What is the management for post-cesarean section urinary retention in a female?

Management of Post-Cesarean Section Urinary Retention

Remove the urinary catheter immediately if still in place, assess bladder volume using bladder ultrasound (Bladderscan), and if the patient cannot void within 4-6 hours or has significant retention (>150 mL post-void residual), perform intermittent catheterization rather than replacing an indwelling catheter. 1, 2

Initial Assessment and Diagnosis

Determine Type of Retention

• Overt retention: Complete inability to void, which is immediately apparent 2
• Covert retention: Patient voids but has incomplete bladder emptying with post-void residual >150 mL 3, 2
• Use bladder ultrasound (Bladderscan) to measure bladder volume non-invasively, which correlates closely with catheterization measurements (r=0.807) and avoids unnecessary catheterization 4

Identify Contributing Factors

• Epidural morphine bolus is the highest risk analgesic method, causing urinary retention in 33.3% of patients versus 15-16.7% with other methods 3
• Assess for overdistension injury if catheter was left in place >12 hours, as prolonged catheterization increases retention risk 1, 5
• Rule out bladder injury during surgery, though this is rare 6

Immediate Management Algorithm

Step 1: Catheter Management

• If catheter is still in place: Remove it immediately unless ongoing strict urine output monitoring is required 1, 7
• Immediate removal (versus 12-hour delayed removal) significantly reduces dysuria, urinary frequency, urgency, and time to first voiding 1, 5

Step 2: Bladder Volume Assessment

• Measure bladder volume using Bladderscan 4-6 hours after catheter removal or when patient reports inability to void 4
• If bladder volume >600 mL: Perform immediate catheterization to prevent overdistension injury to detrusor muscle and parasympathetic nerve fibers 2
• If post-void residual >150 mL: Diagnose covert retention and initiate intermittent catheterization 3, 2

Step 3: Bladder Decompression

• Perform prompt and complete bladder decompression via intermittent catheterization rather than replacing indwelling catheter 6, 2
• Use clean intermittent catheterization every 4-6 hours until spontaneous voiding resumes with post-void residuals <150 mL 6, 2
• Consider silver alloy-impregnated catheters if catheterization is needed, as they reduce urinary tract infection risk 6

Adjunctive Interventions

Non-Pharmacologic Measures

• Sacral region massage: Massage every hour for 10-15 minutes post-cesarean, which reduced mean time to void to 3.4 hours versus 6.2 hours in controls and prevented retention entirely in one study 8
• Encourage early mobilization as soon as regional anesthesia wears off to promote bladder emptying 1, 7
• Increase fluid intake to promote natural voiding 5

Pain Management Adjustment

• If epidural morphine bolus was used, recognize this significantly increases retention risk (21.7% needed catheterization versus 3.3-6.7% with other methods) 3
• Switch to multimodal analgesia with scheduled acetaminophen and NSAIDs, which are opioid-sparing and reduce retention risk 7

Monitoring and Follow-Up

Short-Term (First 24-48 Hours)

• Most patients with post-cesarean retention (88% in one study) achieve spontaneous micturition before hospital discharge 3
• Continue intermittent catheterization every 4-6 hours until two consecutive post-void residuals are <150 mL 2
• Monitor for signs of urinary tract infection (dysuria, frequency, urgency, fever) given catheterization increases infection risk 1, 5

Persistent Retention (Beyond 3 Days)

• If retention persists beyond day 3 postpartum: This constitutes persistent urinary retention requiring further evaluation 2
• Consider neurologic causes, pelvic organ injury, or severe overdistension injury requiring urology consultation 6, 2
• Teach clean intermittent self-catheterization if retention continues beyond hospital discharge 6

Long-Term Follow-Up

• At 3 months postpartum, 4% may have obstructive voiding problems and 4.7% irritative symptoms even after resolution of acute retention 3
• Reassure patients that epidural morphine-associated retention, while increasing acute risk, is not detrimental to long-term urinary function 3

Critical Pitfalls to Avoid

• Never leave the bladder overdistended: Volumes >600 mL can cause permanent detrusor muscle damage and, in rare cases, bladder rupture—a life-threatening but entirely preventable complication 2
• Do not replace indwelling catheters: Use intermittent catheterization instead to minimize infection risk and promote return of normal voiding 6, 2
• Do not delay catheter removal: Keeping catheters in place for 12 hours versus immediate removal significantly increases bacteriuria, dysuria, and delayed ambulation 1, 5
• Recognize covert retention: Many patients with incomplete emptying will not report symptoms, making objective bladder volume assessment essential 2