of catheterisation within 6 hours postpartum if voiding had not occurred. Table 1 presents the findings of this study. It appears that there is wide variation in bladder care.

Risk factors for puerperal voiding dysfunction

Many risk factors have been identied for the development of postpartum voiding dysfunction, including the following:

primiparity instrumental delivery epidural analgesia prolonged labour perineal trauma.

Glavind and Bjrk1 identied postpartum voiding dysfunction in 12/1649 women (0.7%). Instrumental delivery was performed in 33% of the retention group, compared with 8% of the total population. Anal sphincter injury and large perineal tears were present in 33% and 42% of the retention group respectively, compared with 1% and 4% of the total group. Epidural analgesia was used in 33% of the retention group, compared with 11% of the total group. Similarly, in Ramsay and Torbetts study,4 abnormal voiding parameters were found in 74% of women after forceps delivery, compared with 36% of women after spontaneous delivery and 50% of women following epidural, compared with 27% with no epidural. Abnormal parameters were also identied in 35% of women who had perineal tears sutured, compared with 16% of women with an intact perineum. A prospective observational study of 2866 women by Ching-Chung et al.2 identified 114 women (4%) with retention of urine following vaginal delivery. Women in the retention group were more likely to be primiparous (78.1% versus 45.8%) and had longer duration of labour. Instrumental delivery was performed in 16.7% of the retention group compared with 4.7% of the control group. In a retrospective study of 11 322 women, Carley et al.7 studied 51 cases of women with clinically overt urinary retention following vaginal delivery. Retention was unresolved more than 72 hours after delivery in 13 women (25.5%). Again, when compared with the control group, significant risk
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Current practice
The Royal College of Obstetricians and Gynaecologists Study Group report on incontinence5 recommends that no woman should be allowed to go longer than 6 hours

Table 1

Results of the 2003 UK questionnaire study6 of intrapartum and postpartum bladder care

Units (%) Indwelling catheter placed For caesarean section Labour with epidural After instrumental delivery After manual removal of the placenta After repair of a third-degree tear Time to catheterisation if not voiding postpartum (hours) 4 6 8 12 18 24 No time limit 88 15 18 19 24 2 23 15 26 0.6 2 31

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factors for the development of urinary retention included instrumental delivery (47.1% versus 12.4%) and epidural analgesia (98% versus 68.8%). A study by Khullar and Cardozo8 demonstrated that normal bladder sensation is impaired up to 8 hours following the last epidural top-up and that, during this stage, diuresis occurs and the postpartum bladder is vulnerable to overdistension. The effect of new drug dosages and techniques of epidural anaesthesia on bladder sensation needs to be evaluated further.

during labour, this can be achieved by intermittent catheterisation or the placement of an indwelling catheter. Alternatively, real-time ultrasound can be used to estimate total bladder volume during labour.10 If catheterisation is likely to be required more than twice during labour, it may be reasonable to site an indwelling urethral catheter. All women should void urine within 6 hours of delivery or 6 hours of catheter removal. It is important to be aware that epidural anaesthesia can affect bladder sensation and, therefore, it may be appropriate to leave an indwelling catheter in place for a longer period following delivery. In many units, the catheter is deated or removed during active pushing and delivery to prevent the theoretical risk of bladder trauma. If a catheter remains in situ following an instrumental delivery, manual removal of the placenta or repair of a thirddegree tear, the catheter should not be removed until the woman is mobile and careful attention should be paid to voiding within the following 6 hours. If bladder emptying has not occurred within 6 hours of delivery or catheter removal, either the bladder must be emptied by catheterisation and the volume of urine recorded, or bladder volume must be estimated by ultrasound, followed by catheterisation as appropriate. Further management aims to identify any factors contributing to delayed bladder emptying and to ensure adequate bladder drainage while waiting for normal function to return (see Figure 1). Following the diagnosis of urinary retention, a urine sample should be analysed and sent for culture, as the presence of infection can contribute to and prolong voiding dysfunction. If a urinary tract infection is suspected, prompt antibiotic treatment is required. The perineum should be examined and, if swollen or painful, a catheter should be sited until the swelling and pain have

Postpartum warning signs

Overt urinary retention is the inability to void postpartum. Covert retention occurs when a woman has an elevated postvoid residual urine volume of 150 ml with no symptoms of urinary retention. Studies assessing the effect of covert voiding dysfunction in the postpartum period have not established an increased risk of future urinary problems. Andolf et al.9 identied a residual urine volume 150 ml in 1.5% of 534 women scanned 3 days postpartum. At a 4-year follow-up by questionnaire and ultrasound, the incidence of urinary symptoms was not found to be higher than in the general population. Prevention, therefore, of long-term sequelae of postpartum retention should aim to identify all women unable to pass urine 6 hours following delivery and women who are symptomatic of voiding dysfunction. Acute retention can be painless in the postpartum period, especially following epidural anaesthesia. Other symptoms that should alert the clinician to voiding dysfunction include slow urinary stream, urinary frequency, incomplete emptying and incontinence. There is no evidence to suggest that measuring residual urine volume in asymptomatic women is helpful.

