LUTS (2013)

ORIGINAL ARTICLE

Incidence of Early Postpartum Voiding Dysfunction

in Primiparae: Comparison Between Vaginal Delivery
and Cesarean Section
Hazem AL-MANDEEL,1 Ahmed AL-BADR,2 and Ghadeer AL-SHAIKH1
1
Department of Obstetrics and Gynecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia and
2
Department of Urogynecology and Pelvic Reconstructive Surgery, Womens Specialized Hospital, King Fahad Medical
City, Riyadh, Saudi Arabia

Objectives: To compare the incidence of early postpartum voiding dysfunction (PPVD) in primiparae women delivered
vaginally (VD) to those delivered by elective Caesarean section (CS).
Methods: A prospective study of primiparae in early postpartum period, were grouped into: VD group and CS
group. Following the first 24 h from delivery, patients had uroflowmetry and post-void residual urine (PVR) volume
measurement.
Results: Two hundred and fifty six primiparae women recruited; 204 (81%) had VD and 48 (19%) had primary
elective CS. Forty-two women in the VD group (20.2%) diagnosed with PPVD compared to only four (8.3%) in the
CS group (P = 0.05). Within VD group, women who had vaginal tear (86.4% vs. 44%, P < 0.001) or epidural analgesia
(33.3% vs. 18.1%, P < 0.05) experienced higher incidence of PPVD.
Conclusion: Women who had normal VD are at higher risk of transient PPVD than those delivered by CS during their
early postpartum period.

Key words elective Caesarean section, postpartum, primiparae, voiding dysfunction

1. INTRODUCTION June 2010 and May 2011. Institutional Review Board

Urinary retention and voiding dysfunction has been
recognized for a long time as a clinical problem that
could affect women in the postpartum period. However,
postpartum voiding dysfunction (PPVD) is not a com-
pletely understood clinical condition.1 Overstretching the
bladder wall during pregnancy or delivery can result in
detrusor damage and possibly causing PPVD. The reported
incidence of PPVD varies in the literature in a general
obstetric population between 1.7% and 43% after vagi-
nal delivery (VD),2,3 and between 3.3% and 24.1% after
Caesarean section (CS),4 depending on the criteria used.
The uses of regional analgesia (epidural or spinal),
instrument-assisted VD (forceps or vacuum), CS, perineal
trauma, and primiparity have been reported frequently as
predisposing factors.5 The precise role of CS, however, in
causing PPVD is difficult to determine because the effects
of the procedure and anesthesia affecting bladder function
have not been studied well.
The objectives of this study are to compare the incidence
of PPVD and urinary retention in the early postpartum
period between primiparous women who had VD to those
who delivered by CS, and to identify associated risk factors
in each group.
2. METHODS
This was a prospective cohort study of primiparae
women who delivered in a tertiary care centre between
approval was obtained prior to commencing the study. All
postpartum primiparae women who delivered during the
12-month period were considered. The exclusion criteria
included: women with any symptoms of voiding dysfunc-
tion prior to delivery, multiparous women, women with
multiple gestation, those who delivered by emergency CS,
women who required indwelling bladder catheterization
during labor or those who required catheterization for
longer than 24 h, and women with gestational diabetes.
Eligible women were recruited during their postpartum
hospital stay and were divided into two groups: Group 1:
VD group and Group 2: primary elective CS group.
For the VD group, there was no specific bladder protocol
used during labor and delivery unless epidural analgesia
was used, then indwelling Foleys catheter was inserted
and kept until the epidural catheter was removed. In the
CS group, the indwelling Foley catheter was inserted prior
to CS and then removed 24 h after surgery. Postoperative
Correspondence: Hazem Al-Mandeel, MBBS, MSc, FRCSC, Division of Urog-
ynecology & Reconstructive Pelvic Surgery, Department of Obstetrics and
Gynaecology, College of Medicine, King Saud University, P.O. BOX 7805,
Riyadh 11472, Saudi Arabia. Tel: +966-1-4670818; Fax: +966-1-4679557.
Email: halmandeel@ksu.edu.sa
Received 3 January 2013; revised 11 May 2013; accepted 18 June 2013
DOI: 10.1111/luts.12027

