A 34-year-old woman, gravida 2 para 1, is evaluated for hospital discharge 8 hours after surgery. She came to the emergency room this morning with hypotension, tachycardia, and vaginal bleeding and was diagnosed with a ruptured ectopic pregnancy for which she underwent a laparoscopic right salpingectomy. The patient's only prior surgery was a cesarean section. Two units of packed red blood cells were transfused in the emergency department and another two in the operating room due to acute blood loss anemia; she also received 2 L of normal saline. A Foley catheter was placed immediately prior to surgery and removed before the patient awakened from anesthesia, after an intraoperative urine output of 200 mL was noted. There were no complications. However, the patient has been unable to pass flatus or void since the procedure. She has mild nausea but no fever, dizziness, weakness, or vomiting. Light vaginal bleeding is present. Blood pressure is 140/90 mm Hg and pulse is 98/min. The abdomen is soft and mildly distended with suprapubic tenderness but no rebound or guarding. Tympany is present under the right costal margin. The incisions are closed and the primary dressings are clean, dry, and intact. Which of the following is the most likely cause of this patient's current condition?

Question

A 34-year-old woman, gravida 2 para 1, is evaluated for hospital discharge 8 hours after surgery.  She came to the emergency room this morning with hypotension, tachycardia, and vaginal bleeding and was diagnosed with a ruptured ectopic pregnancy for which she underwent a laparoscopic right salpingectomy.  The patient's only prior surgery was a cesarean section.  Two units of packed red blood cells were transfused in the emergency department and another two in the operating room due to acute blood loss anemia; she also received 2 L of normal saline.  A Foley catheter was placed immediately prior to surgery and removed before the patient awakened from anesthesia, after an intraoperative urine output of 200 mL was noted.  There were no complications.  However, the patient has been unable to pass flatus or void since the procedure.  She has mild nausea but no fever, dizziness, weakness, or vomiting.  Light vaginal bleeding is present.  Blood pressure is 140/90 mm Hg and pulse is 98/min.  The abdomen is soft and mildly distended with suprapubic tenderness but no rebound or guarding.  Tympany is present under the right costal margin.  The incisions are closed and the primary dressings are clean, dry, and intact.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1c8_b7c8_8f63_8f848408e021_MD0005_00 This patient has postoperative urinary retention, the inability to void after a procedure. This surgical complication occurs due to the combination of anesthesia and the administration of a large volume of intravenous fluid. The anesthesia causes bladder stretch-receptor dysfunction and decreased detrusor contractility, which, along with large fluid volumes, results in rapid overdistension. This bladder overdistension causes suprapubic tenderness and abdominal distension as seen in this patient. Risk factors include age >50 years, surgical duration >2 hours, and previous pelvic surgery. Placement of a urinary catheter is both diagnostic and therapeutic; a large volume of urine is evacuated and prevents continued overdistension injury. Patients typically undergo an outpatient voiding trial within a week, after which the catheter is removed. (Choice A) Postoperative intraabdominal hemorrhage can present with decreased urine output. However, patients typically also have hemodynamic instability (eg, hypotension, tachycardia) and an acute abdomen (eg, rebound, guarding), which are not seen in this patient. (Choices B and C) The structures of the urinary tract (eg, ureters, bladder) can be injured during pelvic surgery due to their close anatomic relationship to the female reproductive tract (eg, fallopian tubes, uterus). A bladder injury that would cause immediate lack of urine output would typically be due to a large cystotomy. Injuries of this size are noted intraoperatively by direct visualization and, in some cases, by the presence of gas distending the Foley catheter collection bag, neither of which was seen in this patient. Ureteral injury can also cause decreased urine output, but patients typically have signs of peritonitis (eg, rebound, guarding) due to the caustic effects of urine in the abdominopelvic cavity; this patient has a benign abdominal examination. (Choice D) Small bowel obstructions can present with decreased urine output secondary to dehydration and decreased volume status. However, such an obstruction typically presents 2-3 days postoperatively with nausea, vomiting, abdominal pain, and obstipation. The right costal margin tympany seen in this patient is common after laparoscopy due to the insufflation of gas into the abdominal cavity during the procedure. This benign finding resolves without intervention. Educational objective: Aggressive volume replacement and anesthesia during surgery may cause bladder dysfunction, resulting in postoperative urinary retention (eg, inability to void). Management includes urinary catheter placement, which is both diagnostic and therapeutic. References: Bladder dysfunction after gynecologic laparoscopic surgery for benign disease. (http://www.ncbi.nlm.nih.gov/pubmed/22118884) Prevention and management of postoperative urinary retention after urogynecologic surgery. (http://www.ncbi.nlm.nih.gov/pubmed/25210477)

A 34-Year-Old Woman, Gravida 2 Para 1, Is Evaluated for Hospital