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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
R.M. Rizvi, J. Rizvi / Reviews in Gynaecological and Perinatal Practice 6 (2006) 140144
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
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
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].
R.M. Rizvi, J. Rizvi / Reviews in Gynaecological and Perinatal Practice 6 (2006) 140144
143
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].
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