Postpartum urinary retention: a systematic review of adverse effects and management

Incidence and risk factors of postpartum urinary retention following cesarean section: a retrospective nationwide inpatient sample database study

AIM

To investigate the risk factors associated with postpartum urinary retention after cesarean section (CS) and to determine the associated morbidity rate.

METHODS

This study was a population-based retrospective case-control study analyzed using National Inpatient Sample (NIS) data from 2010 to 2019. The study classified women according to whether they developed postpartum urinary retention after delivery. Predictors of postpartum urinary retention occurring after CS were identified by multivariate logistic regression analysis, and the corresponding incidence rates were examined after adjusting for basic maternal demographic and clinical characteristics.

RESULTS

A total of 2,397,168 CSs were extracted from the NIS database. The overall incidence of urinary retention after CS was 0.20%. Patients who experienced urinary retention after CS demonstrated longer length of stay (LOS), higher total costs, and more postoperative complications. The following variables have been identified as potential risk factors for urinary retention: age between 25 and 34 years (OR = 1.27; 95% CI = 1.17-1.38; P < 0.001), 35 years and older (OR = 1.35; 95% CI = 1.22-1.48; P < 0.001), Asian and Pacific Islander (OR = 1.85; 95% CI = 1.68-2.05; P < 0.001), one comorbidity (OR = 1.51; 95% CI = 1.28-1.79; P < 0.001), two comorbidities (OR = 1.51; 95% CI = 1.09-2.08; P = 0.013), three and more comorbidities (OR = 1.79; 95% CI = 1.06-3.04; P = 0.031), large hospitals (OR = 1.16; 95% CI = 1.07-1.26; P < 0.001), teaching hospitals (OR = 1.93; 95% CI = 1.79-2.07; P < 0.001), eastern hospitals (OR = 1.24; 95% CI = 1.14-1.35; P < 0.001), coagulation disorders (OR = 1.32; 95% CI = 1.08-1.61), fluid and electrolyte disorders (OR = 2.46; 95% CI = 1.94-3.11), other neurological disorders (OR = 1.51; 95% CI = 1.20-1.89), paralysis (OR = 3.24; 95% CI = 1.95-5.38), and weight loss (OR = 2.34;95% CI = 1.26-4.35). In addition, urinary retention was associated with postoperative complications related to bladder or ureteral injury (OR = 6.12; 95% CI = 2.46-15.23), blood transfusion (OR = 1.51; 95% CI = 1.31-1.76), acute renal failure (OR = 4.74; 95% CI = 3.46-6.48), respiratory failure (OR = 2.21; 95% CI = 1.23-3.98), endometritis (OR = 1.32; 95% CI = 1.02-1.71), hemorrhage/hematoma ( OR = 2.52; 95% CI = 1.38-4.62), uterine rupture (OR = 1.75; 95% CI = 1.21-2.54), hysterectomy (OR = 2.30; 95% CI = 1.66-3.18), peritonitis (OR = 2.86; 95% CI = 1.03-7.92), severe puerperal infections (OR = 3.31; 95% CI = 2.60- 4.22), chorioamnionitis (OR = 1.78; 95% CI = 1.59-2.00). Notably, the presence of cephalopelvic disproportion (OR = 1.37; 95% CI = 1.11-1.67), breech or other fetal position abnormalities (OR = 1.10; 95% CI = 1.00-1.20), placenta previa (OR = 1.39; 95% CI = 1.06-1.84), multiple gestation (OR = 1.39; 95% CI = 1.23-1.58), anatomy of the bladder (OR = 3.93; 95% CI = 1.42-10.90), bladder catheter placement (OR = 22.57; 95% CI = 20.24-25.17) and intravenous infusion (OR = 1.22; 95% CI = 1.09-1.36) was associated with a significantly increased risk of urinary retention, while low cervical CS (OR = 0.62; 95% CI = 0.50-0.76), previous CS (OR = 0.87; 95% CI = 0.82-0.93) and prolapsed cord (OR = 0.52; 95% CI = 0.31-0.86) conferred some protective effect against it.

CONCLUSION

In this study, we identified an overall prevalence of 0.20% for urinary retention after CS and several risk factors, including advanced maternal age, Asian and Pacific Islander background, comorbidities, and delivery in large or teaching hospitals, particularly in the Eastern region. Protective factors included hospitals in the southern region, urban hospitals, obesity, and hypertension. Urinary retention was associated with increased postoperative complications, longer LOS, and higher healthcare costs. Several confounders also significantly influenced the incidence of urinary retention. To mitigate these risks, healthcare professionals should prioritize antenatal screening, manage comorbidities, and closely monitor high-risk patients during the postpartum period to reduce adverse outcomes.

Urinary retention during and after labor with programmed intermittent epidural bolus (PIEB) analgesia: a prospective observational study

BACKGROUND

This study investigates the incidence and risk factors for urinary retention during and after labor in women receiving programmed intermittent epidural bolus (PIEB) analgesia and evaluates the optimal bladder management strategy.

METHODS

This prospective observational study assessed urinary retention during voiding attempts every two to three hours during labor and postpartum, among women with labor epidural analgesia using PIEB. Urinary retention was defined as a post-void residual volume >150 mL, determined by catheterization after spontaneous voiding.

RESULTS

Among 137 women included, with 277 voiding attempts during labor, the urinary retention rate was 20.6%, occurring in 48 women (35%). When the spontaneously voided volume was >50 mL, urinary retention was observed in less than 10% of attempts. Postpartum urinary retention occurred in nine women (6.7%) with a mean post-void residual volume of 1133 ± 447 mL; all were nulliparous, seven had induced labor, and five had an episiotomy.

CONCLUSIONS

Women who are able to successfully void during labor have a low risk of intrapartum urinary retention. We would recommend considering catheterization every 3 to 4 hours for women who are unable to urinate spontaneously, void less than 50 ml, or experience complete motor blockade during labor.

Risk factors for postpartum urinary retention: An updated systematic review and meta-analysis

BACKGROUND

There are conflicting reports on the factors that increase the likelihood of postpartum urinary retention (PUR).

OBJECTIVES

We completed an updated systematic review and meta-analysis to identify the risk factors for PUR.

SEARCH STRATEGY

An exhaustive search of the literature was undertaken using multiple databases, including PubMed, Web of Science, the Cochrane Library, and Embase to identify pertinent studies published up until November 4, 2023.

SELECTION CRITERIA

Observational studies that provided outcomes to calculate the risk factors for PUR were included.

DATA COLLECTION AND ANALYSIS

Two investigators separately performed the extraction of pertinent data from the articles. The risk factors for PUR were identified by pooling adjusted and unadjusted odds ratios (ORs) and 95% confidence intervals (CIs). Heterogeneity test, sensitivity analysis, and publication bias assessment were performed.

MAIN RESULTS

This meta-analysis included 21 studies with a total of 36 951 participants. Meta-analysis was performed for 14 risk factors, and eight of these were statistically significant. The risk factors that were identified in this review included instrumental delivery (OR, 2.96 [95% CI, 1.82-4.80]; 95% prediction interval [PI], 0.67-12.98), relatively long duration of labor (OR, 1.04 [95% CI, 1.02-1.06]; 95% PI, 1.00-1.08), episiotomy (OR, 1.56 [95% CI, 1.19-2.06] 95% PI, 0.64-3.83), nulliparity (OR, 1.55 [95% CI, 1.30-1.84]; 95% PI, 0.94-2.77), epidural analgesia (OR, 2.99 [95% CI, 1.78-5.03]; 95% PI, 0.53-16.76), labor augmentation (OR, 2.21 [95% CI, 1.49-3.28]; 95% PI, 0.12-39.26), labor induction (OR, 1.73 [95% CI, 1.12-2.66]; 95% PI, 0.40-7.39), and perineal injury (OR, 2.75 [95% CI, 1.95-3.89]; 95% PI, 1.10-6.92).

CONCLUSION

Instrumental delivery, extended labor duration, episiotomy, nulliparity, epidural analgesia, labor augmentation/induction, and perineal injury are significant risk factors for PUR. The findings could help physicians identify patients at risk in the postpartum setting.

