Curr Bladder Dysfunct Rep (2012) 7:260263
DOI 10.1007/s11884-012-0162-7
ACQUIRED VOIDING DYSFUNCTION (CV COMITER, SECTION EDITOR)
Evaluation and Management of Postpartum
Urinary Retention
Sukrant Mehta & Jennifer Anger
Published online: 31 October 2012
# Springer Science+Business Media New York 2012
Abstract Postpartum urinary retention (PUR) is a clinically
significant problem for women after delivery. Despite the
large body of literature that covers this topic, PUR is not a
clearly defined or well understood condition. The aim of this
review article is to provide a better understanding of the risk
factors and pathophysiology that contribute to the develop-
ment of PUR. We provide a framework with which to
evaluate and manage PUR. Meticulous attention to bladder
care combined with early detection are key elements in
minimizing PUR.
Keywords Postpartum urinary retention (PUR) . Post-void
residualbladdervolume(PVR) . Intermittentcatheterization(IC)
Introduction
Postpartum urinary retention (PUR) is a common and dis-
tressing condition for postpartum women. The wide range of
reported incidence reflects the lack of a standardized defini-
tion of PUR, as well as varying obstetric practices [1]. Two
commonly used definitions are the absence of spontaneous
micturition after 6 hours of vaginal delivery or no spon-
taneous micturition within 6 hours after the removal of
indwelling catheter after cesarean section [1]. Many practi-
tioners also define PUR based on an estimation of the post-
void residual bladder volume (PVR) of more than 150 mL
S. Mehta
Department of Obstetrics and Gynecology,
Cedars-Sinai Medical Center,
Los Angeles, CA, USA
J. Anger (*)
Department of Surgery, Division of Urology,
Cedars-Sinai Medical Center,
99 N. La Cienega Blvd., Ste 307,
Beverly Hills, CA 90211, USA
e-mail: janger@mednet.ucla.edu
obtained via catheterization or noninvasive ultrasound [1].
PUR has been classified into covert and overt retention.
Women with a PVR of more than 150 mL, identified by
bladder scanner, ultrasound, or by catheterization, without
symptoms of urinary retention, are classified as having
covert urinary retention. Overt urinary retention refers to
the inability to void in the presence of signs and symptoms
of urinary retention [2].
It is a relatively common event, with the reported inci-
dence ranging anywhere from 1.7 % to 17.9 % after vaginal
delivery [1, 3], and up to 24.1 % after cesarean delivery [4].
Andolf et al., in a prospective case controlled study, found
that 8 (1.5 %) of 530 women developed PUR after vaginal
delivery [5]. Kekre et al. reported PUR in 84 (10.9 %) out of
771 women after vaginal delivery, of which 82 (10.6 %) had
covert PUR and 2 (0.3 %) had overt PUR [6]. Liang et al.,
in a prospective study that enrolled 605 women who under-
went cesarean delivery, reported PUR in 146 (24.1 %) of the
605 women, of which 101 (16.7 %) had covert PUR and 45
(7.4 %) had overt PUR [4]. It is important to note that each
of the aforementioned studies used slightly different diag-
nostic criteria when determining the incidence of PUR.
In this review article we seek to highlight risk factors,
review the pathophysiology, outline management, and lastly
highlight the importance of prevention.
Risk Factors
The etiology of PUR is complex and multifactorial. Recog-
nized and postulated risk factors include physiologic
changes during pregnancy, nulliparity, cesarean delivery
for lack of progress in the first stage of labor, operative
vaginal delivery (including both forceps delivery or vacuum
extraction), perineal damage, and use of narcotics during
delivery [79]. Prolonged first and second stages of labor
are considered to be significant risk factors, with Yip et al.
Curr Bladder Dysfunct Rep (2012) 7:260263
showing that labor that exceeded 600 minutes (11 hours and
40 minutes) had a significant association with PUR [10].
Yip et al., in an attempt to create a screening test model
using duration of labor to predict PUR, enrolled 691
patients, of which 101 (14.6 %) had PUR [10]. The 691
patients were randomized into two groups and a receiver
operating characteristic (ROC) curve was constructed to
determine the optimum cutoff value for screening for PUR
using the duration of labor. A range of cutoff values (with
specificity ranging from 0.60 to 0.99) for the duration of
labor was determined, with the optimal cutoff value for the
duration of labor determined to be 600 minutes. A duration
of labor of 600 minutes was determined to have a specificity
of 0.95, negative predictive value of 0.86, and likelihood
ratio for a positive test of 0.88 [10].
