A 26-year-old woman, gravida 2 para 2, is in the postpartum unit after an uncomplicated spontaneous vaginal delivery with involuntary dribbling of small amounts of urine. It has been 6 hours since the delivery and the patient has been unable to empty her bladder. During labor, she received epidural anesthesia for severe pain with contractions and her bladder was intermittently catheterized. The patient has no chronic medical conditions, takes no medications, and has no known allergies. Vital signs are normal. Examination shows a firm uterine fundus palpable at the umbilicus and fullness and tenderness above the pubic symphysis. The perineum and vagina are edematous but without lacerations. Sensation is intact in the lower extremities, but the patient is unable to void a measurable amount. Which of the following is the most appropriate next step in management of this patient?

Question

A 26-year-old woman, gravida 2 para 2, is in the postpartum unit after an uncomplicated spontaneous vaginal delivery with involuntary dribbling of small amounts of urine.  It has been 6 hours since the delivery and the patient has been unable to empty her bladder.  During labor, she received epidural anesthesia for severe pain with contractions and her bladder was intermittently catheterized.  The patient has no chronic medical conditions, takes no medications, and has no known allergies.  Vital signs are normal.  Examination shows a firm uterine fundus palpable at the umbilicus and fullness and tenderness above the pubic symphysis.  The perineum and vagina are edematous but without lacerations.  Sensation is intact in the lower extremities, but the patient is unable to void a measurable amount.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da9d_476d_bc81_4368d842fda3_MD0003_00 This patient has postpartum urinary retention, which is the inability to void ≥6 hours after vaginal delivery (or ≥6 hours after catheter removal following cesarean delivery). Risk factors include primiparity, regional neuraxial anesthesia (eg, epidural anesthesia), and pudendal nerve injury from prolonged labor (perineal stretching and swelling). The combination results in an inability to sense the need to void, loss of the micturition reflex, bladder atony (eg, palpably overdistended bladder with suprapubic fullness and tenderness), and urinary retention. Overflow incontinence (eg, involuntary dribbling of urine) can occur due to bladder pressure rising above urethral pressure. Urethral catheterization is required for both diagnosis and treatment, particularly in patients who are unable to void (Choice B). A postvoid residual volume of ≥150 mL is consistent with urinary retention. Urethral catheterization decompresses the bladder, preventing upper urinary tract damage from urine reflux or increased pressure. Symptoms are self-limited, and most patients regain bladder function after catheterization. (Choice A) Antibiotics are administered if the patient has clinical features of a urinary tract infection (UTI), including suprapubic tenderness (as in this patient). However, patients with a UTI also typically have fever and urinary frequency, but not urinary retention. (Choice C) Oxybutynin, an anticholinergic, inhibits smooth muscle contractions, promoting bladder relaxation in the treatment of overactive bladder (ie, urgency due to detrusor spasm). This therapy would worsen urinary retention in this patient. (Choice D) A pessary is used to manage stress incontinence and pelvic organ prolapse by stabilizing the pelvic floor. Although this patient may have some pelvic floor laxity from her recent delivery, her incontinence is due to overflow from pudendal nerve injury and bladder atony, not urethral hypermobility. (Choice E) Suprapubic catheter placement is a more invasive procedure and is therefore typically performed only when urethral catheterization is contraindicated (eg, urethral injury or stricture). This patient had recent urethral catheterization (suggesting no stricture) and has no perineal or vaginal lacerations (suggesting no urethral injury). Educational objective: Patients with postpartum urinary retention, the inability to void ≥6 hours after vaginal delivery, may have dribbling of urine from overflow incontinence. Urethral catheterization is indicated for diagnosis and treatment. References: Prolonged second stage of labour, maternal infectious disease, urinary retention and other complications in the early postpartum period. (http://www.ncbi.nlm.nih.gov/pubmed/25601143) Risk factors for acute postpartum urinary retention after vaginal delivery: focus on episiotomy direction. (http://www.ncbi.nlm.nih.gov/pubmed/25731655) Extensive postpartum urinary retention successfully treated with clean intermittent catheterization. (http://www.ncbi.nlm.nih.gov/pubmed/29664554)

A 26-Year-Old Woman, Gravida 2 Para 2, Is in the Postpartum