Postpartum urinary retention: Risk factors, clinical impact and management - Thesis

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Postpartum urinary retention

Risk factors, clinical impact and management

Mulder, F.E.M.

Publication date

2017

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Mulder, F. E. M. (2017). Postpartum urinary retention: Risk factors, clinical impact and

management.

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POSTPARTUM

URINARY

RETENTION

IMPACT AND MANAGEMENT

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Postpartum urinary retention

Risk factors, clinical impact

and management

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Cover design:

Maaike van Oudenaarden-Mulder

ISBN:

978-94-028-0853-7

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Postpartum urinary retention

Risk factors, clinical impact and management

ACADEMISCH PROEFSCHRIFT

Ter verkrijging van de graad van doctor

aan de Universiteit van Amsterdam

op gezag van de Rector Magnificus

prof. dr. ir. K.I.J. Maex

ten overstaan van een door het College voor Promoties ingestelde commissie,

in het openbaar te verdedigen in de Aula der Universiteit

op vrijdag 22 december 2017, te 11.00 uur

door

Femke Elisabeth Maria Mulder

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Promotores:

Prof. dr. J.P.W.R. Roovers

AMC - UvA

Prof. dr. J.A.M. van der Post

AMC - UvA

Copromotor:

Dr. R.A. Hakvoort

Martini Ziekenhuis

Overige leden:

Prof. dr. M.Y. Bongers

Universiteit Maastricht

Prof. dr. S.E. Geerlings

AMC - UvA

Prof. dr. M.P. Laguna Pes

AMC - UvA

Prof. dr. E. Pajkrt

AMC - UvA

Dr. A. Vollebregt

Spaarne Gasthuis

Dr. M.I.J. Withagen

UMC Utrecht

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Voor mijn kinderen,

van jullie leer ik meer dan wetenschappelijk kan worden aangetoond

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CLINICAL PROBLEM OF POSTPARTUM URINARY RETENTION

Pregnancy as well as delivery are both associated with pelvic floor disorders later in life such as pelvic organ prolapse, faecal incontinence, overactive bladder syndrome and urinary incontinence.1-6_{The lifetime risk for women to develop one or more of these}

problems is high. Incidences of micturition related problems vary in literature but the cumulative risk lies between 26 and 69 %.7,8_{As these conditions can result in severe}

discomfort they often have a negative effect on the quality of life of affected patients.9-12

As it is widely accepted that that pregnancy and (vaginal) delivery are risk factors for the development of voiding dysfunctions later in life and many researchers focus on anatomical changes or adjustment during pregnancy or delivery.13-16_{In addition, with}

regard to prevention of (urinary) incontinence, the influence of delivery positions, elective caesarean sections and prenatal pelvic floor exercises are popular topics.17-22_However,

little is known about the relationship between voiding dysfunction and postpartum urinary retention (PUR). It is feasible that the onset of voiding problems is related to the period immediately after delivery when inadequate voiding is a frequently encountered condition.

Therefore it is important to gain insight in PUR and its potential influence on micturition related complaints later in life but to evaluate the best treatment strategy after delivery. In order to gain insight in these clinical problems, for this thesis, we studied women after vaginal delivery with symptomatic (overt) and asymptomatic (covert) postpartum urinary retention.

DEFINITIONS, ETIOLOGY AND CLINICAL FACTORS

Definition and incidence

Postpartum urinary retention (PUR) is a common finding after delivery.23-26_{In literature,}

frequently a distinction is made between two types of PUR. The first is the type in which women are completely unable to void spontaneously after delivery and therefore require catheterisation. This is called overt or symptomatic PUR. The other entity is called covert or asymptomatic PUR. Here, women are able to void spontaneously but with a high post void residual volume (PVRV). While screening for abnormal PVRV is not standard postpartum

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General Introduction

incidence.24,29,32_{In literature intervals between childbirth and PVRV measurement vary}

from 6 up to 12 hours after delivery.23,36_{Yip et al. were the first to define covert PUR as}

“patients who had no urinary symptoms but with a PVRV of ≥ 150 ml on postpartum day 1”.23_{In later studies, intervals between delivery and measurements have still varied}

extensively, from measurement directly after the first void up to PVRV measurements after 72 hours. These variations in time and volume not only result in a large variation in observed prevalences but also hamper a correct comparison of data. Therefore current literature needs consistency in used definitions for covert as well as overt PUR.