It remains unclear whether neuraxial anesthesia (which
includes both epidural and spinal anesthesia) is a significant
independent risk factor for PUR. There are many conflicting
studies in the literature, some of which suggest the use of
neuraxial anesthesia, as compared to alternative pain man-
agement strategies, including the Bradley method, is asso-
ciated with an increased risk of developing PUR, while
others have failed to find an association [8, 1113]. These
findings may represent the effects of various concentrations
and types of local anesthetics as well as variation in obstetric
practice. The lack of a clear relationship between neuraxial
anesthesia and PUR highlights the presence of many con-
founding variables, including the use of oxytocin during
labor, which has been argued to shorten the duration of
labor and thereby reduce the risk of bladder hypotonia and
subsequent PUR [11, 14] as well as the fact that nulliparity
and operative vaginal delivery are associated with both
epidural use and urinary retention.
Pathophysiology
Normal voiding occurs when there is relaxation of the
urethral sphincter and pelvic floor musculature followed
by contraction of the detrusor muscle and a concomitant
rise in intra-abdominal pressure. Dysfunction or lack of
synchrony at any of these steps can result in voiding dys-
function. The pathophysiology of PUR is poorly under-
stood, but it is believed to be the result of a combination
of physiological and traumatic events during pregnancy and
delivery, including damage to nerves, pelvic muscles and
bladder musculature that can all contribute to the risk of
urinary retention in the postpartum period [5, 9].
During pregnancy and the postpartum period, progester-
one reduces smooth muscle tone, which leads to dilatation
of the renal pelvices, ureters and bladder [5, 9]. As the tone
in the detrusor muscle slowly decreases, bladder capacity
begins to increase. When standing, the gravid uterus places
261
increased pressure on the bladder, such that a doubling of
bladder pressure has been observed in women at term [15].
In the immediate postpartum period, without the weight of
the gravid uterus to limit the capacity of the bladder, the
bladder tends to become hypotonic, thereby placing women
at risk for PUR.
Operative vaginal delivery, which includes both forceps
or vacuum assisted delivery, has been shown to be a signif-
icant independent risk factor for PUR, and may affect the
ability of the urethral sphincter to relax [2]. Operative vag-
inal delivery may result in perineal trauma, also a risk factor
for PUR. The proposed mechanism of PUR is urethral and
perineal edema leading to increased resistance to urine flow
[2]. Pudendal nerve damage has also been postulated as a
contributing factor to PUR, as the pudendal nerve innervates
the external urethral sphincter, and impaired relaxation can
result in increased resistance to urine flow [16].
Diagnosis
In women unable to void within six hours after vaginal
delivery or catheter removal, noninvasive ultrasound or
catheterization can help identify those who need closer
monitoring. In most obstetric units, estimation of the PVR
by ultrasound is used as a noninvasive method to detect
urinary retention. The reliability of ultrasound in the mea-
surement and estimation of PVR was validated by Yip et al.
in 2003. The results of this study demonstrated ultrasound to
be an accurate estimation of PVR, allowing for a noninva-
sive assessment to help determine whether catheterization is
then necessary [17]. While a standardized approach to the
early detection and diagnosis of PUR remains to be estab-
lished, a bladder scan is recommended in women who do
not void by six hours, are unable to void despite an urge to
do so, or experience voiding difficulty.
Management
In women unable to void within 6 hours after vaginal
delivery or catheter removal, initial management should be
focused on conservative, non-invasive measures, known as
helping measures. Helping measures are commonly used
practice measures in obstetrical units, and consist of oral
analgesia, namely NSAIDS, aimed at reducing perineal and
periurethral edema, early ambulation, providing the patient
with privacy, and warm baths. These measures alone have
been shown to resolve temporary urinary retention in 60 %
of post-operative general surgery patients [18].
Helping measures are unlikely to help women void who
are in frank retention, and therefore should be tried only
briefly. If a woman experiences pain from a full bladder,
262
catheterization should be performed immediately. Although
some teach that intermittent catheterization (IC) should be
performed every 46 hours until women void with a residual
volume < 150 mL [19], often patients who void the majority
of the urine in their bladder can avoid IC, even if bladder
volumes are over 150 mL. IC is generally recommended
over continuous catheterization, given the reduced incidence
of infection, mucosal irritation, and maternal discomfort
[20]. However, the decision to place an indwelling catheter
or perform IC depends on patient preference and degree of
perineal pain and edema.
The volume of urine initially drained may be a predictor
of the need for repeat catheterization. In one study, no
patient with an initial residual volume of less than 700 mL
required repeat catheterization, while 14 % of patients with a
residual volume of 700999 mL and 20 % of patients with a
residual volume of more than 1000 mL required repeat
catheterization [21].
