What is the management for dysuria (painful urination) after a cesarean section (C-section)?

Management of Dysuria After Cesarean Section

Dysuria after cesarean section is most commonly caused by urinary tract infection related to catheterization and should be treated with appropriate antibiotics after urine culture, while ensuring early catheter removal to prevent complications. 1

Etiology and Diagnosis

• Urinary tract infection is one of the most common complications after cesarean delivery, often associated with indwelling urinary catheters 1
• Dysuria may present with urinary frequency, urgency, burning on micturition, and suprapubic pain 1
• Less commonly, dysuria may be caused by bladder distortion or injury that occurred during the cesarean section 2, 3
• Diagnostic approach should include:
  • Urine dipstick testing for nitrite and leukocyte esterase (negative results often suggest absence of UTI) 1
  • Urine culture before starting antibiotics to guide targeted therapy 1
  • Assessment of other symptoms such as fever, flank pain, or systemic symptoms that might indicate pyelonephritis 4

Prevention Strategies

• Immediate removal of urinary catheters after cesarean delivery significantly reduces the risk of urinary tract infection and associated dysuria 1
• A prospective randomized clinical trial showed that immediate catheter removal versus 12-hour removal resulted in significantly lower incidence of postoperative bacteriuria, dysuria, and burning on micturition 1
• Early catheter removal (within 2 hours) is associated with:
  • Reduced urinary frequency 5
  • Decreased microscopic hematuria 5
  • Shorter postoperative mobilization time 5
  • Reduced length of hospital stay 5
• For women who do not need ongoing strict assessment of urine output, the urinary catheter should be removed immediately after cesarean delivery 1

Treatment Algorithm

1. Confirm diagnosis:

   • Obtain urine sample for culture and sensitivity testing 1
   • Perform dipstick testing for nitrite and leukocyte esterase 1

2. Initiate empiric antibiotic therapy if UTI is suspected:

   • Third-generation cephalosporins have shown superiority over fluoroquinolones for urinary infections 6
   • Adjust antibiotic regimen based on culture results 1, 6

3. Pain management:

   • NSAIDs (diclofenac, ibuprofen) as first-line treatment for pain relief 6
   • Use lowest effective dose to minimize cardiovascular and gastrointestinal risks 6
   • Opioids as second-choice when NSAIDs are contraindicated 6

4. Hydration and supportive care:

   • Encourage increased fluid intake to help flush bacteria from the urinary tract 1
   • Early mobilization to promote bladder emptying 1, 5

5. Monitor for complications:

   • Assess for signs of upper urinary tract involvement (fever, flank pain) 1, 4
   • Consider bladder ultrasound (Bladderscan) to assess for urinary retention rather than repeated catheterization 7

6. For refractory cases:

   • Consider urologic consultation if symptoms persist despite appropriate antibiotic therapy 2, 3
   • Evaluate for possible bladder injury or distortion that may have occurred during cesarean section 2, 3

Special Considerations

• Bladder injuries during cesarean section are more common with:

  • Previous cesarean deliveries 3
  • Adhesions 3
  • Emergency cesarean deliveries 3
  • Cesarean sections performed during second stage of labor 3

• If bladder distortion is suspected (persistent dysuria despite appropriate antibiotic treatment), cystography may be needed for diagnosis 2

• Bladderscan can be used as an alternative to intermittent catheterization to assess for urinary retention following cesarean section 7

• For patients with atypical or severe symptoms, consider other rare complications such as bladder flap hematoma or ureteral injury 3