2013 Wiley Publishing Asia Pty Ltd

2 Hazem Al-Mandeel et al.

analgesia was given for 24 h by intramuscular injection of TABLE 1. Characteristics of primiparae women
Pethidine (50100 mg) every 6 h as well as non-steroidal
VD group CS group
anti-inflammatory drugs, as needed. Characteristics (n = 208) (n = 48) P-value
Following the first 24 h from delivery and after removal
of Foleys catheter, a research nurse approached eligible Age in years 25.4 3.7 26.3 4 0.31
candidates. An informed consent form explaining the (Mean SD)
BMI in kg/cm2 30. 5 31.7 6.3 0.17
study in details was taken from all participating women. (Mean SD)
All consented patients had free Uroflowmetry (FloPoint Baby birth weight in g 3062.4 615.9 2588.9 995.2 0.004
Elite Uroflow System, Verathon) followed by measure- (Mean SD)
ment of post-void residual bladder (PVR) volume using Regional anesthesia 44 (21.2%) 26 (54.2%) <0.001
automated bladder scanner (BladderScan BVI 9400) (epidural/spinal)
Postpartum UTI 7 (6.7%) 1 (4.2%) 0.537
within 10 min. Study subjects were asked to void once First voided volume in 218.9 171.7 220.5 191.7 0.97
they felt the urge and it was in a secluded toilet with a mL (Mean SD)
special uroflow machine placed inside the toilet seat to First Qmax 21.6 10.7 23.6 10.4 0.41
minimize any possible effect on their voiding pattern. All (Mean SD)
First PVR (Mean SD) 259.7 153.7 173.3 149.4 0.02
participants were asked whether they had a sensation
of incomplete emptying, straining, or voiding difficulty. CS, Caesarean section; PVR, post void residual urine volume; Qmax,
Postpartum voiding dysfunction was diagnosed if PVR maximum ow rate; UTI, urinary tract infection; VD, vaginal delivery.
was > 150 mL and maximum flow rate of < 15 mL/sec
with or without symptoms of difficult micturition. TABLE 2. Characteristics of primiparae women in the vaginal delivery
According to the International Continence Society (ICS) group
subcommittee on the standardization of terminology of
lower urinary tract function, PVR volume of > 150 mL is VD with PPVD VD w/out PPVD
Characteristics (n = 42) (n = 166) P-value
abnormal, voiding dysfunction is identified as maximum
flow rate < 15 mL/sec with a voided volume of > 150 mL.6 Age in years (Mean SD) 25.7 2.6 25.4 3.9 0.74
Uroflowmetry and PVR measurements were repeated BMI in kg/cm2 (Mean SD) 29.1 4.4 30.2 5.2 0.38
for women who met the diagnostic criteria of PPVD on Duration of rst stage of 537.9 163.3 478.2 266 0.33
their day of discharge to confirm if PPVD was still present. labor in minutes
(mean SD)
The following parameters for women in Group 1 were Duration of second stage 47.3 46.4 45.5 44.3 0.82
examined: age, duration of first and second stages of of labor in minutes
labor, epidural analgesia, birth weight, presence of any (mean SD)
birth canal trauma, such as vaginal or perineal lacerations, Oxytocin use (%) 20 (47.6%) 80 (48.2%) 0.87
Episiotomy/vaginal tear (%) 38 (86.4%) 52 (31.3%) <0.001
or episiotomy. For patients in both groups, further data
Epidural (%) 14 (33.3%) 30 (18.1%) 0.04
collected including: timing of Uroflowmetry, voided vol- Baby BW in g (mean SD) 2961.0 441.8 3088.0 652.3 0.4
ume, maximum flow rate (Qmax), and post-void residual Postpartum UTI (%) 1 (4.8%) 6 (7.2%) 0.57
bladder volume after the measured void. Timing of rst measured 2481.5 1661.0 2275.1 1806.0 0.63
Statistical analysis was conducted with SPSS software void from delivery in
min, (mean SD)
(version 16.0 for Windows; SPSS Inc., Chicago, IL, USA). First voided volume in mL 98.2 63.5 249.5 177.1 <0.001
Students t-test or MannWhitney test was used for (mean SD)
statistical comparisons involving quantitative data. For First Qmax (mean SD) 9.4 3.2 24.7 9.7 <0.001
comparisons involving qualitative data, 2 analysis was First PVR (mean SD) 330.3 155.5 133.6 119.3 <0.001
used. Logistic regression was applied to determine the
BMI, body mass index; PVR, post void residual urine volume; Qmax,
covariates associated with (PPVD). A P-value of < 0.05 maximum ow rate; UTI, urinary tract infection; VD, vaginal delivery.
was considered statistically significant.