Diagnoses of postpartum urinary retention using next-generation non-piezo ultrasound technology: assessing the accuracy and benefits

Postpartum urinary retention has a wide range of publicized incidences, likely caused by frequent misdiagnosis of this puerperal complication. Especially covert postpartum urinary retention has a high number of missed diagnoses due to the lack of symptoms and the time-extensive diagnostics via ultrasound, leading to no treatment and no appropriate follow-up. To simplify the diagnosis and establish a screening tool we analyzed the application of portable handheld-ultrasound devices  (PUD) as used in Point-of-care diagnostics in comparison to established standard ultrasound devices (SUD). This prospective study aimed to evaluate the reliability of non-piezo, chip-based PUD in comparison to the measurement withSUD, containing a piezo transducer, as golden standard for the ultrasound diagnosis of postpartum urinary retention. Randomly, 100 participants between the first and seventh day after delivery in an obstetric ward underwent ultrasound examinations using a EPIQ 5 W (Philips) as SUD and a Butterfly iQ (Butterfly Network) as PUD to compare the accuracy in bladder size after micturition and the estimated post-void residual volume. Intraclass correlation coefficients, Bland-Altman plots, and Pearson correlation coefficients were used for analyzing the reliability and agreement between the measurements of these devices and were calculated for subgroups as body mass index, mode of delivery and timepoint of delivery. The results show a near-perfect agreement (0.994) and correlation (r = 0.982) for estimated post-void residual volume and for most measurements between the two types of ultrasound devices. The agreement rate for the diagnosis of covert postpartum urinary retention is 100%. Subgroup analyses lack a significant difference reflected by agreement and correlation rates. These findings affirm the high reliability of PUD for the diagnosis of postpartum urinary retention and supports their integration into daily clinical practice, thereby simplifying regular controls of the bladder by physicians during daily rounds on the ward. This technology may allow a higher diagnosis rate so that patient care can be optimized and the long-term impact on continence and quality of life can be studied and analysed.

The Risk Factors of Postpartum Urinary Retention for Women by Vaginal Birth: A Systematic Review and Meta-Analysis

INTRODUCTION AND HYPOTHESIS

Postpartum urinary retention is one of the most common complications in women during the immediate postpartum period. The objective was to systematically assess risk factors for postpartum urinary retention after vaginal delivery.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved relevant studies from PubMed, Embase, Cochrane Library, Web of Science Core Collection, China National Knowledge Internet, Wangfang Database, and Chinese Biomedical Database for observational studies investigating the risk factors for postpartum urinary retention from inception to 11 November 2022. The Newcastle-Ottawa Scale and Joanna Briggs Institute's tool were used to assess the risk of bias. We conducted a meta-analysis using RevMan 5.3.

RESULTS

In total, 3,074 articles were screened and data from 27 studies were used in the meta-analysis. Sixteen risk factors were identified, namely, labor augmentation (OR = 1.72, 95% CI = 1.17-2.51), primiparity (OR = 2.36, 95% CI = 1.64-3.38), manual fundal pressure (OR = 2.84, 95% CI = 1.00-8.11), perineal hematoma (OR = 7.28, 95% CI = 1.62-32.72), vulvar edema (OR = 7.99, 95% CI = 5.50-11.63), the total duration of labor (MD = 90.10, 95% CI = 49.11-131.08), the duration of the first stage of labor (MD = 33.97, 95% CI = 10.28-57.65), the duration of the second stage of labor (MD = 14.92, 95% CI = 11.79-18.05), the duration of the second stage of labor > 60 min (OR = 3.18, 95% CI = 1.32-7.67), mediolateral episiotomy (OR = 3.65, 95% CI = 1.70-7.83), severe perineal tear (OR = 3.21, 95% CI = 1.84-5.61), epidural analgesia (OR = 3.23, 95% CI = 1.50-6.96), forceps delivery (OR = 4.95, 95% CI = 2.88-8.51), vacuum delivery (OR = 2.44, 95% CI = 1.30-4.58), neonatal birth weight > 4,000 g (OR = 3.61, 95% CI = 1.96-6.65), and neonatal birth weight > 3,500 g (OR = 1.89, 95% CI = 1.12-3.19).

CONCLUSIONS

Our results demonstrated that labor augmentation, primiparity, manual fundal pressure, perineal hematoma, vulvar edema, the total duration of labor, the duration of the first stage of labor, the duration of the second stage of labor, the duration of the second stage of labor > 60 min, mediolateral episiotomy, severe perineal tear, epidural analgesia, forceps delivery, vacuum delivery, and neonatal birth weight > 4,000 g and > 3,500 g were risk factors for postpartum urinary retention in women with vaginal delivery. The specific ranges of the first and the second stages of labor causing postpartum urinary retention need to be clarified.

The Effectiveness and Safety of Intrapartum or Postpartum Catheterization in the Prevention of Postpartum Urinary Retention: A Scoping Review

INTRODUCTION AND HYPOTHESIS

Catheterization is a common treatment for postpartum urinary retention (PUR); however, its application before diagnosis of PUR remains unclear. The aim was to give an overview of the existing literature on the effectiveness and safety of intrapartum or postpartum catheterization in the prevention of PUR.

METHODS

This scoping review followed a methodological framework. PubMed, the Cochrane Library, Embase, Web of Science, the China National Knowledge Infrastructure, WanFang, the China Science and Technology Journal Database, and the China Biomedical Literature Database were searched from the inception of each database to 21 May 2023.

RESULTS

The search revealed 16 studies examining three different catheterization methodologies, including 12 intrapartum studies. Ten studies concluded that intrapartum or postpartum catheterization prevented PUR, two of which were only for overt or covert PUR. In 4 out of 13 experimental studies, no significant difference was found: one for intrapartum catheterization versus routine nursing, the other for intrapartum or postpartum intermittent versus indwelling catheterization. However, one found that postpartum disposable catheterization after ineffective targeted care reduced the incidence of PUR compared with indwelling catheterization. One out of the 3 case-control studies concluded that prenatal catheterization ≥2 times was a risk factor for PUR.

CONCLUSIONS

Based on the findings in this scoping review, catheterization prior to the diagnosis of PUR appears to play a role in preventing PUR and is safe. Preliminary evidence is accumulating on the effectiveness of three types of catheterization methods in preventing PUR, but more comprehensive studies are needed to establish these findings.

Persistent Postpartum Urinary Retention: A Case Report and Review of Literature

This case report describes persistent urinary retention lasting over 30 days postpartum in a 23-year-old primiparous female after an otherwise uncomplicated vaginal delivery at 37 weeks gestation. Notable risk factors present included epidural anesthesia, episiotomy, third-degree perineal laceration, and inability to void spontaneously before leaving the delivery room. Despite initial catheterization draining a large volume, the patient experienced recurrent failed voiding trials requiring ongoing intermittent catheterization during her admission. One month after delivery, voiding trials were finally successful, and she regained normal spontaneous voiding without catheterization. This case highlights persistent postpartum urinary retention (PUR) as an uncommon but potentially serious obstetric complication requiring prompt diagnosis and appropriate management to prevent adverse events and optimize outcomes. Although most cases are self-limited, a high index of suspicion is needed to institute timely treatment with intermittent catheterization given the morbidity associated with sustained bladder overdistension postpartum.

The Occurrence and Factors Associated with Overt Urinary Retention Among Postpartum Women After Vaginal Delivery with Labor Epidural Analgesia

Background

Early recognition and prompt intervention for overt postpartum urinary retention (PUR) takes on a critical significance when a woman chooses labor epidural analgesia for pain relief. However, there have been rare fewer reports on the incidence and factors influencing overt PUR in women after vaginal delivery with labor epidural analgesia in China. Therefore, this study aimed to investigate the incidence and factors correlated with overt urinary retention in postpartum women undergoing vaginal delivery with labor epidural analgesia.

Methods

In total, 462 Chinese postpartum women with labor epidural analgesia and vaginal delivery were recruited in one tertiary hospital in Beijing from Dec. 2020 to Nov. 2021. Factors associated with overt PUR for these women were identified through multivariate logistic regression analysis.

