Acute urinary retention in pregnancy: a case

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Abstract Female acute urinary retention in pregnancy is a ... complication of early pregnancy with few serious sequelae. ... Genital prolapse e.g., cystocele.
Eur Clinics Obst Gynecol DOI 10.1007/s11296-008-0079-z

REVIEW ARTICLE

Acute urinary retention in pregnancy: a case presentation and review of the literature Dushyant Maharaj & Malanie Gajanayaka

Received: 21 January 2008 / Accepted: 30 July 2008 # European Board and College of Obstetrics and Gynaecology 2008

Abstract Female acute urinary retention in pregnancy is a relatively uncommon condition. Its relatively low incidence and little published evidence base leads to inconsistent and often suboptimal management. The underlying cause of urinary retention must be diagnosed and treated. There is a lack of prospective trials of investigations and management. The following databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and SCOPUS. Keywords Acute urinary retention . Urine retention in pregnancy . Female urinary retention

Case presentation Ms. FJB, a 35-year-old para 1 gravida 2 woman at 18 weeks of gestation, was referred to the emergency room by her family practitioner, with acute urinary retention (AUR). She presented at 1000 hours having last voided at 2030 hours the previous night. It was the first time that she had ever

experienced this problem. There was no history of voiding difficulties in the past, or any history suggestive of a urinary tract infection. Her bowel habits had not changed in the recent past. Examination revealed a distended suprapubic cystic mass, which reduced after emptying of the bladder with an indwelling urinary catheter. A total of 1,000 ml of urine was drained. The height of uterine fundus was in keeping with the calculated gestational age; soft non-tender and anteverted. Her previous vaginal delivery at term 18 months ago followed spontaneous labor, however, she had to be taken to theatre for manual removal of the placenta. There was no other significant history. There was no growth of organisms from a catheter specimen sample. Her complete blood count and blood urea, creatinine and electrolytes were within normal range for pregnancy. A renal and obstetric ultrasound revealed an 18 week singleton, cephalic fetus and no renal tract abnormalities. After an 8day stay in the ward, during which she had an indwelling catheter, she was able to void completely and was discharged home with a follow-up appointment.

Review of the literature D. Maharaj (*) Department of Obstetrics and Gynecology, Wellington School of Medicine, University of Otago, P.O. Box 4373, Wellington South 6242, New Zealand e-mail: [email protected] D. Maharaj Wellington Women’s Hospital, Wellington, New Zealand M. Gajanayaka Department of Obstetrics and Gynecology, Wellington Women’s Hospital, Wellington, New Zealand

Female acute urinary retention is relatively uncommon compared to AUR in men. Its incidence is reported to be three to seven per 100,000 persons per year [1, 2]. Its relatively low incidence and little published evidence base leads to inconsistent and often suboptimal management of female AUR. Acute urinary retention is defined as the inability to void urine, with a retained volume of urine of 200 ml or greater [3]. Urinary retention is a rare complication of early pregnancy with few serious sequelae. It may cause severe lower abdominal pain with a palpable bladder on abdominal examination. Reported cases have

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been associated with the uterus impacted in the pelvis, ectopic pregnancy, retroversion of the uterus and a fibroid uterus. In all cases, the central event was mechanical occlusion of the internal urethral orifice by pressure on the bladder, proximal to the urethra [4] (Table 1). Forty percent of non-pregnant women surveyed in 2002 following acute urinary retention were given the impression that their condition was psychological [5]. Urodynamic

Table 1 Common causes of female urinary retention Common causes Anatomical • Genital prolapse e.g., cystocele • Mass effect Gynaecological tumors e.g., fibroids Urological tumors Faecal impaction and constipation Urinary system obstruction e.g., impacted calculus in urethra Pregnancy—incarcerated uterus, cervical and tubal ectopic pregnancies Blood clot in bladder Urethral rupture Bladder neck stenosis Paraurethral abscess Urethral stricture Drugs • Allergy or cold medications containing decongestants or antihistamines • Ipratropium bromide, • Albuterol • Epinephrine • Opiates • Antimuscarinics • Αlpha adrenergic agonists • Antipsychotics Surgery • Pain • Anesthesia related e.g., epidural/spinal anesthesia • Post-gynaecological/urological surgery e.g. incontinence procedures Neurological • Cauda equina syndrome • Fowler’s syndrome • Spinal cord injury/nerve damage • Degenerative neurological disorders e.g., multiple sclerosis • Prolapse of invertebral disc Infective • Urinary tract infection • Herpes genitalis • Herpes zoster Miscellaneous • Hysteria and conversion psychologic disorder • Prolonged exposure to cold temperatures • Alcohol • Long period of inactivity or bed rest