Physiological adaptions of the bladder in pregnancy

During pregnancy, many physiological changes occur in order to adapt to the requirements of pregnancy and delivery itself. Multiple organ systems are part of this process, for example the cardiovascular, metabolic, renal, respiratory and urogenital system. Regarding bladder physiology, it has been shown that bladder capacity increases during pregnancy.37_{Considering the close proximity of the bladder to the exponentially growing}

gravid uterus this could be seen as an adaption to prevent loss of bladder wall compliance and urgency. Iosif et al. performed urodynamic tests in pregnant and postpartum women, which showed alterations in urethral length and urethral closure pressures during pregnancy. This increase in the length of the urethra as well as the increase in the maximum urethral pressure and urethral closure pressure are responsible for (relative) protection against urinary incontinence in pregnancy.38

These adaptations are likely to be affected by changes in hormonal status. Progesterone levels are well-known to increase during pregnancy which is not only important in retaining pregnancy but also known to influence bladder function by reduction in contraction pressure and increase of bladder capacity.39,40_{Relaxin is a less known hormone}

of the insulin-like growth factor family. It is produced by the corpus luteum, decidua and placenta and plays a role in collagen remodelling and regulation of haemodynamic and water metabolism during pregnancy.41_{In the 48 hours before labour, relaxin causes rapid}

depolymerisation of collagen bonds to the point where the collagen loses 95% of its strength, allowing the stretching of the vagina and its supporting structures to expand sufficiently for vaginal delivery but also likely to change bladder compliance.40,42

Pathophysiology and clinical risk factors

Various authors have described causal factors for postpartum urinary retention. Identification of these factors can be used to generate hypotheses on pathophysiology of PUR and to re-evaluate (the necessity of) treatment regimes. Bladder function is regulated by the autonomic nervous system and is an illustration of the fine and complex interaction between the central motor system and the sympathetic and parasympathetic divisions of the visceral system. As the first creates the ability to voluntary control urination, the second operates (largely) involuntarily. Animal studies have shown that during pregnancy, adrenergic nerve fibres showed

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signs of degeneration.43_{Damage to the pelvic nerves and/or muscles during}

delivery could be related to bladder related problems. Vaginal delivery can also result in innervation injury, while the pudendal nerve, arising from the S2-S4 nerve and supporting continence, can be compressed and stretched during childbirth. Also anxiety and pain can play a role in incomplete voiding or the inability to void after delivery. Anxiety is likely to obstruct bladder outflow through an alfa adrenergic stimulation of the bladder outlet and by unaware pelvic floor contractions, as shown in patients after surgery.44_{Pain can result in central inhibition, causing disturbed relaxation of the pelvic floor.}45

Apart from the abovementioned causality there are more studies that have dealt with obstetric risk factors. Several studies have found that nulliparity, epidural analgesia, higher birth weight, instrumental delivery and episiotomy are risk factors for incomplete voiding after delivery.26,34,46,47

It has been well established that vaginal delivery can directly traumatize pelvic floor muscles and innervation. It is possible that this leads to decreased bladder sensibility and contractility.48,49_{Moreover, the trauma can cause peri-urethral and vulvar oedema,}

which may also result in PUR by local obstruction. It is rational to assume that the change in anatomy caused by delivery that occurs in primiparous women is more sudden and greater than the change that occurs in the already more adapted pelvic floor of multiparous women.24,47_{From this point of view, it is also likely that the birth of neonates}

with a higher birth weight can cause more trauma.49_{This can subsequently result in a}

more painful delivery with eventually a central inhibitory effect on bladder sensitivity and contractility affecting bladder function.50-53_{A similar mechanism could be true for}

instrumental delivery and episiotomy. However, current literature fails to consistently show which clinical relevant factors are directly and indirectly associated with covert and overt PUR. When these risk factors would be available, clinicians could decide which patients should be observed more closely in order to detect and possibly treat voiding dysfunctions.