Results

The incidence of overt PUR was obtained as 10.2% among these women after vaginal delivery with labor epidural analgesia. As indicated by the result of univariate analysis, forceps-assisted delivery, lateral episiotomy, perineal pain, and fluid administration in the delivery room were correlated with PUR. The result of the multivariate logistic regression suggested that forceps-assisted delivery (odds ratio [OR]=2.46, 95% confidence interval [CI]: 1.14-5.32, P=0.022), lateral episiotomy (OR=4.55, 95% CI: 1.91-10.80, P=0.001), and perineal pain (OR=4.23, 95% CI: 2.05-8.73, P<0.001) were factors affecting overt PUR for these women.

Conclusion

Postpartum women undergoing vaginal delivery with labor epidural analgesia showed a high incidence of overt PUR, and health-care providers should pay more attention to their postpartum urination status in clinical practice. Effective and timely intervention is strongly recommended to reduce the occurrence of overt PUR for these kinds of postpartum women undergoing vaginal delivery with labor epidural analgesia, such as ones experienced forceps-assisted delivery, lateral episiotomy, and more severe perineal pain.

Noninvasive external therapy of traditional Chinese medicine for preventing postpartum urinary retention in women with vaginal delivery: A network meta-analysis

BACKGROUND

To compare the effect of different noninvasive external therapies of traditional Chinese medicine (TCM) on the prevention of postpartum urinary retention (PUR) using a network meta-analysis (NMA).

METHODS

A search of the China National Knowledge Infrastructure, WanFangDate, VIP, China Biomedical Literature Database, PubMed, The Cochrane Library, Embase, and Web of Science databases were reviewed for related randomized controlled trials dated between database inception and December 31, 2022, on the prevention of PUR by noninvasive TCM. Two researchers independently screened the literature, extracted the data, and assessed the risk of bias in the included studies; then, a NMA was performed using Revman5.3 software, State13.1 software, and frequency methodology.

RESULTS

In total, 16 studies involving 3637 cases of parturients and 9 types of noninvasive TCM external treatments were incorporated into the NMA. The NMA results show that based on routine nursing, in terms of reducing the incidence of urinary retention, acupoint compressing combined with auricular acupressure is ranked first, followed by acupoint hot compress, acupoint massage combined with auricular acupressure, Yin-Yang therapy, acupoint massage, auricular acupressure, acupoint compressing, and routine nursing. In terms of urination time, acupoint compressing combined with auricular acupressure ranked first, followed by acupoint massage combined with auricular acupressure, acupoint electrical stimulation, acupoint compressing, TCM heating therapy, acupoint massage, auricular acupressure, and routine nursing. In terms of reducing residual urine volume after the first urination, acupoint compressing combined with auricular acupressure was ranked first, followed by auricular acupressure, acupoint compressing, acupoint massage, TCM heating therapy, and routine nursing.

CONCLUSION

Current evidence shows that acupoint compressing combined with auricular acupressure may be the best noninvasive TCM treatment for preventing PUR based on routine nursing; however, further high-quality clinical randomized controlled trials are needed for validation and support.

Intermittent vs continuous catheterization for postpartum urinary retention: A multicenter randomized controlled trial

BACKGROUND

Postpartum urinary retention is a common complication in the immediate postpartum period. However, there is no consensus regarding optimal management.

OBJECTIVE

This study aimed to compare 2 catheterization strategies for the treatment of postpartum urinary retention.

STUDY DESIGN

A multicenter prospective randomized controlled trial was conducted at 4 university-affiliated medical centers between January 2020 and June 2022. Individuals with postpartum urinary retention (bladder volume of >150 mL) up to 6 hours after vaginal or cesarean delivery were randomly allocated to 1 of 2 protocols: intermittent catheterization every 6 hours, up to 4 times, or continuous catheterization with an indwelling urinary catheter for 24 hours. If postpartum urinary retention was not resolved after 24 hours, an indwelling catheter was inserted for an additional 24 hours in both groups. The primary endpoint was the mean time to postpartum urinary retention resolution. The secondary endpoints included postcatheter urinary tract infection rate and length of hospital stay. The satisfaction rate was estimated using the 30-Item Birth Satisfaction Scale questionnaire.

RESULTS

After randomization, 73 individuals were allocated to the intermittent catheterization group, and 74 individuals were allocated to the continuous catheterization group. The mean time to postpartum urinary retention resolution was significantly shorter in the intermittent catheterization group than in the continuous catheterization group (10.2±11.8 vs 26.5±9.0 hours; P<.001), with 75% and 93% resolution rates after 1 and 2 catheterizations, respectively. The number of individuals who achieved resolution at 24 hours was 72 (99%) in the intermittent catheterization group and 67 (91%) in the continuous catheterization group (P=.043). The satisfaction rate was higher in all categories in the intermittent catheterization group than in the continuous catheterization group (P<.001). No intercohort difference was found in the urinary tract infection rates (P=.89) or hospital stay length (P=.58).

CONCLUSION

Compared with indwelling catheterization, intermittent catheterization for urinary retention after delivery was associated with quicker postpartum urinary retention resolution and a higher satisfaction rate without increasing the complication rates.

Prolonged second stage of labor is associated with persistent urinary retention after forceps delivery: An observational study

The occurrence of urinary retention is significantly higher in women undergoing forceps-assisted midwifery. However, the majority of these women typically regain the ability to urinate spontaneously within 72 hours after delivery. Instances of persistent urinary retention beyond this timeframe are relatively uncommon and have been rarely documented. This study aimed to investigate the risk factors associated with the persistence of urinary retention after forceps-assisted midwifery. A retrospective analysis was conducted on women who underwent forceps-assisted deliveries at the Obstetrics and Gynecology Hospital of Fudan University (China) between August 1, 2019 and December 1, 2019. The study involved collecting general clinical information of these women. Based on the duration of ureter retention, women who had a retention time >72 hours were categorized into group A, while those with a retention time <72 hours were allocated to group B. After performing analysis on the risk factors of persistent urinary retention following forceps delivery, the t test was utilized for analyzing single factors, while logistic regression analysis was employed for assessing multiple factors. Univariate analysis revealed a significant difference in the duration of the second stage of labor between group A and group B. However, logistic regression analysis did not indicate any significant difference between the 2 groups. Further research is still required to determine whether the association between persistent urinary retention following forceps delivery and prolonged second stage of labor is significant, considering the limited number of cases available for analysis.

Postpartum urinary retention: an expert review

Postpartum urinary retention is a relatively common condition that can have a marked impact on women in the immediate days following childbirth. If left untreated, postpartum urinary retention can lead to repetitive overdistention injury that may damage the detrusor muscle and the parasympathetic nerve fibers within the bladder wall. In rare circumstances, postpartum urinary retention may even lead to bladder rupture, which is a potentially life-threatening yet entirely preventable complication. Early diagnosis and timely intervention are necessary to decrease long-term consequences. There are 3 types of postpartum urinary retention: overt, covert, and persistent. Overt retention is associated with an inability to void, whereas covert retention is associated with incomplete bladder emptying. Persistent urinary retention continues beyond the third postpartum day and can persist for several weeks in rare cases. Recognition of risk factors and prompt diagnosis are important for proper management and prevention of negative sequelae. However, lack of knowledge by providers and patients alike creates barriers to accessing and receiving evidence-based care, and may further delay diagnosis for patients, especially those who experience covert postpartum urinary retention. Nationally accepted definitions and management algorithms for postpartum urinary retention are lacking, and development of such guidelines is essential for both patient care and research design. We propose intrapartum recommendations and a standardized postpartum bladder management protocol that will improve patient outcomes and contribute to the growing body of evidence-based practice in this field.

Study protocol: 'a large cohort study of postnatal events in a not-for-profit referral centre in Vellore, South India'

INTRODUCTION

In a large developing country, with diverse population characteristics and differential access to healthcare, it is important to identify factors that influence postnatal health. This knowledge will help frame recommendations to enhance universal postnatal care.

