Difficult Case: Postpartum Voiding Difficulty after Cesarean Delivery

A 39-year-old patient presented with postpartum voiding difficulty (PVD) after cesarean delivery (spinal anesthesia) that required urethral catheterization.

Background clinical history:

• 1 abortion 2 cesareans
• Past history of UTI with uroculture negative but treated with antibiotics
• History of feeling of incomplete voiding
• LUTS during pregnancy - again treated with antibiotics with negative culture
• Post-void residual: 45 ml
• Supra pubic pain

Post-delivery:

When the patient went to the room after cesarean, she reported suprapubic discomfort. After a few hours with urinary retention, 1.5L of urine was probed. Intermittent catheterization was indicated. Patient reported pain with bladder filling, feeling of bladder emptying and incomplete bowel movement. Patient very frustrated and feeling incapable of taking care of her newborn baby and 4-year-old son due to her bladder conditions.

The patient presented to the physiotherapy clinic with global pelvic floor dysfunction:

• Voiding dysfunction needing intermittent catheterization
• Feeling of incomplete voiding and defecation
• Pelvic floor incoordination
• Pelvic floor spasm
• Deficit of relaxation in the EMG biofeedback

Post-operative:

The patient was referred to physiotherapy post-cesarean with voiding difficult needing intermittent catheterization. She underwent pelvic floor muscle training (PMFT) and biofeedback under the care of an experienced women’s health physiotherapist. Deficit relaxation of the pelvic floor muscles was observed during the digital assessment and pelvic floor muscle spam. In the evaluation with surface electromyography, an increase in resting tone, incoordination of the pelvic floor muscles and relaxation deficit were observed. Suprapubic hot bag, pelvic floor muscle rehabilitation exercises with a focus on relaxation, and intravaginal manual therapy were suggested. After two visits, post voiding residue of less than 20 ml was evaluated, the intermittent catheterization was removed and after 5 sessions the patient reported improvement in evacuation, return to sexual life and reduction in lower urinary tract symptoms.

Progress:

At 3-month follow up, patient reported good results and no voiding dysfunction. She has been doing pelvic floor exercises and behavior therapy. She is still emotionally shaken from not having been indicated for physical therapy treatment and having taken antibiotics during pregnancy even with negative tests. Pandemic restrictions prevented her from seeing her eldest son during the period of hospitalization. She reports that this experience affected her eldest child's development, and she feels guilty. She is currently without symptoms and refers to important improvement with the coordination of the pelvic floor muscles and with superficial heat.

Expert Response: Physiotherapy Perspective

From a physical perspective, this case study highlights the importance of the assessment and treatment of increased pelvic floor muscle resting tension and decreased muscle relaxation that appears to have played a role in this patient’s ongoing symptoms after acute postpartum urinary retention.

The use of EMG in biofeedback training of pelvic floor muscle electrical activity, notably the use of intravaginal EMG which measures electrical activity of the deep layer of PFM at rest, on contraction and relaxation, is not only clinically useful for physiotherapists’ assessment and subsequent outcome measures but can provide valuable, visual information to the patient. Given the history of pain and increased resting tension, probe selection would be important to minimize increasing patient discomfort and obviously for some patients this would not be an appropriate tool.

What might be missing in detail in this case as presented, however no doubt addressed, is the influence of a patient’s history and experience of pain in addition to the emotional and psychological stress on pelvic floor muscle function, specifically with regards to increased tension and guarding. Patient education, support and reassurance, guidance with sexual activity as needed, and the focus on moving forward, continuing her daily routine, getting outdoors, and participating in activities she enjoys (of course the inclusion of whatever physical activities she loves) would be necessary to address. Of course, if her worries continue to be concerning, referral to her GP and a psychologist could be quite helpful, as is an overall multidisciplinary approach to overall management.