Postpartum bladder dysfunction and urinary retention

1. Postpartum voiding
dysfunction and urinary retention
Prativa Dhakal
Lecturer, Maternal Health Nursing
UCMS, Bhairahawa

2. Introduction
• Voiding difficulty and urinary retention is a
common phenomenon in the immediate
postpartum period.
• The importance of prompt diagnosis and
appropriate management of this condition is
the key to ensuring a rapid return to normal
bladder function.

3. Definition
• Postpartum voiding dysfunction—if defined as
failure to pass urine spontaneously within 6 hours
of vaginal delivery or catheter removal after
delivery—occurs in 0.7–4% of deliveries.
• Postpartum urinary retention is the inability to
void, with a painful (usually), palpable or
percussable bladder and the need for
catheterisation to obtain relief

4. Definition…
• Persistent postpartum urinary retention may be
defined as the inability to void spontaneously despite
the use of an indwelling catheter for three days.
• Overt retention refers to the inability to void
spontaneously within 6 hours of vaginal birth or
removal of indwelling catheter.
• Covert retention refers to increased post void
residual volumes of > 150 ml and no symptoms of
urinary retention.

5. • 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 UTI and
incontinence

6. • The RCOG Study Group report on incontinence
recommends that no woman should be allowed to go
longer than 6 hours, without voiding or catheterisation
postpartum.

7. Incidence
• Estimated incidences range from 0.05% to
37.0%

8. Risk factors
• Primiparity
• Instrumental delivery
• Epidural, spinal or pudendal block in labour
• Prolonged second stage of labour
• Catheterisation during or after birth

9. Risk factors…
• Perineal trauma, vaginal or vulval hematomas,
edema
• History of voiding difficulties
• First vaginal birth
• Birth weight > 3.8 kg
• Caesaren section

10. Pathophysiology of urinary
retention
• One of the most common cause is the use of
regional anaesthesia due to afferent neural
blockade which supresses the sensory stimuli from
the bladder to the pontine micturition centre.
• As a result, the reflex mechanism that induces
micturition is blocked which may result in reduced
contractility of bladder and urinary retention

11. Pathophysiology…
• Result of nerve injury during delivery: The
pudendal nerve, with afferent nerve branches (S2-
4) supplying the bladder, is damaged during pelvic
surgery and vaginal delivery. There is a significant
increase in pudendal nerve terminal motor
latencies, which may take a few months to recover
post delivery

12. Pathophysiology…
• Pelvic floor tissue stretching during delivery
resulting in pudendal nerve damage: Both
instrumental delivery and prolonged labour can be
predisposing factors to this damage.
• Tissue oedema around the urogenital area,
resulting in a transient mechanical obstruction to
urine outflow.

13. Physiological changes contributing to
PPUR
Elevated progestogen levels in pregnancy and the immediate postpanum period
Reduced smooth muscle tone
Dilated bladder, ureters and renal pelvises during pregnancy and the first few
weeks post-partum.
Coupled with changes in vesical pressures (an initial rise in pregnancy followed
by a rapid drop to normal values within a few days after delivery)
Results in a hypotonic bladder in the early puerperium.

14. Clinical presentation
• Comp1ete or inability to void, to the asymptomatic patient with
large post void residual volumes.
• Clinical suspicion:
– Small voided volumes,
– urinary frequency,
– slow or intermittent stream,
– urgency,
– bladder pain or discomfort,
– urinary incontinence and those who strain to void, or
describe no sensation to void.

15. Management
• Intrapartum bladder management: Women
should be encouraged to void every 2-3 hours in
labour with a low threshold for catheterisation if
unable to void (unable to void on 2 occasions or a
palpable bladder.
• Women who have epidural analgesia: Offered
indwelling catheter for a minimum of 6 hours
postpartum or until full sensation has returned.

16. Management…
Postpartum management:
• No patient should be left >6 h without voiding or being
catheterised for residual volumes.
• Strict input and output chart should be instituted.
• Timing of voids should be recorded, and voided volumes
and post void residual volumes should be measured.
• Timed voiding every 3-4 h in the immediate postpartum
period.

17. Measures to aid voiding
• Ensure patient is well analgesed.
• Ice to perineum to help reduce oedema.
• Help the patient to stand and walk to the toilet.
• Provide privacy.
• Assist patient into a warm bath.
• Prevent constipation.

18. Management…
• Following the diagnosis of urinary retention, a
urine sample should be sent for culture. If UTI is
suspected, prompt antibiotic treatment is required.
• Place a catheter if swollen pr painful perineum
until the swelling and pain have settled.
• Avoid constipation

19. Management…
• Provide adequate analgesia as perineal pain is a
significant factor in the development of retention.
• Record the voided volume and postvoid residual
volume after removal of catheter.
• Further retention or increased residual volume
requires continued baldder emptying.

20. Management…
• Clean intermittent self catheterisation can be
taught, or if the perineum is still tender, an
indwelling catheter can be sited up to 2 weeks.
• Voiding dysfunciton after this period requires
careful assessment, including a neurological
examination.

21. Summary of management

22. Complications
• Urinary tract infection
• Urinary / faecal incontinence
• Short and long term bladder dysfunction
• Ureteric reflux
• Bilateral hydronephrosis
• Acute renal failure
• Long-term renal impairment

23. Reference
• Kearney R, Cutner A. Postpartum voiding dysfunction. The
Obstetrician & Gynaecologist 2008;10:71-74
• Postpartum bladder dysfunction. South Asian Perinatal Practice
guidelines. Department of Health. Government of South
Australia. 2012
• Lim J.L. Postpartum Voiding Dysfunction and urianry retention.
Australian and New Zealand Journal of Obstetrics and
Gynaecology 2010; 50: 502-505
• Postpartum Bladder Care: Background, practice and
complications. 2011 Retrieved form
http://www.ogpnews.com/2011/12/post-partum-bladder-care-
background-practice-and-complications/444