METHODS AND ANALYSIS

A prospective cohort study will be conducted by recruiting all participants who deliver in a referral centre in South India during a 1-year period after written consent is obtained from them. In addition to clinical information pertaining to their delivery and demographics, details of physical health, mental health socioeconomic status and emotional support will also be collected. Every participant will be followed up physically and/or by telephonic consultation at 3, 9 and 18 months of their postnatal period to reassess their status and that of their babies. As there are several independent and dependent variables requiring multivariate analysis, a sample size of 10 000 is considered adequate. Any unplanned visits to a health facility will be enquired into and documented for analysis.During data analysis, the effect of Caesarean section, high-risk characteristics and gestational age of the baby at delivery on various outcome measures and postnatal status will be evaluated. Interpretation of the large volume of collected data will help frame recommendations to improve postnatal care ETHICS AND DISSEMINATION: The study is approved by the Institutional Review Boards (Research and Ethics Committees) of Christian Medical College, Vellore, Tamil Nadu, India (IRB 12178 date 24 June 2020).Women are provided with a detailed information sheet and written consent is obtained. They are reassured that their care will not be compromised if they do not consent to the study. Data will be available on the clinical trial portal to assist in the dissemination of results after the project is published.

TRIAL REGISTRATION NUMBER

CTRI/2022/03/041343.

Protracted Postpartum Urinary Retention: Incidence, Risk Factors, and Natural History of a Rare Postpartum Urinary Retention Subtype

IMPORTANCE

Postpartum urinary retention (PUR) is a multifactorial condition that requires a high degree of clinical suspicion for timely diagnosis and proper intervention.

OBJECTIVES

The aims of the study are to describe PUR incidence and to compare natural history, obstetric characteristics, and associated risk factors for protracted PUR (extending ≥3 days postpartum) versus PUR.

STUDY DESIGN

This is a retrospective cross-sectional study of women who underwent an obstetric delivery over 24 months at an academic institution. International Classification of Diseases, Tenth Revision, codes were used to identify PUR. Patient characteristics, obstetric delivery data, and peripartum care surrounding delivery were collected. A P value of 0.05 or less was significant.

RESULTS

Between January 1, 2018, and December 31, 2019, there were 23,844 deliveries (vaginal and cesarean section) and 77 patients (0.32%) experienced PUR. Within this group, 12 (0.05%) experienced protracted PUR. Patients with protracted PUR had a significantly later postpartum diagnosis day (median 1 [interquartile range, 1-2] vs 1 [0-1], P = 0.004), longer time to retention onset (22.0 [10.7-37.0] vs 10.7 [7.9-19.4] hours, P = 0.03), and greater retention duration (12.5 [5.5-17.0] vs 1.0 [0.0-1.0] days, P < 0.001) compared with those with PUR. There were no significant differences in patient or delivery characteristics for those delivering vaginally between the groups.

CONCLUSIONS

Protracted PUR is rare, occurring in 0.05% of deliveries. Women with protracted PUR were more likely to have a greater onset time, later diagnosis date, and longer retention duration, out to 47 days, compared with women with PUR resolution before postpartum day 3.

Postpartum urinary retention after the institution of a universal voiding protocol

OBJECTIVE

Postpartum urinary retention is a frequently occurring condition for which screening is not typically a standardized part of postpartum care. The aim of this study was to determine the incidence of and risk factors for postpartum urinary retention after the introduction of a universal postpartum voiding protocol.

METHODS

This was a single-center retrospective case-control study of women delivering in a 12-month period. Women with a documented diagnosis of postpartum urinary retention per the institution's voiding protocol were classified as cases, and a matched sample of those without urinary retention were controls. Demographic and obstetric characteristics were compared between both groups using univariate and multivariate analyses as a means to identify risk factors for postpartum urinary retention.

RESULTS

8992 women were studied during the time period examined; 195 (2.2%) were identified to have postpartum urinary retention. On multivariate logistic regression analysis, operative vaginal delivery (aOR 2.98 95% CI 1.32-6.70) and second-degree or greater perineal laceration (aOR 2.83 CI 1.59-5.04) were significantly associated with postpartum urinary retention.

CONCLUSIONS

The incidence of postpartum urinary retention with a postpartum voiding protocol in place was low. Risk factors identified for urinary retention included operative vaginal delivery and second degree or greater perineal laceration. Awareness of these risk factors and implementation of standardized voiding protocols may aid with the early identification and prevention of postpartum urinary retention.

Prevalence of urinary retention after vaginal delivery: a systematic review and meta- analysis

INTRODUCTION AND HYPOTHESIS

Postpartum urinary retention requires timely detection and intervention as late detection can lead to long-term voiding dysfunction; however, trends in the prevalence of urinary retention during the postpartum period remain unclear. This systematic review and meta-analysis aimed to estimate the pooled overall prevalence of overt and covert urinary retention in women after vaginal delivery and the difference in prevalence within 4 days after delivery.

METHODS

MEDLINE, CINAHL, Ichu-shi web, and J-stage databases were searched up until October 2020. Two researchers screened and included observational studies reporting the prevalence of urinary retention up to 4 days postpartum based on inclusion criteria. The overall prevalence of overt and covert urinary retention was calculated.

RESULTS

From 24 studies, the overall overt and covert urinary retention prevalence rates were estimated to be 1% and 13%, respectively. The prevalence of overt urinary retention over time was 2% at 6 h postpartum, 1% at 6-12 h, and 3% from postpartum to 24 h postpartum. The prevalence of covert urinary retention over time was 19% (6 h postpartum), 15% (24 h postpartum), 11% (1 day postpartum), 7% (2 days postpartum), 8% (3 days postpartum), and 0.1% (4 days postpartum).

CONCLUSIONS

By postpartum day 4 after vaginal delivery, 14% of women were found to have experienced urinary retention. The highest prevalence was observed at 6 h postpartum, suggesting that urinary retention could be identified at 6 h postpartum.

Association between obstetrical anal sphincter injury and postpartum urinary retention: a contemporary nationwide cohort study

INTRODUCTION AND HYPOTHESIS

Identification and prompt management of postpartum urinary retention after vaginal birth is essential to minimize long-term morbidity. Obstetrical anal sphincter injuries (OASIS) have been identified as a possible risk factor for urinary retention. The objective of this study was to estimate the association between OASIS and postpartum urinary retention and compare the length of hospital stay and cost of admission between postpartum patients who experienced urinary retention and those who did not.

METHODS

We conducted a population-based, retrospective cohort study of pregnant individuals delivering singleton fetuses via vaginal birth in the United States using the National Inpatient Sample (NIS) database. Multivariate logistic regression models were used to estimate the odds ratio (OR) for the association between OASIS and postpartum urinary retention. Simple linear regression was used to compare means.

RESULTS

A total of 2,013,052 delivery admissions were included, which was representative of a population size of 10,065,253 utilizing the complex sampling design of the NIS database. 47,192 (2.34%) admissions sustained OASIS and 5,339 (0.27%) admissions experienced overt urinary retention. After adjusting for potential confounders, vaginal deliveries where OASIS occurred had 3.60 times the odds of postpartum urinary retention compared with vaginal deliveries where OASIS was not sustained (95% CI 3.26-3.97). Postpartum urinary retention was associated with an increased mean length of stay (2.94 vs 2.28 days, p<0.001) and 1.37 times the mean total cost of admission (US$22,946.38 vs US$16,758.85, p<0.001).

CONCLUSIONS

Obstetrical anal sphincter injuries are associated with increased odds of postpartum urinary retention compared with vaginal deliveries where OASIS did not occur.

Covert postpartum urinary retention: causes and consequences (PAREZ study)

Introduction and hypothesis

Increased post-voiding residual volume (PVRV), known as covert postpartum urinary retention (PUR), is an asymptomatic condition with unknown long-term adverse effects. The objectives were to determine the frequency of this phenomenon 3 days after delivery and to examine the associated risk factors and consequences of the increased residuum on women´s health 6 weeks postpartum.

Methods

We carried out a prospective observational study including a total of 926 primiparous women, giving birth to singletons. All participants underwent ultrasound determination of PVRV on day 3 postpartum. Then, risk factors were determined using logistic regression analysis. After 6 weeks, participants were invited to return for PVRV determination and to complete urogynecological and general health questionnaires. Using these data, the consequences of increased PVRV were determined.

