Neurogenic Bladder After Extensive Pelvic Surgery
The correct answer is (b): neurogenic bladder after extensive pelvic surgery is characterized by large bladder capacity with overflow incontinence.
Pathophysiology and Clinical Presentation
Extensive pelvic surgery can damage the autonomic nerve supply to the bladder, resulting in detrusor underactivity or acontractility 1. This creates a specific clinical pattern:
- Large bladder capacity develops because the detrusor muscle loses its ability to contract effectively, allowing the bladder to overdistend beyond normal physiologic volumes 1
- Overflow incontinence occurs when the bladder fills beyond capacity and urine leaks passively due to mechanical overflow rather than active detrusor contraction 2
- Elevated post-void residual volumes are characteristic, as the bladder fails to empty completely 2, 1
Why Other Options Are Incorrect
Option (a): Painful Urine Retention
This is not typical of post-surgical neurogenic bladder. The denervation process typically results in painless retention because sensory nerve damage accompanies motor nerve injury 1. Patients often lack the normal sensation of bladder fullness.
Option (c): Small Residual Volume and Uninhibited Contractions
This describes overactive bladder or detrusor overactivity, not the underactive/acontractile bladder seen after pelvic surgery 2. Post-surgical neurogenic bladder shows the opposite pattern: large residual volumes and absent or weak contractions 1.
Option (d): Autonomic Dysreflexia
Autonomic dysreflexia occurs specifically with spinal cord injuries at T6 or above, not from pelvic surgery 2. This is a life-threatening hypertensive response to bladder distension in high spinal cord lesions and is not a feature of peripheral nerve damage from pelvic surgery 2.
Clinical Management Implications
Post-void residual assessment is essential in patients with relevant conditions like radical pelvic surgery 2. The AUA/SUFU guidelines specifically identify radical pelvic surgery as a condition requiring PVR monitoring 2.
Intermittent catheterization becomes the primary management strategy for these patients, as they develop incomplete bladder emptying with overflow incontinence 2, 1. The goal is regular, complete bladder emptying to prevent complications including urinary tract infections, hydronephrosis, and upper tract deterioration 3.
Indwelling catheters should be avoided except as a last resort due to high risks of infection, urethral erosion, and stone formation 2.