to assessment of voiding parameters was not statisti-

3. RESULTS
Over the study period, 510 eligible women were iden-
tified, 110 had exclusion criteria (21.5%), and 256 (64%)
of the remaining primiparae women agreed to participate;
204 (81%) had VD and 48 (19%) had primary elective CS.
Characteristics of women in each group are demonstrated
in Table 1. None of the VD group had instrument-assisted
delivery. Age, body mass index, or postpartum urinary
tract infections were not different between the two
groups. Regional analgesia/anesthesia was significantly
higher in the CS group compared to VD group (54.2%
vs. 21.1%, P = 0.01). Infant birth weight was significantly
higher in the VD group compared to CS group (3063 + 615
vs. 2589 + 595, P = 0.004). The mean time from delivery
cally different between the two groups (38.6 + 12 h vs.
47.2 + 15 h, P = 0.31). Forty-two women in the VD group
(20.2%) met the diagnosis of PPVD compared to only four
women out of 48 (8.3%)in the CS group (P = 0.05). No
woman, in either group, had complete retention of urine.
Within the VD group, women who met the criteria of
PPVD had more vaginal tears or episiotomies (86.4% vs.
44%, P < 0.001) as well as more likely used epidural anal-
gesia (33.3% vs. 18.1%, P < 0.05) compared to those who
did not have PPVD. The other obstetric parameters were
not different between women with PPVD and those with
no PPVD within the VD group, as illustrated in Table 2.
For CS group, the absolute number of women with
PPVD (n = 4) was small to assess any possible risk factor