Results

A total of n=90 women were diagnosed with abnormal PVRV. Mean age in the studied population was 30.4 years, BMI prior to delivery 27.8, weight of the newborn 3,420 g, and percentage of cesarean sections 15.9%. Gestational week (p=0.043), vaginal tear (p=0.032), and induction of labor (p=0.003) were risk factors for covert PUR. Puerperal incidence of urinary tract infection was 1.1% (6 out of 526) and of urinary incontinence 29.2% (155 out of 530), with no differences between the groups. In the second examination, covert PUR was no longer present, and the values of residual urine decreased for all patients in the case group. No statistically significant differences were observed in questionnaire scores in general health and wellbeing perceptions between the groups.

Conclusions

We have found a few significant obstetrical–pediatric risk factors for abnormal PVRVs. Data from the follow-up suggest that covert PUR has no impact on morbidity and quality of life 6 weeks postpartum. Therefore, abnormal PVRV is a self-limited phenomenon with a tendency toward self-correction. Our findings support those of previous studies that advocate against screening for asymptomatic retention in the postpartum period, despite some similar previous recommendations.

Postpartum urinary retention: what are the sequelae? A long-term study and review of the literature

INTRODUCTION AND HYPOTHESIS

Postpartum urinary retention (PUR) may cause long-term urogenital tract morbidity. The incidence ranges from 0.18 to 14.6%, but the importance of prompt diagnosis and appropriate management is often underappreciated. The paucity of data on long-term outcome after PUR contributes to these drawbacks. The aim of this study was to assess long-term persistence of elevated PVR (post-void residual urine) volume after PUR. Pathophysiology, risk factors and management of PUR are reviewed.

METHODS

In our tertiary referral urogynecology unit in the University Women's Hospital of Bern, Switzerland, all patients who were referred for PUR were asked to participate in this study. PVR was measured sonographically every 2 days until day 15, then after 6, 12, 24 and 36 months and, if increased, the patients were instructed to perform clean intermittent self-catheterization. If retention persisted longer than the lactation period, multichannel urodynamics was performed.

RESULTS

Sixty-two patients were included. The median PVR normalized at day 7. Long-term voiding disorders were found in 8.2%, 6.7%, and 4.9% after 1, 2, and 3 years respectively. Multichannel urodynamics confirmed in all patients with persisting retention an acontractile detrusor and de novo stress urinary incontinence in 4 cases. Quantile regression did not reveal any factor contributing to earlier recovery. Eighty-nine percent of the patients with PUR had operative vaginal deliveries, emphasizing the importance of this risk factor for PUR.

CONCLUSIONS

In most cases PUR resolves early, but voiding difficulties persist more often than previously thought, and for these patients the consequences are devastating. Obstetric awareness, early active management, and developing management strategies in the postpartum period might preclude lower urinary tract morbidity.

Effect of Acupoint Hot Compress on Postpartum Urinary Retention After Vaginal Delivery: A Randomized Clinical Trial

IMPORTANCE

Acupoint hot compress during the early postpartum period may benefit patients after a vaginal delivery, but the evidence of this effect is limited.

OBJECTIVE

To assess whether acupoint hot compress involving the abdominal, lumbosacral, and plantar regions could reduce the incidence of postpartum urinary retention, relieve postpartum uterine contraction pain, prevent emotional disorders, and promote lactation.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter randomized clinical trial was conducted at 12 hospitals in China. Pregnant patients were screened for eligibility (n = 13 949) and enrolled after vaginal delivery (n = 1200) between January 17 and August 15, 2021; data collection was completed on August 18, 2021. After vaginal delivery, these participants were randomized 1:1 to either the intervention group or control group. Statistical analysis was based on per-protocol population.

INTERVENTIONS

Participants in the control group received routine postpartum care. Participants in the intervention group received routine postpartum care plus 3 sessions of a 4-hour acupoint hot compress involving the abdominal, lumbosacral, and plantar regions within 30 minutes, 24 hours, and 48 hours after delivery.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of postpartum urinary retention, defined as the first urination occurring more than 6.5 hours after delivery and/or use of an indwelling catheter within 72 hours after delivery. The secondary outcomes were postpartum uterine contraction pain intensity (assessed with the visual analog scale [VAS]), depressive symptoms (assessed with the Edinburgh Postnatal Depression Scale), and lactation conditions (including lactation initiation time, breastfeeding milk volume, feeding mood and times, and newborn weight).

RESULTS

Of the 1200 participants randomized, 1085 completed the study (537 in the intervention group and 548 in the control group, with a median [IQR] age of 26.0 [24.0-29.0] years). Participants in the intervention group compared with the control group had significantly decreased incidence of postpartum urinary retention (relative risk [RR], 0.58; 95% CI, 0.35-0.98; P = .03); improved postpartum uterine contraction pain when measured at 6.5 hours (median [IQR] VAS score, 1 [1-2] vs 2 [1-2]; P < .001), 28.5 hours (median [IQR] VAS score, 1 [0-1] vs 1 [1-2]; P < .001), 52.5 hours (median [IQR] VAS score, 1 [0-1] vs 1 [0-1]; P < .001), and 76.5 hours (median [IQR] VAS score, 0 [0-1] vs 0 [0-1]; P = .01) after delivery; reduced depressive symptoms (RR, 0.73; 95% CI, 0.54-0.98; P = .01); and increased breastfeeding milk volume measured at 28.5, 52.5, and 76.5 hours after delivery. No adverse events occurred in either of the 2 groups.

CONCLUSIONS AND RELEVANCE

Results of this trial showed that acupoint hot compress after vaginal delivery decreased postpartum urinary retention, uterine contraction pain, and depressive symptoms and increased breastfeeding milk volume. Acupoint hot compress may be considered as an adjunctive intervention in postnatal care that meets patient self-care needs.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR2000038417.

Prevalence and risk factors of overt postpartum urinary retention among primiparous women after vaginal delivery: a case-control study

Background

Postpartum urinary retention (PUR) may lead to bladder neuromuscular damage and subsequently voiding dysfunction. However, the literature regarding the incidence of and risk factors for PUR remains unclear. Moreover, previously reported studies are limited to small sample sizes. Thus, this study aimed to assess the incidence of and risk factors for overt PUR after vaginal delivery.

Methods

This retrospective case-control study included all primiparas who delivered vaginally between July 1, 2017, and June 30, 2019, at our institution. The case group comprised 677 women diagnosed with overt PUR who required catheterisation after delivery. The control group comprised 677 women without overt PUR randomly selected in a 1:1 ratio matched for date of delivery and who delivered immediately after each woman with overt PUR to minimise the impact of variations over time in obstetric practice. Univariate and multivariate logistic regression analyses were performed to investigate the factors associated with overt PUR.

Results

Of the 12,609 women included in our study, 677 were diagnosed with overt PUR (incidence 5.37%). Univariate analysis identified epidural analgesia, episiotomy, perineal tears, instrument-assisted delivery, duration of labour stage, intrauterine operation, and vulvar oedema as risk factors for PUR. Multivariate logistic regression identified epidural analgesia (odds ratio [OR] = 1.41, 95% confidence interval [CI]: 1.11–1.79, P = 0.005), vulvar oedema (OR = 6.92, 95% CI: 4.65–10.31, P < 0.001), forceps delivery (OR = 8.42, 95% CI: 2.22–31.91, P = 0.002), episiotomy (OR = 1.37, 95% CI: 1.02–1.84, P = 0.035), and second-degree perineal tear (OR = 3.42, 95% CI: 2.37–4.94, P < 0.001) as significant independent risk factors for PUR.

Conclusions

PUR was highly associated with epidural analgesia, forceps delivery, vulvar oedema, episiotomy, and second-degree perineal tears. More attention should be paid to women at high risk to reduce the incidence of PUR.

Intrapartum pudendal nerve block analgesia and risk of postpartum urinary retention: a cohort study

Introduction and hypothesis

Pudendal nerve block analgesia (PNB) is used as pain relief in the final stage of childbirth. We hypothesized that PNB is associated with higher rates of postpartum urinary retention.

Methods

We performed a cohort study among primiparous women with a singleton, cephalic vaginal birth at Oslo University Hospital, Norway. Women receiving PNB were included in the exposed group, while the subsequent woman giving birth without PNB was included in the unexposed group. We compared the likelihood of postpartum urinary retention, defined as catheterization within 3 h after birth. Logistic regression analysis stratified by mode of delivery was performed adjusting for epidural analgesia, episiotomy and birth unit.