The decision to discontinue IC is based on the presence
of a decreasing PVR to an acceptable level. In addition, a
significant decrease in symptoms of voiding difficulty may
be helpful in deciding to discontinue intermittent catheteri-
zation. The duration of catheterization typically ranges from
24 to 48 hours depending on the initial residual volume and
factors causing PUR [9]. If a woman is still unable to void at
the time of discharge, it is recommended to teach her clean
intermittent self-catheterization. If this is not feasible, then
she should be sent home with a continuous catheter for
48 hours followed by a voiding trial. For some women
who are already overwhelmed with taking care of a new-
born, an indwelling urethral catheter may be less burden-
some than IC.
Women who require catheterization should receive pro-
phylactic antibiotics to reduce the likelihood of urinary tract
infection. Recommended antibiotics include nitrofurantoin,
ampicillin, or trimethoprim-sulfamethoxazole, the latter of
which is contraindicated if breastfeeding [3].
Additional pharmacologic agents that have been sug-
gested in the management of post-surgical urinary retention
include alpha-adrenergic blocking agents, prostaglandin F2
alpha, and diazepam [2225]. Their use, however, is limited
in women who are breastfeeding, and none have been for-
mally studied in postpartum women for this specific clinical
indication [3].
Prevention
The key to prevention of PUR is attention to bladder care
during labor combined with early detection and manage-
ment. Identifying women at high risk for PUR based upon
risk factors will also aid with early recognition of PUR.
Hinman, in an editorial from 1976, reported that bladder
Curr Bladder Dysfunct Rep (2012) 7:260263
overdistention can produce irreversible damage to the detru-
sor muscle, once again highlighting the importance of early
detection of PUR [26].
Complications
While PUR is almost always a temporary condition in
which voiding returns to normal within 2 to 6 days of
diagnosis [9, 14, 27], there are case studies of women
who do not resume normal voiding for several weeks,
including rare cases of long-term retention [1, 2832].
Prolonged retention that last several weeks should be evalu-
ated with urodynamics to determine if retention is obstructive
or atonic in nature. Long-term management can then be tai-
lored to the specific type of voiding dysfunction. Fortunately,
most women with PUR in a 4-year follow up study did not
reveal a higher incidence of stress incontinence, fecal incon-
tinence, frequency, nocturia, urgency or urge incontinence
compared to age-matched controls [33].
Conclusions
PUR is a clinically significant problem for postpartum wom-
en. It remains a relatively poorly defined and understood
condition, and yet can result in significant short and poten-
tially long-term complications if it goes unrecognized. At-
tention to bladder care during labor and vigilance in the
early detection and management remain the cornerstones
of prevention. Future studies are still needed to further
elucidate the mechanism, risk factors, and pathophysiology
of PUR, all of which will help develop more standardized
guidelines for the management of PUR.
Disclosure No potential conflicts of interest relevant to this article
were reported.
References
Papers of particular interest, published recently, have been
highlighted as:
Of importance
1. Yip S, Sahota D, Pang MW, et al. Postpartum urinary retention.
Acta Obstet Gynecol Scand. 2004;83:88191.
2. Carley ME, Early JM, Vasdev G, et al. Factors that are associated
with clinically overt postpartum urinary retention after vaginal
delivery. Am J Obstet Gynecol. 2002;187(2):4303.
3. Saultz JW, Toffler WL, Shackles JY. Postpartum urinary retention.
J Am Board Fam Pract. 1991;4:3414.
Curr Bladder Dysfunct Rep (2012) 7:260263
4. Liang CC, Chang SD, Chang YL, et al. Postpartum urinary reten-
tion after cesarean delivery. Int J Gynecol Obstet. 2007;99:22932.
5. Andolf E, Iosif CS, Jorgensen C, et al. Insidious urinary retention
after vaginal delivery: prevalence and symptoms at follow-up in a
population-based study. Gynecol Obstet Invest. 1994;38:513.
6. Kekre A, Vijayanand S, Dasgupta R, et al. Postpartum urinary
retention after vaginal delivery. Int J Gynecol Obstet. 2011;112:112
5. This is a recent study that points to operative vaginal delivery and
labor longer than 700 minutes as being significant obstetric risk
factors in the development of PUR.
7. Ching-Chung L, Shuenn-Dhy C, Ling-Hong T, et al. Postpartum
urinary retention: assessment of contributing factors and long-term
clinical impact. Aust NZ J Obstet Gynaecol. 2002;42:3658.
8. Musselwhite KL, Faris P, Moore K, et al. Use of epidural anesthe-
sia and the risk of acute postpartum urinary retention. Am J Obstet
Gynecol. 2007;196:472.e15.