CLINICAL IMPACT OF INCOMPLETE BLADDER EMPTYING

POST-PARTUM

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urinary retention and its recovery to normal in the short term.25,62-72_{Data on long term}

micturition related problems in patients after both overt and covert PUR are however limited. These data are necessary to discriminate between physiology and pathology. The current hypothesis on covert PUR is that residual volumes vary greatly and that the observation of a “high” PVRV might be just an observation of a physiological phenomenon with a normal distribution. This idea is based on the finding that 96–100% of the included patients with covert PUR are able to void adequately within 2 to 5 days after delivery.24,27,36,46_{However, in most of these studies, catheterisation was applied}

to achieve this normalization. Catheterisation is in itself non-physiological and the aid of catheterisation hampers interpretation about the real physiology of the problem. In order to learn whether incomplete voiding after (vaginal) delivery is in fact physiological, studies should focus on the real natural course of covert PUR, without any interventions, and evaluate if women with covert PUR have more late term voiding dysfunctions than women who void adequately. The absence of this knowledge is a serious clinical problem and should be topic of future research.

OPTIMISING POSTPARTUM BLADDER CARE

Diagnostics

The standard method to diagnose incomplete bladder emptying is transurethral catheterisation. This can be done by clean intermittent catheterisation (CIC) or by inserting a transurethral indwelling catheter (TIC) or suprapubic catheter. However, in many cases non-invasive measurements are preferred to diagnose abnormal post void residual volumes (PVRV). Several studies have shown that (real time) ultrasonography is a reliable alternative for transurethral catheterisation.73_{Through innovative and advancing}

technologies, automatic scanning devices are nowadays often part of standard hospital care, for example after urogynaecologic or orthopaedic surgery.74-77 _{In postpartum care,}

the rationale for use of automatic scanning devices is still not established. Clinicians are careful with relying on scanning machines post-delivery as these could also measure fluid (blood) in the uterus, resulting in possible overestimation of PVRV and therefore leading to unnecessary catheterisations. Studies have shown automatic scanning devices after delivery are in fact reliable. However all these studies have been performed in patients who are at risk of PUR (for example after instrumental delivery) or in patients with already a TIC in situ.29,78-81_{No studies have been done in unselected group of patients with}

possible lower residual volumes. Since in literature evidence is lacking on the comparison of non-invasive techniques with direct catheterisation to determine abnormal urinary retention postpartum, future research should focus on prospectively comparing these two techniques in an unselected patient population.

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Management

Although evidence for the requirement of treatment in patients with overt PUR is unavailable, it is reasonable and widely accepted to catheterize patients who are fully unable to void spontaneously after delivery.82_{In clinical practice the period and technique}

of catheterisation for overt PUR differ greatly between institutions, regions and even countries. Transurethral indwelling catheterisation (TIC) is often performed, mostly for a period of several hours up to 3-7 days. While several authors have shown that clean intermittent catheterisation (CIC) has benefits over TIC,83,84_{in many hospitals this is not}

routinely performed. The lack of evidence and, consequently, evidence based guidelines can be a contributor to these (local) differences.60,85_{Furthermore, information on patient}

preferences regarding types of catheterisation is missing. It is known that medical staff applies indwelling catheterisation to quick and too long in hospitalized patients.86,87

Indwelling catheterisation is often continued too long without really knowing whether the indication is still there. And finally, although CIC could have several advantages over TIC, often medical staff still has thoughts about the alleged burden patients might perceive when repeated introduction with CIC is necessary.88-90 _{One of the shortcomings in available}

literature is that standard treatment options for overt PUR have not been compared yet; this should be done in order to evaluate not only which method of catheterisation leads to the resumption of spontaneous adequate micturition but also which is best accepted by affected patients.