Results

Of the 1007 included women, 499 were exposed to PNB and 508 were unexposed. In adjusted analyses, women exposed to PNB did not differ in likelihood of postpartum urinary retention compared to women unexposed to PNB in either spontaneous (odds ratio[OR]: 0.82, 95% confidence interval [CI] 0.55–1.22) or instrumental (OR 1.45, 95% CI 0.89–2.39) births. Furthermore, no differences between the groups were observed with excessive residual urine volume or catheterization after > 3 h.

Conclusions

PNB was associated with neither risk of postpartum urinary retention nor excessive residual urine volume and is therefore unlikely to hamper future bladder function.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04768-0.

Indwelling catheter increases the risk of urinary tract infection in total knee arthroplasty: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this meta-analysis was to assess whether a urinary catheter is necessary for all patients in primary total knee arthroplasty (TKA).

METHODS

PubMed, EMBASE, the Cochrane Library, Web of Science, and China National Knowledge Infrastructure were systematically searched for randomized controlled trials (RCTs). All RCTs were compared with receive either an indwelling urinary catheter or no urinary catheter in TKA. Primary outcomes were urinary retention and urinary tract infection. Secondary outcomes were the length of stay, duration of the surgery, and the first urination time.

RESULTS

A total of 6 RCTs involving 1334 patients were included in the meta-analysis. No significant difference between the 2 groups was found in urinary retention (P = .52), length of stay (P = .38), duration of the surgery (P = .55). However, patients with an indwelling catheter were associated with a higher risk of urinary tract infections and longer time for the first urination than patients without indwelling catheters (P = .009 and P = .004).

CONCLUSION

The available evidence indicates that patients without using the indwelling catheters could reduce urinary tract infections and the time for the first urination, without increase in the incidence of urinary retention in primary TKA.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Acute Kidney Injury Caused by Obstructive Nephropathy

Acute kidney injury secondary to obstructive nephropathy is a frequent event that accounts for 5 to 10% of all acute kidney injury cases and has a great impact on the morbidity and mortality in those affected. The obstruction in the urinary tract has a profound impact on kidney function due to damage produced by ischemic and inflammatory factors that have been associated with intense fibrosis. This pathology is characterized by its effects on the management of fluids, electrolytes, and the acid-base mechanisms by the renal tubule; consequently, metabolic acidosis, hyperkalemia, uremia, and anuria are seen during acute kidney injury due to obstructive nephropathy, and after drainage, polyuria may occur. Acute urine retention is the typical presentation. The diagnosis consists of a complete medical history and should include changes in urinary voiding and urgency and enuresis, history of urinary tract infections, hematuria, renal lithiasis, prior urinary interventions, and constipation. Imaging studies included tomography or ultrasound in which hydronephrosis can be seen. Management includes, in addition to drainage of the obstructed urinary tract system, providing supportive treatment, correcting all the metabolic abnormalities, and initiating renal replacement therapy when required. Although its recovery is in most cases favorable, it seems to be an undervalued event in nephrology and urology. This is because it is mistakenly believed that the resolution and recovery of kidney function is complete once the urinary tract is unobstructed. It can have serious kidney sequelae. In this review, we report the epidemiology, incidence, pathophysiological mechanisms, diagnosis, and treatment of acute kidney injury due to obstructive nephropathy.

The risk factors of postpartum urinary retention after vaginal delivery: A systematic review

Objectives

This review aimed to explore the independent risk factors of postpartum urinary retention (PUR) after a vaginal delivery.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed and relevant studies were retrieved from eleven databases. The quality of the included articles was assessed using Critical Appraisal Skills Programme tools or the Appraisal tool for Cross-Sectional Studies. The data analysis was performed using Review Manager version 5.3.

Results

A total of nine articles were included and five risk factors were identified, namely, episiotomy (OR = 2.99, 95%CI = 1.31–6.79, P = 0.009), epidural analgesia (OR = 2.48, 95%CI = 1.09–5.68, P = 0.03), primiparity (OR = 2.17, 95%CI = 1.06–4.46, P = 0.03), instrumental delivery (OR = 4.01, 95%CI = 1.97–8.18, P < 0.001), and the duration of the second stage of labor (MD = 15.24, 95%CI = 11.20–19.28, P < 0.001). However, fetal birth weights of more than 3800 g were not identified as an independent risk factor (MD = 64.41, 95%CI = −12.59 to 141.41, P = 0.10).

Conclusion

This systematic review indicated that the independent risk factors for PUR were found to include episiotomy, epidural analgesia, instrumental delivery, primiparity, and a longer second stage of labor. In clinical practice, healthcare providers could pay more attention to women with these factors and prevent postpartum urinary retention.

Recommendations and future research initiative to optimize bladder management in pregnancy and childbirth International Consultation on Incontinence - Research society 2018

With increasing birth rates globally, obstetric bladder care and long term pelvic floor dysfunction continues to be a issue. This paper aims to provide an overview of the concerns in the antenatal, intrapartum an post partum periods and presents recommendation for the research requirements necessary and education to challenge current practice.

Prevalence and risk factors for postpartum urinary retention after vaginal delivery in Japan: A case-control study

AIM

This study aimed to clarify the prevalence and risk factors of postpartum urinary retention after vaginal delivery. It also described the healing process of women who had postpartum urinary retention.

METHODS

In this case-control study, 77 women who had postpartum urinary retention were matched by age and parity with 385 women as controls. Data were analyzed by conditional logistic regression analysis. Data were collected from the women in the case group regarding their healing process and conditions for urinary retention (overt or covert urinary retention).

RESULTS

The prevalence of postpartum urinary retention was 1.2%. The adjusted odds ratio and the 95% confidence intervals for risk factors were as follows: epidural analgesia 4.72, 95% CI 2.38, 9.39; episiotomy 2.68, 95% CI 1.40, 5.13; length of second stage of labor 1.85, 95% CI 0.98, 3.49; labor augmentation 1.78, 95% CI 0.90, 3.51; instrument delivery 0.96, 95% CI 0.43, 2.17; and Kristeller maneuver 0.93, 95% CI 0.37, 2.37. Among 59 women with overt urinary retention, 29 (49.2%) transitioned to covert urinary retention within 10 days after delivery. More than half of the women were normal within 72 hr, but there were five women whose urinary retention did not resolve 11 days following delivery.

CONCLUSIONS

The statistically significant risk factors for postpartum urinary retention were epidural analgesia and episiotomy. Initiatives for the prevention and management of postpartum urinary retention are necessary.

Validity of bladder volume measurement by ultrasound in women postpartum

INTRODUCTION

Vaginal birth increases the risk of urinary retention and overdistention of the bladder. To avoid unnecessary discomfort by catheterization, it is preferable to use ultrasound for diagnosis of these conditions. The aim of this study was to determine the validity of transabdominal ultrasound and a portable ultrasound system, Biocon-700, to measure bladder volume in women postpartum.

METHODS

Fifty women were included in this method comparison study. Within 48 h of giving birth, their bladder volume was measured in randomized order with both transabdominal ultrasound and Biocon-700. After urination, participants were scanned with Biocon-700 to measure residual bladder volume, and finally the bladder was emptied by catheterization. The total bladder volume was calculated as the voided volume plus the catheterized volume.

RESULTS

Biocon-700 measured 43.4 ml ± 117.4 ml (mean ± SD) lower than the total bladder volume, while volumes measured by transabdominal ultrasound were 117.8 ml ± 110.0 ml (mean ± SD) lower. Linear regression showed significant proportional bias in both methods. The Biocon-700 could detect a residual bladder volume > 150 ml with a positive predictive value of 66.7% and a negative predictive value of 100%.

CONCLUSIONS

Neither transabdominal ultrasound nor the portable ultrasound system, Biocon-700, can be used to measure bladder volume precisely after vaginal delivery. However, both ultrasound methods can be used as screening tools to prevent overdistention of the bladder, and Biocon-700 can furthermore be used to screen women for a residual bladder volume > 150 ml.

Protracted postpartum urinary retention-a long-term problem or a transient condition?