9. Yip SK, Brieger G, Hin LY, et al. Urinary retention in the postpar-
tum period: the relationship between obstetric factors and the post-
partum post-void residual bladder volume. Acta Obstetric Gynecol
Scand. 1997;76:66772.
10. Yip S, Sahota D, Pang M, et al. Screening test model using
duration of labor for detection of postpartum urinary retention.
Neurourol Urodyn. 2005;24:24853.
11. Lieberman E, ODohoghue C. Unintended effects of epidural
analgesia during labor: a systematic review. Am J Obstet Gynecol.
2002;186:S3168.
12. Weissman A, Grisaru D, Peyser RM, et al. Postpartum surveillance
of urinary retention by ultrasonography: The effect of epidural
analgesia. Ultrasound Obstet Gynaecol. 1995;6:1304.
13. Rizvi RM, Khan ZS, Khan Z. Diagnosis and management of
postpartum urinary retention. Int J Obstet Gynecol. 2005;91
(1):712.
14. Bennetts FA, Judd GE. Studies of the post-partum bladder. Am J
Obstet Gynecol. 1941;42:41927.
15. Glavind K, Bjork J. Incidence and treatment of urinary retention
postpartum. Int Urogyn J. 2003;14:11921.
16. Damaser MS, Broxton-King C, Ferguson C, et al. Functional and
neuroanatomical effects of vaginal distention and pudendal nerve
crush in the female rat. J Urol. 2003;170:102731.
17. Yip S, Sahota D, Chang AM. Determining the reliability of ultra-
sound measurements and the validity of the formulae for ultrasound
estimation of postvoid residual bladder volume in postpartum wom-
en. Neurourol Urodyn. 2003;22(3):25560.
263
18. Stallard S, Prescott S. Postoperative urinary retention in general
surgical patients. Br J Surg. 1988;75:11413.
19. Yip S, Sahota D, Pang MW. Postpartum urinary retention. Obstet
Gynecol. 2005;106(3):6026.
20. Page G, Buntinx F, Hanssens M. Indwelling bladder catheteriza-
tion as part of postoperative care for cesarean section (Protocol for
Cochrane review). In: the Cochrane library, issue 3. Chichester,
UK: Wiley;2004.
21. Burkhart FL, Porgers RF, Gibbs CE. Bladder capacity postpartum
and catheterization. Obstet Gynecol. 1965;26:1769.
22. Livne P, Kaplan B, Ovadia Y, et al. Prevention of post-hysterectomy
urinary retention by alpha-adrenergic blocker. Acta Obstet Gynecol
Scand. 1983;62:33740.
23. Tammela T, Kontturi M, Kaar K, et al. Intravesical prostaglandin
F2 for promoting bladder emptying after surgery for female stress
incontinence. Br J Urol. 1987;60:436.
24. Jaschevatzky OE, Anderman S, Shalit A, et al. Prostaglandin F2
alpha for prevention of urinary retention after vaginal hysterecto-
my. Obstet Gynecol. 1985;66:2447.
25. Burger D, Kappetein AP, Boutkan H, et al. Prevention of urinary
retention after general surgery: a controlled trial of carbachol/
diazepam versus alfusozine. J Am Coll Surg. 1997;185:2346.
26. Hinman F. Editorial: postoperative overdistension of the bladder.
Surg Gynecol Obstet. 1976;45:9012.
27. Lee SNS, Lee CP, Tang OSF, et al. Postpartum urinary retention.
Int J Gynecol Obstet. 1999;66:2878.
28. Groutz A, Levin I, Gold R, et al. Protracted postpartum urinary
retention: the importance of early diagnosis and timely interven-
tion. Neurourol Urodyn. 2011;30:836.
29. Kulkarni R, Bradford WP, Forster SJ, et al. Chronic retention of
urine following childbirtha rare complication in the puerperium.
Aust N Z J Obstet Gynecol. 1994;34(1):1078.
30. Jeffery TJ, Thyer B, Tsokos N, et al. Chronic urinary retention
postpartum. Aust N Z J Obstet Gynaecol. 1990;4:3646.
31. Watson WJ. Prolonged postpartum urinary retention. Mil Med.
1991;156:5023.
32. Groutz A, Gordon D, Wolman I, et al. Persistent postpartum
urinary retention in contemporary obstetric practice. Defini-
tion, prevalence and clinical implications. J Reprod Med.
2001;46:448.
33. Yip S, Sahota D, Chang A, et al. Four year follow-up of woman
who was diagnosed to have postpartum urinary retention. Am J
Obstet Gynecol. 2002;187:64852.