Intrapartum and postpartum bladder care

Bladder care is an important part of intrapartum care. Adequate bladder care can reduce the incidence of bladder overdistension and enable prompt recognition of women who have voiding dysfunction. An awareness of the risk factors for the development of voiding dysfunction, outlined above, is important but any woman can develop postpartum voiding dysfunction, regardless of the mode of analgesia or delivery. Bladder emptying should be documented in all women during labour. There are no clear guidelines as to how frequently the bladder should be emptied; however, every 46 hours is prudent. Individual circumstances inuencing urine output, including uid load and oxytocin use, should be considered. If catheterisation is required following an epidural, or if a woman is unable to pass urine spontaneously
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Figure 1

Suggested management of postpartum urinary retention

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settled. Adequate analgesia is important, as perineal pain is a signicant factor in the development of retention. Constipation should be avoided and treatment given if required. Upon catheter removal, the voided volume and postvoid residual urine volume must be recorded. Any further retention or elevated residual urine volume requires continued bladder emptying. Clean intermittent self catheterisation can be taught or, if the perineum is still tender, an indwelling urethral catheter can be sited for up to 2 weeks. The catheter material is not important for short-term catheterisation, except in the presence of latex allergy. The catheter should be inated with a maximum of 10 ml of sterile water or saline. Voiding dysfunction after this period requires careful assessment, including a neurological examination, and is treated by intermittent self catheterisation. In the absence of acute retention, where a woman has other symptoms of voiding dysfunction including hesitancy, slow stream, incomplete emptying, frequency or incontinence, both the voided volume and postvoid residual urine volume should be measured. The suggested management of women with an elevated postvoid residual urine volume is shown in in Figure 1. There is no evidence to suggest that measuring the postvoid residual urine volume in all women following delivery is benecial.

from this condition, bladder emptying must be documented in all women during labour and within the 6 hours following delivery or catheter removal. Inability to void must be treated promptly with catheterisation, until the resolution of symptoms and adequate bladder emptying has occurred. The ow chart (Figure 1) shows one of several possible guidelines for the management of postpartum voiding dysfunction. Some units advocate the use of suprapubic catheters or self catheterisation. The important issue is that every unit has a guideline for bladder care and the management of postpartum voiding dysfunction and that these guidelines are audited to ensure women receive appropriate care. References

Conclusion
Postpartum voiding dysfunction is a recognised complication in the puerperium. Instrumental delivery, epidural anaesthesia and perineal tears are recognised risk factors for the development of urinary retention. To reduce morbidity resulting

1 Glavind K, Bjrk J. Incidence and treatment of urinary retention postpartum. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:11921. doi:10.1007/s00192-002-1014-3 2 Ching-Chung L, Shuenn-Dhy C, Ling-Hong T, Ching-Chang H, Chao-Lun C, Po-Jen C. Postpartum urinary retention: assessment of contributing factors and long-term clinical impact. Aust N Z J Obstet Gynaecol 2002;42:3658. doi:10.1111/j.0004-8666.2002.00367.x 3 Dringer A, Monga A. Voiding dysfunction. Curr Opin Obstet Gynecol 2001;13:50712. doi:10.1097/00001703-200110000-00010 4 Ramsay IN, Torbet TE. Incidence of abnormal voiding parameters in the immediate postpartum period. Neurourol Urodyn 1993;12:17983. doi:10.1002/nau.1930120212 5 MacLean AB, Cardozo L. Incontinence in Women. London: RCOG Press; 2002. 6 Zaki MM, Pandit M, Jackson S. National survey for intrapartum and postpartum bladder care: assessing the need for guidelines. BJOG 2004;111:8746. doi:10.1111/j.1471-0528.2004.00200.x 7 Carley ME, Carley JM, Vasdev G, Lesnick TG, Webb MJ, Ramin KD, et al. Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. Am J Obstet Gynecol 2002;187:4303. doi:10.1067/mob.2002.123609 8 KhullarV, Cardozo LD. Bladder sensation after epidural analgesia. Neurourol Urodyn 1993;89:4245. 9 Andolf E, Iosif CS, Jrgensen C, Rydhstrm H. Insidious urinary retention after vaginal delivery: prevalence and symptoms at follow-up in a population-based study. Gynecol Obstet Invest 1994;38:513. 10 Gyampoh B, Crouch N, OBrien P, O'Sullivan C, Cutner A. Intrapartum ultrasound estimation of total bladder volume. BJOG 2004;111:1038. doi:10.1046/j.1471-0528.2003.00025.x

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