INTRODUCTION AND HYPOTHESIS

Protracted postpartum urinary retention (P-PUR) is a rare puerperal complication of overt urinary retention that proceeds beyond the 3rd postpartum day. Long-term consequences of P-PUR are poorly reported. The objective of the study was to compare the long-term outcome of patients with P-PUR with a matched control group, using a validated pelvic floor distress questionnaire.

METHODS

All medical files of women diagnosed with P-PUR between 2005 and 2016 were reviewed. The control group was comprised of women who had a consecutive birth, matched in a 1:2 ratio, by maternal age, parity, neonatal birth weight, analgesia, and route of delivery. All women were evaluated for long-term symptoms of urinary or fecal incontinence and pelvic-organ-prolapse-related complaints by a telephone interview, at least 1 year following their delivery, using the Pelvic Floor Distress Inventory-Short Form (PFDI-20) questionnaire.

RESULTS

During the study period, there were 27 cases of P-PUR out of 52,662 deliveries (0.051%). There were no differences between the study group (n = 27) and controls (n = 54) in age, BMI (kg/m²), parity, birth weight, route of delivery, and rate of episiotomy. The majority of patients in both groups opted for epidural analgesia. Second stage of labor was longer in the study group than in controls, 134.1 ± 74.6 min vs. 73.4 ± 71.6 min, respectively, p < 0.001. The scores of the PFDI-20, UDI-6, and POPDI-6 did not differ between the groups. However, the study group had minimally elevated scores on the CARDI-8 scale (1.0 ± 2.6 vs. 0.0 ± 0.0, p = 0.012).

CONCLUSIONS

P-PUR is a rare postpartum complication, yet this disturbing condition has negligible if any clinical impact on long-term urogynecologic disorders. These findings carry a reassuring message to both patients and their health care providers.

Prevalence and outcome of postpartum urinary retention at an Australian hospital

OBJECTIVE

Postpartum urinary retention is thought to be a potentially significant complication of childbirth. A universal postpartum void review process has been in place since 2008 at this tertiary obstetric hospital to screen for voiding dysfunction. Procedure compliance audits were undertaken on implementation but local prevalence and clinical outcomes of both acute and persistent postpartum urinary retention had not been documented for our cohort to date.

DESIGN

A clinical audit was undertaken to review the medical files for all women who birthed between January 1st 2016-March 31st 2016 (n = 1108 cases) to determine the prevalence of acute postpartum urinary retention. Medical files of persistent postpartum urinary retention cases occurring in 2016 requiring follow up were individually reviewed.

MEASUREMENT AND FINDINGS

An overall 3.8% baseline prevalence of acute postpartum urinary retention was observed retrospectively (n = 42/1108) in a 3 month period, with 28.6% of these experiencing significant bladder over distension (n = 12/42). Following urinary catheterisation, and often a period of bladder rest, 100% of women who failed their first void review were able to successfully void on catheter removal. There were 3 cases of persistent postpartum urinary retention over 12 months, representing an overall prevalence of 0.07% (n = 3/4353).

KEY CONCLUSIONS

The existing postpartum void review process appears to be a reliable framework for the early detection and management of postpartum urinary retention, but could be further enhanced by objectively confirming effective bladder emptying and function.

IMPLICATIONS FOR PRACTICE

In spite of a universal void review framework for postnatal void review, urinary retention and bladder overdistension still occurs. Staff education to encourage compliance with the framework and to facilitate timely clinical reasoning and decision making may improve prevalence rates.

Accuracy of postvoid residual volumes after vaginal delivery: a prospective equivalence study to compare an automatic scanning device with transurethral catheterization

Introduction and hypothesis

Abnormal postvoid residual volumes (PVRV) after delivery are common in daily clinical practice. By using an automatic scanning device, unnecessary catheterizations can be prevented. The aim of this study was to determine the accuracy of PVRV after vaginal delivery measured by an automatic scanning device through a comparison with transurethral catheterization.

Materials and methods

This prospective observational equivalence study was performed in patients who delivered vaginally between June 2012 and May 2017 in three teaching hospitals in The Netherlands. After the first spontaneous void after delivery, postvoid residual volume (PVRV) was measured with a portable automatic scanning device (BladderScan® BVI 9400). Directly afterward, it was measured by catheterization. Correlation between measurements was calculated using Spearman’s correlation coefficient and agreement plot. The primary outcome was to validate the correlation between the BladderScan® compared with the gold standard of transurethral catheterization.

Results

Data of 407 patients was used for final analysis. Median PVRV as measured by BladderScan® was 380 ml (± 261–0–999 ml) and by catheterization was 375 ml (± 315–1800 ml). Mean difference between measurements was −12.9 ml (± 178 ml). There was a very good correlation between methods (Spearman’s rho = 0.82, p < 0.001). Using a cut-ff value of >500 ml, specificity and sensitivity were 85.4 and 85.6%, respectively.

Conclusions

The BladderScan® (BVI 9400) measures PVRV precisely and reliably after vaginal delivery and should be preferred over catheterization.

Impact of systematic urinary catheterization protocol in delivery room on covert postpartum urinary retention: a before-after study

We investigated whether implementation of a routine catheterization procedure in labor improves covert postpartum urinary retention (cPUR) rates. We conducted a prospective before-after study. 121 women admitted to delivery room in the observational group, and 82 in the intervention group, in a tertiary university hospital in Southern France were included. All patients in the intervention group were systematically catheterized 2 hours after delivery. cPUR was screened for in both groups. The primary end-point was cPUR (post-void residual bladder volume >150 ml when voided volume is >150 mL). The rate of cPUR decreased from 50% (60 out of 121 patients) in the observational group to 17% (14/82) in the intervention group (OR = 0.21; 95% Confidence Interval [0.13;0.58]; p < 0.001). Similarly, in the subgroup of patients who underwent instrumental delivery, the rate of cPUR was lower in the intervention group (18%, 2/11) than in the observational group (65%, 15/23) (p = 0.02). Systematic intermittent bladder catheterization immediately postpartum could decrease cPUR. Further studies are necessary to assess the long-term outcomes and improve understanding of postpartum voiding dysfunction.

Conceptual and Operational Definitions for the Nursing Diagnosis "Urinary Retention"

PURPOSE

To develop conceptual and operational definitions for defining characteristics and related factors for nursing diagnosis of urinary retention, as contained in Taxonomy II of NANDA-I.

DATA SOURCES

Integrative literature review and elaboration of terms related to urinary retention.

DATA SYNTHESIS

It includes operational and conceptual definitions of the nursing diagnosis urinary retention.

CONCLUSIONS

It is necessary to review the definition of this nursing diagnosis and most of its defining characteristics and related factors.

IMPLICATIONS FOR NURSING PRACTICE

The use of internationally known terms for various disciplines in areas of common knowledge helps to standardize the language used by professionals.

Comparison of clean intermittent and transurethral indwelling catheterization for the treatment of overt urinary retention after vaginal delivery: a multicentre randomized controlled clinical trial

Introduction and hypothesis

Overt postpartum urinary retention (PUR) is the inability to void after delivery and affects up to 7% of patients. Clean intermittent catheterization (CIC) and transurethral indwelling catheterization (TIC) are both standard treatments, but have not previously been compared. Clinical guidelines on postpartum bladder management are lacking.

Methods

A total of 85 patients were randomised for TIC (n=45) and CIC (n=40). In total 68 patients (34 patients with TIC and 34 patients with CIC) completed the UDI-6 questionnaire 3 months after delivery.. Patients allocated to TIC received an indwelling catheter for 24 h and if necessary, another catheter for 48 h. Patients with CIC were intermittently catheterized or taught to self-catheterize until adequate voiding with a postvoid residual volume (PVRV) of <150 mL was achieved. The primary outcome was the presence of bothersome micturition symptoms as measured using the Dutch-validated Urogenital Distress Inventory (UDI-6).

Results

Only seven patients (10%) reported bothersome micturition problems 3 months after delivery. No significant differences in the occurrence of micturition symptoms were found. Median PVRV was 800 mL in the CIC group and 650 mL in the TIC group. PVRV was ≥1,000 mL in 24% of the patients. The median duration of catheterization was significantly shorter in the CIC group than in the TIC group (12 h vs. 24 h, p < 0,01). In patients with CIC, 35% required only one catheterization before complete bladder emptying occurred. The duration of treatment was not related to the initial PVRV. Both treatments were equally well accepted by the patients.