evidence suggested that the underlying disorder in these women was usually detrusor failure rather than outflow obstruction [6], except in the rare Fowler’s syndrome where there is failure of relaxation of the urethral sphincter [7]. This condition was first described in 1985 as a cause of urinary retention in young women. The abnormality lies in the urethral sphincter’s failure to relax to allow urine to be passed normally. There is no neurological disorder associated with the condition. Up to half the women have associated polycystic ovaries. The typical woman who is seen with the condition is in her 20–30s and may infrequently pass urine with an intermittent stream. The normal sensation of urinary urgency expected with a full bladder are not present, but as the bladder reaches capacity there may be pain and discomfort, and the woman finds that she is not able to pass urine. This can happen spontaneously, or following an operative procedure, or following childbirth. The key diagnostic test for the condition is a sphincter electromyogram (EMG), however, transvaginal or transrectal ultrasound has also been used as a non-invasive method of determining urethral sphincter muscle volume. In the most severe cases of retention, sacral nerve stimulation has been shown to restore voiding.

Risk factors Women with a history of kidney stones or urinary tract infections (UTIs), pregnant women and those who have had recent gynaecological surgery are at higher risk for AUR. The risk factors that predispose to an incarcerated uterus are prior gynaecologic surgery, pelvic adhesions secondary to pelvic inflammatory disease or endometriosis and posterior wall leiomyoma. Severe vulval oedema is a rare complication, especially in early pregnancy. It has been reported in relationship with tocolysis, ovarian hyperstimulation and pre-eclampsia, in limited numbers. Trauma, infection, vascular or lymphatic obstruction may also cause vulval oedema leading to AUR [8].

Pathophysiology Ward et al. [9] suggested that AUR is produced by compression of the proximal urethra and bladder neck by virtue of a mass effect. However, Yang et al. [10] investigated the mechanism by means of transabdominal and transvaginal ultrasonography and concluded that AUR due to an impacted pelvic mass tends to be caused by a displaced cervix compressing the lower portion of the bladder with an obstruction of the internal urethral orifice. Retention secondary to an impacted, gravid uterus is an emergency. Retroversion of the uterus, a history of pelvic inflammatory disease and large fibroids are predisposing

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factors. The enlarging gravid uterus and uterine fibroids may trap the uterus within the pelvis, preventing it from ascending into the abdominal cavity. Furthermore, a history of inflammatory disease may trap the fundus of the uterus within scar tissue that also may prevent the enlarging, gravid uterus from ascending into the abdominal cavity. This condition has been described in all trimesters, but is commonly seen between the tenth and 16th week of gestation when the enlarging, retroverted, gravid uterus becomes impacted within the pelvis and causes extrinsic compression of the urethra [11–13]. Urinary retention in pregnancy is an emergency and a failure to make a prompt diagnosis and institute treatment rapidly will result in irreversible uterine ischemia and spontaneous abortion, rupture of the uterus or bladder, rectal gangrene, intrauterine infection, or death [11]. A history of retroversion or retroflexion of the uterus is another predisposing factor to urinary retention during pregnancy. The incidence of retroversion of the uterus during pregnancy is 10% to 15%, and the incidence of urinary retention owing to a retroverted, gravid uterus is 1.4% [14, 15]. Retroversion is often transient; however, the gravid, retroverted uterus can become impacted, requiring prompt repositioning of the uterus. Incarceration of the retroverted uterus can clinically present as urinary frequency, urgency, abdominal pain and urinary retention. The incidence of an incarcerated uterus is 1:3,000 [16]. During the latter part of the first trimester, the uterus begins to enlarge out of the pelvis to become an abdominal organ. However, in the presence of a retroverted uterus, the body of the uterus can become entrapped within the pelvis, causing the cervix to wedge against the pubic symphysis, impinging on the urethra [17].

Diagnosis The diagnosis of AUR is based on a history of severe lower abdominal pain and/or the sudden inability to pass urine. Bladder distention or a cystic suprapubic mass is felt during a physical examination. A detailed history should include drug history, bowel habit, sensory/motor deficit, lower urinary tract symptoms and previous surgery, particularly gynaecological or urological. This should be accompanied by a detailed examination including neurological and pelvic examination. Initial investigations include a urine dipstick and urine microscopy, culture and sensitivity to exclude infection and a pelvic ultrasound to identify any occult pelvic mass. Further investigations should be tailored to identifying potential serious or reversible causes. Flexible cystoscopy is quick, safe and well-tolerated by patients to visualise the urethra and bladder. It should be used to exclude anatomical

abnormalities and intravesical pathology but there is no published evidence regarding its role in urinary retention in women [3].

