February 18, 2021 February 18, 2021/ Melli Tilbrook
Post partum urinary retention (PPUR) is defined as the inability to urinate within 6 hours of giving birth. More clinically it is defined as more than 150 ml of urine being left behind in the bladder after urinating. If your bladder does not expel the urine your bladder will stretch. If it stretches too much and left untreated this can lead to sometimes irreversible bladder muscle and nerve damage, which could mean permanent catheter use to urinate. It can resolve spontaneously but can persist for months. Immediate diagnosis and management is vital.
“Immediate diagnosis and management is vital.”
Pregnancy hormones progesterone, increase during pregnancy to decrease bladder muscle tone. This is so that when the baby grows and starts compressing your bladder, you don’t feel the urge to be going to the toilet all the time. This reduced bladder tone and thus decreased urge to go reverses post birth with decreasing progesterone but takes a while.
The perineum and urethra can swell due to the trauma of vaginal birth and this can block the urethra making urinating hard.
Opiate pain relief and epidurals can reduce bladder sensitivity.
Constipation can also block the urethra.
Nerves can be damaged with child birth, episiotomies and tears which can reduce bladder function.
Pain from child birth can cause nervousness and hesitation to wee.
“Nerves can be damaged with child birth, episiotomies and tears which can reduce bladder function.”
When your baby has just been born, you may be unaware of any symptoms. That is why the medical staff supporting you need to check that you wee (urinate) within 6 hours of your babies birth. Make them aware if you have any concerns that you haven’t urinated.
Your medical staff can also check your bladder fullness by palpating your bladder. An ultrasound to see how full your bladder is after urinating can be performed but is less reliable soon after birth due to the enlarged uterus in the way.
Signs you can look out for are:
difficulty weeing- hesitancy, slow flow, intermittent flow.
feeling you have incompletely emptied your bladder, that is, needing to return to the toilet soon after weeing.
dribbling urine may not suggest incontinence but your bladder actually spilling over because it is over full.
abdominal pain.
“check that you wee (urinate) within 6 hours of your babies birth. ”
If urinary retention becomes a persistent problem a cystoscopy can be performed by a Urologist (a Doctor specialising in urinary issues) to assess whether there is any bladder nerve damage. Hopefully it does not come to this.
What are the risk factors for urinary retention?
As your baby descends down into your pelvic cavity to be born it can put pressure on to nerves that supply your bladder. If the nerves to your bladder are damaged this can affect your bladder muscle’s ability to contract, thus expel urine from your body.
This risk can be increased by a:
Prolonged second stage of labour
Episiotomy
Perineal tears that damage the pelvic floor muscles and nerves
Baby > 4kg
Instrumental delivery
Epidural and opiate pain relief (2, 3).
If you have not been able to urinate within 6 hours they may catheterise you to protect the bladder for 2 to 3 days, giving the bladder and other issues time to recover.
They will then likely trial you voiding again to see if you can get your bladder volume down to 150 ml post void/ wee.
If not they will probably teach you to self catheterise as well as trying to get you to self void. The self catherisation will need to be used until you can get your post void volume down to 150ml.
You will need to void every 2 hours, so that the bladder can shrink back to a normal size, which will make the bladder wall more sensitive, thus increase your urge to go. The aim is to reduce the need to catheterise as hopefully the nerves to your bladder recover.
If urinary retention becomes a long term problem surgery can be performed to insert a sacral nerve stimulator which can help the bladder to contract.
“catheterise you to protect the bladder for 2 to 3 days, giving the bladder and other issues time to recover”
If urinary retention is mild (ie you can void >50 % of your bladder volume and the residual bladder volume is less than 250 ml), cathertisation may be able to be avoided and conservative treatment followed:
They can assess your pelvic floor to see if there is any weakness, tightness or scar tissue that may be preventing voiding. They can use massage, stretches or exercises to address this.
When there is nerve damage or poor activation, vaginal probes can be prescribed to stimulate the pelvic floor to contract and relax.
They can recommend bladder stimulators too which can be used to stimulate the bladder muscle (detrusor) to contract when you are trying to naturally void.
They can give you tips on how to sit on the toilet to encourage urination.
Urinary retention can be very confronting and distressing so physiotherapists are very good at helping reassure you that although the road to recovery can be long with nerve healing, there is potential.
Urinary retention and the stress of a new born can make our pelvic floor tighten which provides a barrier to successful voids. Practising relaxation exercises, deep breathing and visualising the pelvic floor muscles relaxing can help voiding.
When trying to void naturally there are stressors that can make the process harder including being stressed, tired, in a rush, needing to get to your crying baby or some appointment. Try to control these factors if you can.
Double voiding can be a useful technique to help void more. After you have gone to the toilet, walk around and then try to void a second time. This is good to do in the morning when you will presumably have your largest volume to void.
Reduce perineal swelling that might be blocking the urethra with RICE (rest, ice, compression, elevation).
A warm bath may help if pain is the inhibitor.
Manage constipation with medication, diet etc.
“Practising relaxation exercises, deep breathing and visualising the pelvic floor muscles relaxing can help voiding”
YES if the retention is due to swelling, constipation, progesterone changes but it is,
UNCERTAIN if retention is due to bladder trauma, nerve damage or prolonged opiate pain relief is used.
Summary
Post partum urinary retention is a fairly common and potentially devastating post birth complication.
Early detection and treatment is vital- make sure you have voided successfully within 6 hours of your baby’s birth.
If you have had a big baby, long second stage, epidural or opiate pain relief, episiotomy, perineal tears or instrumental delivery keep an eye out for symptoms.
If you are still suffering from voiding issues after discharge follow up with your doctor, nurses or women’s health physiotherapist.
References
Perú Biurrun G, Gonzalez-Díaz E, Fernández Fernández C, Fernández Corona A. Post Partum Urinary Retention and Related Risk Factors. Urology. 2020 Sep;143:97-102. doi: 10.1016/j.urology.2020.03.061. Epub 2020 May 19. PMID: 32439549.
Kekre AN, Vijayanand S, Dasgupta R, Kekre N. Postpartum urinary retention after vaginal delivery. Int J Gynaecol Obstet. 2011 Feb;112(2):112-5. doi: 10.1016/j.ijgo.2010.08.014. Epub 2010 Dec 4. PMID: 21130452.
Cavkaytar S, Kokanalı MK, Baylas A, Topçu HO, Laleli B, Taşçı Y. Postpartum urinary retention after vaginal delivery: Assessment of risk factors in a case-control study. J Turk Ger Gynecol Assoc. 2014 Aug 8;15(3):140-3. doi: 10.5152/jtgga.2014.13102. PMID: 25317040; PMCID: PMC4195322.
Melli Tilbrook is the Director and Physiotherapist of Mummyotherapy and also practices Physiotherapy and Pilates at Milkwood Studio, Tusmore
February 18, 2021/ Melli Tilbrook/