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Reviews in Gynaecological and Perinatal Practice 6 (2006) 140–144

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 catheter-

ization 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 Interna-

tional 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 manage-

ment 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) 140–144 141

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 urody-

namics 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, result-

ing 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 800–1000 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

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

withpostpartumurinaryretention returned tonormalwithin2–

6daysofdiagnosis [12,13,19].However,althoughtheproblem

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 post-

void residual bladder volume in the postpartum period is

R.M. Rizvi, J. Rizvi / Reviews in Gynaecological and Perinatal Practice 6 (2006) 140–144142

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.

7. Management

There are two types of patients

1. O

vert urinary retention with urgency and stranguria.

2. C

overt 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].

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].

8. Helping measures

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 women’s 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) 140–144 143

postoperative urinary retention after surgical operations

[23].

9. Catheterization

Retention without obstruction can be dealt with by

intermittent catheterization and resorting to indwelling

catheter only if it becomes necessary. Indwelling catheter-

ization 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 self-

catheterization. Recently, Yip et al. recommended that for

hospitalized women intermittent catheterization should be

performed every 4–6 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 catheter-

ization was necessary for 14% of patients with 700–999 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-sulphamethia-

zole (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

Bjork’s 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

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.

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 catheteriza-

tion. After delivery bladder volume should be assessed if:

� T

he uterus is high and deviated, especially if there is

heavy lochia.

� T

he bladder is palpable and patient is unable to void.

� T

here 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 catheter-

ization every 4–6 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 catheteriza-

tions 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 6–8-weeks postpartum

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