Conclusions

In patients with overt PUR, CIC is the preferred treatment as a considerable percentage of patients appear to be over-treated when the standard duration of TIC is 24 h. The occurrence of micturition symptoms is not associated with the catheterization method used. CIC is well tolerated in patients with overt PUR.

Ultrasound induces contraction of the bladder smooth muscle

PURPOSE

To investigate whether the treatment of overt postpartum urinary retention (PUR) with low-intensity pulsed ultrasound (LIPUS) was clinically effective and whether LIPUS could accelerate bladder smooth muscle (BSM) contraction by opening the L-type calcium channels and activating the Ca(2+) signaling pathway.

METHODS

Records of 136 patients undergoing PUR were retrospectively reviewed in two different groups for LIPUS and neostigmine between from 2014 to July 2015. The rats BSM strips in vitro were irradiated by LIPUS. The contraction frequency and amplitude were recorded with BL-410F biological experimental system. The BSM cells were constructed and identified by α-actin-specific antibody staining, and the intracellular Ca(2+) concentration was analyzed by flow cytometry.

RESULTS

The clinical trial indicated that LIPUS had potential therapeutic effect on PUR (80.6 vs. 64.1 %, p < 0.05), and the BSM strip contractility was increased by LIPUS (p < 0.001), and the concentration of Ca(2+) was markedly enhanced by about twofold than that without LIPUS exposure (p < 0.01). Besides, nimodipine could suppress the contraction of BSM and the concentration of intracellular Ca(2+) which was caused by ultrasound.

CONCLUSIONS

The results suggested LIPUS had potential therapeutic effect on PUR and the Ca(2+) signaling pathway was involved in the mechanism. The ultrasound irradiation may provide a new method for PUR therapy.

Neuroanatomic and behavioral correlates of urinary dysfunction induced by vaginal distension in rats

The aim of the present study was to use a model of simulated human childbirth in rats to determine the damage to genitourinary structures and behavioral signs of urinary dysfunction induced by vaginal distension (VD) in female rats. In experiment 1, the length of the genitourinary tract and the nerves associated with it were measured immediately after simulated human delivery induced by VD or sham (SH) procedures. Electroneurograms of the dorsal nerve of the clitoris (DNC) were also recorded. In experiment 2, histological characteristics of the bladder and major pelvic ganglion of VD and SH rats were evaluated. In experiment 3, urinary parameters were determined in conscious animals during 6 h of dark and 6 h of light before and 3 days after VD or SH procedures. VD significantly increased distal vagina width (P < 0.001) and the length of the motor branch of the sacral plexus (P < 0.05), DNC (P < 0.05), and vesical nerves (P < 0.01) and decreased DNC frequency and amplitude of firing. VD occluded the pelvic urethra, inducing urinary retention, hematomas in the bladder, and thinness of the epithelial (P < 0.05) and detrusor (P < 0.01) layers of the bladder. Major pelvic ganglion parameters were not modified after VD. Rats dripped urine in unusual places to void, without the stereotyped behavior of micturition after VD. The neuroanatomic injuries after VD occur alongside behavioral signs of urinary incontinence as determined by a new behavioral tool for assessing micturition in conscious animals.

Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery

Introduction and hypothesis

Postpartum urinary retention (PUR) is a common consequence of bladder dysfunction after vaginal delivery. Patients with covert PUR are able to void spontaneously but have a postvoid residual bladder volume (PVRV) of ≥150 mL. Incomplete bladder emptying may predispose to bladder dysfunction at a later stage of life. The aim of this cross-sectional study was to identify independent delivery-related risk factors for covert PUR after vaginal delivery in order to identify women with an increased risk of covert PUR.

Methods

The PVRV of women who delivered vaginally was measured after the first spontaneous micturition with a portable bladder-scanning device. A PVRV of 150 mL or more was defined as covert PUR. Independent risk factors for covert PUR were identified in multivariate regression analysis.

Results

Of 745 included women, 347 (47 %) were diagnosed with covert PUR (PVRV ≥150 mL), of whom 197 (26 %) had a PVRV ≥250 mL (75th percentile) and 50 (7 %) a PVRV ≥500 mL (95th percentile). In multivariate regression analysis, episiotomy (OR 1.7, 95 % CI 1.02 – 2.71), epidural analgesia (OR 2.08, 95 % CI 1.36 – 3.19) and birth weight (OR 1.03, 95 % CI 1.01 – 1.06) were independent risk factors for covert PUR. Opioid analgesia during labour (OR 3.19, 95 % CI 1.46 – 6.98), epidural analgesia (OR 3.54, 95 % CI 1.64 – 7.64) and episiotomy (OR 3.72, 95 % CI 1.71 – 8.08) were risk factors for PVRV ≥500 mL.

Conclusions

Episiotomy, epidural analgesia and birth weight are risk factors for covert PUR. We suggest that the current cut-off values for covert PUR should be reevaluated when data on the clinical consequences of abnormal PVRV become available.

Prolonged second stage of labour, maternal infectious disease, urinary retention and other complications in the early postpartum period

Objective

To study the association between duration of second stage of labour and risks of maternal complications (infection, urinary retention, haematoma or ruptured sutures) in the early postpartum period.

Design

Population‐based cohort study.

Setting and sample

We included 72 593 mothers with singleton vaginal deliveries at ≥37 weeks of gestation in cephalic presentation, using the obstetric database from the Stockholm‐Gotland region in Sweden, 2008–12.

Methods

Logistic regression analysis. Odds ratios (ORs) with 95% confidence intervals (95% CI) were calculated and adjustments were made for maternal age, body mass index, height, smoking, cohabitation, gestational age, labour induction, epidural analgesia and oxytocin augmentation.

Results

Rates of any complication varied by parity from 7.3% in parous women with previous caesarean section, 4.8% in primiparas and 1.7% in parous women with no previous caesarean section. Compared with a second stage <1 hour, the adjusted ORs for any complication (95% CI) in primiparas were for 1 to <2 hours 1.28 (1.11–1.47); 2 to <3 hours 1.54 (1.32–1.79), 3 to <4 hours 1.63 (1.38–1.93) and ≥4 hours 2.08 (1.74–2.49). The corresponding adjusted ORs for parous women without previous caesarean were 2.27 (1.78–2.90), 2.97 (2.09–4.22), 3.65 (2.25–5.94) and 3.16 (1.44–6.94), respectively. The adjusted ORs for women with previous caesarean were for 1 to <2 hours 1.62 (1.13–2.32); 2 to <3 hours 1.56 (1.00–2.43), 3 to <4 hours 2.42 (1.52–3.87), and ≥4 hours 2.31 (1.25–4.24).

Conclusions

Risks of maternal complications in the postpartum period increase with duration of second stage of labour also after accounting for maternal, pregnancy and delivery characteristics. Special attention has to be given to parous women with previous caesarean deliveries.

Postpartum urinary retention after vaginal delivery: Assessment of risk factors in a case-control study

OBJECTIVE

To assess the obstetrics risk factors for postpartum urinary retention after vaginal delivery.

MATERIAL AND METHODS

Of 234 women with a vaginal delivery, 19 (8.1%) women who had postpartum urinary retention were cases, and 215 (91.9%) women who did not were controls. Postpartum urinary retention was defined as the presence of postvoid residual bladder volume ≥150 mL or the inability to void within 6 hours after vaginal delivery. Logistic regression analysis identified risk factors for urinary retention.

RESULTS

Prolonged duration of the second stage of labor (OR=0.46, 95% CI for OR=0.06-3.67, p<0.001), presence of episiotomy (OR=0.07, 95% CI for OR=0.01-0.68, p=0.022) and perineal laceration (OR=97.09, 95% CI for OR=7.93-1188.93, p<0.001), and birth weight of >4000 g for the newborn (OR=0.04, 95% CI for OR=0.01-0.20, p<0.001) were found as independent risk factors for postpartum urinary retention after vaginal delivery.

CONCLUSION

Postpartum urinary retention after vaginal delivery is a relatively common condition. Awareness of risk factors, including prolonged second stage of labor, episiotomy, perineal lacerations, and macrosomic birth, may allow us to take the necessary precautions against this complication.