Treatment The underlying cause of urinary retention must be diagnosed and treated. Primary treatment involves the insertion of a catheter into the bladder. The decision to remove the catheter will depend on the amount of urine obtained and the likelihood that symptoms will return. The impacted uterus should be manually replaced in the anterior position. Clean intermittent catheterisation and placement of a vaginal pessary are temporizing measures. Women should be given the option of learning clean intermittent self-catheterisation. Manual decompression is the most effective and definitive treatment in reducing the incarceration and restoring the blood supply to the gravid uterus. After the bladder is decompressed, the patient is placed in the dorsal lithotomy or knee-chest prone position. Manual reduction of the incarcerated uterus is undertaken by inserting two fingers into the vagina along the posterior wall, while simultaneously pushing on the lower abdominal wall. In most cases, one is able to feel a sudden loss of resistance as the uterus is repositioned into its anterior location; it is important to apply gentle and slow pressure to prevent separation of the placenta or rupture of the uterus. If attempts to reduce the incarceration are not successful in the out-patient setting, the manoeuver may be performed in the operating room under intravenous sedation. The position of the gravid uterus can be verified with a pelvic sonogram. In addition, patients should be monitored for post-obstructive diuresis after reduction [17]. The use of a pessary for temporary treatment of urinary retention during pregnancy has been advocated. An opposing view is that pessaries should not be used when impaction of the uterus is present because it will not help restore the blood flow to the uterus and are best suited for patients with a gravid uterus associated with vaginal prolapse. The use of a pessary helps elevate the cervix and uterus, thereby restoring the proper vesicourethral angle. Once ascent of the gravid uterus is documented by physical examination after the first trimester, the pessary can be removed [17]. Elucidation as to why some patients develop AUR may lie in videourodynamic testing. Such a test would provide radiological real-time information regarding the anatomy of the lower urinary tract and identify the point of obstruction. Unfortunately, the use of radiation during fluoroscopy precludes its use as a standard diagnostic test during pregnancy [18].

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Conclusion Women who continue to have urinary retention despite initial treatment may need chronic therapy. This may be either in the form of clean intermittent catheterisation or by placing a Foley catheter into the bladder either via the urethra or suprapubically. There is no role for alpha-blockers, or urethral dilatation, and patients with apparently idiopathic retention should not be labeled hysterical. There is a lack of prospective trials of investigations and management and multi-centre trials may be necessary to improve evidence-based practice [3].

References 1. Klarskov P, Andersen JT, Asmussen CF et al (1987) Acute urinary retention in women: a prospective study of 18 consecutive cases. Scand J Urol Nephrol 21(1):29–31 2. Choong S, Emberton M (2000) Acute urinary retention. BJU Int 85:186–201 3. Ramsey S, Palmer M (2006) Int Urol Nephrol 38:533–535 4. Heazell AEP, Dwarakanath LS, Sundar K (2004) An unusual cause of urinary retention in early pregnancy. Am J Obstet Gynecol 191(1):364–365 5. Swinn MJ, Wiseman OJ, Lowe E, Fowler CJ (2002) The cause and natural history of isolated urinary retention in young women. J Urol 167:151–156

6. Deane AM, Worth PHL (1985) Female chronic urinary retention. BJU 57:24–26 7. Fowler CJ, Christmas TJ, Chapple CR et al (1988) Abnormal electromyographic activity of the urethral sphincter, voiding dysfunction and polycystic ovaries: a new syndrome? BMJ 297:1436–1438 8. Yellamareddygari S, Ahluwalia A (2006) Acute vulval oedema with urinary retention in pregnancy. J Obstet Gynaecol 26(8):816 9. Ward JN, Lavengood RW, Draper JW (1968) Pseudo bladder neck syndrome in women. J Urol 99:65–68 10. Yang JM, Huang WC (2002) Sonographic findings of acute urinary retention secondary to an impacted pelvic mass. J Ultrasound Med 21:1165–1169 11. Nelson MS (1986) Acute urinary retention secondary to an incarcerated gravid uterus. Am J Emerg Med 4:231 12. Myers DL, Scotti RJ (1995) Acute urinary retention and the incarcerated, gravid uterus: a case report. J Reprod Med 40:487–490 13. Devoe RW (1956) Acute urinary retention in pregnancy. Calif Med 85(2):112–113 14. Weekes ARL, Atlay RD, Brown VA et al (1976) The retroverted gravid uterus and its effect on the outcome of pregnancy. BMJ 1:622–624 15. Kondo A, Otani T, Takita T et al (1982) Urinary retention caused by impaction of a large uterus. Urol Int 37:87–90 16. Gibbons JM, Paley WB (1968) The incarcerated gravid uterus. Obstet Gynecol 33:845–848 17. Yohannes P, Schaefer J (2002) Urinary retention during the second trimester of pregnancy: a rare cause. Urology 59:946i–946iii 18. Yohannes P (2004) Ultrasound in acute urinary retention and retroverted gravid uterus. Ultrasound Obstet Gynecol 23:427