2013 Wiley Publishing Asia Pty Ltd


for PPVD. Of note, only two women (50%) had CS under
regional anesthesia and the other two were under general
anesthesia.
All voiding parameters of women with PPVD, includ-
ing PVR, where repeated prior to their discharge and
were normal: mean Qmax of the four women with PPVD
after CS on discharge was 23 mL/h, range 1927 mL/h,
mean PVR was 82 mL, range: 53111 mL. Regarding
42 women with PPVD in the VD group, mean Qmax
was 21 mL/h, range: 1626 mL/h; and mean PVR 94 mL,
range: 59131 mL. The mean number of days from deliv-
ery until discharge in the VD group was 2.6 + 0.3 days,
and 3.4 + 0.5 days for the CS group.
4. DISCUSSION
Postpartum voiding dysfunction may result from
different proposed mechanisms such as tissue edema
secondary to pressure on the pelvic floor, impaired detru-
sor function from bladder overdistention, or detrosal
dysfunction as a result of neuropraxia.1,5 As such, elective
CS might be protective; however, there are no studies
comparing the incidence of PPVD between VD and CS.
Our study is the first to compare PPVD between both
groups in the early postpartum period, and it showed
that PPVD in primiparae women was significantly higher
following VD compared to elective CS (20.2% vs. 8.3%).
Risk factors that are associated with PPVD in the litera-
ture include: epidural analgesia/anesthesia, instrumental
VD, prolonged labor, episiotomy or perineal tear, and
infants birth weight.3 The effect of epidural analgesia
on the urinary bladder and urinary retention has been
well documented.2,3,7 9 In out study, even though more
women in the CS group had regional anesthesia than
in the VD group (54.2% vs. 21.2%), more women in
the VD group had early PPVD. This might be related
to variation in patient response to regional analgesia or
possibly due to the different medication used in epidural
analgesia/anesthesia. The only difference that was noted
between women delivered vaginally and those delivered
by CS is larger size babies in the VD group, which has
been identified as a risk factor in the studies that assessed
obstetric risk factors among women delivered vaginally.10
Regression analysis of women delivered vaginally in our
study showed that the use of epidural analgesia was signif-
icantly higher in women with PPVD than those without
PPVD. These findings are consistent with studies that
found epidural analgesia as an independent risk factor.1
Perineal trauma and/or episiotomy is another risk fac-
tor in our study and in earlier published studies.7,11 13
However, this was different from the study published
by Carley et al.1 which found that perineal trauma and
episiotomy were not identified as independent factors,
mainly because it was associated with instrument assisted
VD. In our study, there was no instrument assisted vaginal
delivery. This difference may be related to the study popu-
lation, or practice since the episiotomy rate in primiparae
women is high in our centre.
Most studies found that prolonged labor, either first
or second stage, is a risk factor for PPVD, which was
2013 Wiley Publishing Asia Pty Ltd
Postpartum Voiding Dysfunction in Primiparae 3
not identified in our study. This is possibly because the
majority of studies included multiparous women along
with primiparae, and since more primiparae women
were in the group with PPVD in those studies, duration
of labor was eventually longer in the group with more
primiparous women.1,5,10,14 No differences in the rates
of induction of labor or birth weights were identified in
the VD group. Such findings are consistent with previous
studies.1
Despite the exact cause of PPVD having not been clearly
determined, we propose that the mechanism that results
in PPVD, based on the identified risk factors, might be
secondary to a temporary mechanical outlet obstruction
as a consequence of perineal edema, or it may be due
to direct bladder trauma. Thus, CS is more likely to be
protective from early PPVD.
In our study population, all women diagnosed with
PPVD had normal PVR at the time of discharge, con-
firming that PPVD is a self-limiting condition and that
conservative treatment is the best approach, as long
as they remained asymptomatic.3,5 Detailed urodynamic
evaluation to further assess women who continue to have
PPVD is usually warranted and may help in understanding
the mechanism involved in causing longer-term PPVD.
Nevertheless, none of our study population continued to
have PPVD on discharge.
Early detection and treatment of persistent urinary
retention is important, as irreversible bladder damage may
result from bladder over distension.14 Assessment of PVR
is considered the best and easiest screening method for the
diagnosis of PPVD,5 but such practice is not common even
in developed countries.15 Limitations of this study include
relatively small sample, study limited to one center, and
small number of woman with PPVD in the CS group.
5. CONCLUSION
In summary, women who had VD are at higher risk
of transient PPVD than those delivered by CS during
their early postpartum period. Thus, CS is more likely to
protect women from early PPVD and possibly permanent
voiding dysfunction. Certain risk factors; such as vaginal
tear or episiotomy and use of epidural analgesia; places
primaparae women at increased risk of PPVD. Large scale
prospective studies with longer follow-up are warranted
to confirm such findings.
Acknowledgements
We would like to acknowledge the support we received
from the Deanship of Scientific Research at King Saud
University for funding this project through Research
Group project #RGB-VPP-241. We would like also to
thank Mrs Joanna Guerrea for her help in data collection
and Ms Bella Rowena Magnaye for her secretarial work.
We extend our sincere appreciation to Dr Arthur Isnani
for his help in data analysis.
Disclosure
The authors declare and disclose that they have no
conflicting interests. The study was funded partially by a
4 Hazem Al-Mandeel et al.
grant from College of Medicine Research Centre of King
Saud University.
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