Ask Anything: Post-Partum Voiding Dysfunction

28 yo complains of difficulty emptying her bladder day 1 following a forceps birth of 3.8kg baby for fetal distress. Labor was uncomplicated and she had an epidural on board. She has no sensation to void and has a post void residual of 300 to 400 ml. There is no significant past medical or surgical history. How do you diagnose post-partum urinary retention (PPUR)? How common is post-partum voiding dysfunction and what is the best management approach? What is the difference between overt and covert post-partum voiding dysfunction? Is there any role for tamsulosin in the management?

Thank you for asking this interesting and highly relevant question. Unfortunately, this is something we see all too often in clinical practice. Covert voiding dysfunction refers to the suspicion of voiding difficulties and clearly this becomes overt once a diagnosis has been made.

I guess the starting point here is to try and work out why this patient has voiding dysfunction. I note she had an instrumental delivery of a large baby and also had an epidural. Was a urethral catheter inserted at the time of the epidural? If not, then it is likely that she may have had an undiagnosed bladder over distension injury. Importantly, was the Bladder Management Protocol followed?

In terms of management, I would want to know what the largest recorded urinary residual was and how it was measured. Bladder scans often have poor accuracy in the post-partum period and therefore in/out catheterization should probably be regarded as the most accurate method of assessment.

If the maximum residual is 300-400mls, then I would probably advise a urethral catheter for 48 hours and then perform a careful trial without catheter – measuring the voided volumes and post void residuals. If these were less than 100-150 mls, then I think it would be safe to remove the catheter. If the residuals were still significant, I would advise that the catheter be left in for one week (with low dose antibiotic prophylaxis) prior to a further trial of void.

Should the second trial of void fail, then I would offer a further week of bladder rest with repeat catheterization or suggest that she may like to learn how to self-catheterize. Unfortunately, there is no role for an alpha-adrenergic antagonist such as Tamsulosin or for a cholinergic drug such as Myotoine. Consideration should be given to prescribing topical vaginal estrogen therapy however, particularly if she is planning to breast feed.

References:

Karim F, Araklitis G, Robinson D, Cardozo L. The management of urogynaecological problems in pregnancy and the postpartum period. The Obstetrician & Gynaecologist. 2022;24(3):167-175.

Postpartum urinary retention is commonly diagnosed when a woman cannot urinate or has a residual urine volume > 150 ml. It is not an uncommon condition in clinical practice. However, the prevalence remains unclear. Based on the most recent systematic review and meta-analysis, 14% of women who delivered vaginally experienced urinary retention within postpartum day 4. The term “covert urinary retention” is more appropriate than the “overt” in this woman because she can void spontaneously but has a significant amount of PVR.

Episiotomy, forceps delivery, degree of perineal and pelvic floor trauma, and epidural analgesia might be risk factors for the problem in this woman. Therefore, intermittent clean catheterization or transurethral indwelling catheterization for at least 24 hours would be helpful. There is not enough evidence regarding efficacy and safety of Tamsulosin in postpartum urinary retention.