OBJECTIVES AND OUTLINE OF THE THESIS

Aims of the study

In current literature, several questions regarding identification of risk factors, adverse effects, natural course, diagnostics and treatment of postpartum urinary retention are still unanswered. These issues are important in order to guide involved caregivers on voiding dysfunction after delivery in daily clinical practice.

Therefore we have identified the following objectives for this thesis. The first aim of this

thesis is to identify obstetrical risk factors related to postpartum urinary retention. The

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observational study on risk factors, of which the results will be presented in chapter 3.

In the second part of this thesis we will discuss the clinical impact of incomplete bladder emptying after delivery. To identify adverse effects of PUR and to evaluate the different treatment options, a second systematic review of literature will be conducted, which will be presented in chapter 4. Additionally, a prospective case control study will be

performed in which a comparison is made between women with adequate voiding (PVRV < 150 mL) and women with inadequate voiding (PVRV ≥ 150 mL) regarding short-term and long-term micturition symptoms. These results, presented in chapter 5, will increase

our insights whether covert PUR is a physiologic condition or a pathologic complication. The final part of this thesis will concern postpartum bladder management. In order to evaluate which we will compare the use of an automatic bladder scanning device with the gold standard to detect PVRV after vaginal delivery, i.e. catheterisation. These data will be shown in chapter 6. Finally, a randomized controlled multicenter trial will

be performed in order to evaluate two standard treatment methods for overt PUR, i.e. transurethral indwelling (TIC) versus clean intermittent catheterisation (CIC). The results of this RCT, reported in chapter 7, will show us which treatment method results in the fastest

resumption of spontaneous voiding with an accompanying acceptance by the affected patients. At last, the content of this thesis and implications for daily clinical practice and recommendations for future research are discussed in chapter 8.

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89. Evron S, Dimitrochenko V, Khazin V, et al. The effect of intermittent versus continuous bladder catheterization on labor duration and postpartum urinary retention and infection: a randomized trial. J Clin Anesth. 2008;20(8):567-572.

90. Wilson BL, Passante T, Rauschenbach D, Yang R, Wong B. Bladder Management With Epidural Anesthesia During Labor: A Randomized Controlled Trial. MCN Am J Matern Child Nurs. 2015;40(4):234-242; quiz E217-238.

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I

PART

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RISK FACTORS FOR

POSTPARTUM URINARY

RETENTION

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British Journal of Obstetrics and Gynaecology 2012;119:1440-1446.

F.E.M. Mulder

M.A. Schoffelmeer

R.A. Hakvoort

J. Limpens

B.W.J. Mol

J.A.M. van der Post

J.P.W.R. Roovers

Risk factors for postpartum urinary

retention: a systematic review and

meta-analysis

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ABSTRACT

Background:

Postpartum urinary retention (PUR) is a common condition with varying prevalences. Measurement of the post void residual volume (PVRV) is not regularly performed. Various studies have been published on overt (the inability to void after giving birth, requiring catheterization) and covert (an increased PVRV after spontaneous micturition) PUR. To evaluate which clinical prognostic factors are related to PUR, identification of independent risk factors for covert and overt PUR are needed.

Objectives:

We performed a systematic review and meta-analysis of observational studies reporting on risk factors for PUR.

Search Strategy:

Systematic search of MEDLINE and EMBASE to September 2011.

Selection criteria:

Articles that reported on women diagnosed with PUR or with an abnormal PVRV.

Data collection and Analysis:

Included articles were selected by two authors. We constructed two-by-two tables for potential risk factors of overt and covert PUR and calculated pooled odds ratios with 95% confidence intervals.

Main Results:

Twenty-three observational studies with original data were eligible for data extraction of which 13 could be used for meta-analysis. Statistically significant risk factors for overt PUR were epidural analgesia (OR 7.7), instrumental delivery (OR 4.5), episiotomy (OR 4.8) and primiparous (OR 2.4). For covert PUR, variety in used definitions resulted in heterogeneity; no significant prognostic factors were found.

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27

Systematic review and meta-analysis of risk factors for postpartum urinary retention

INTRODUCTION

Postpartum urinary retention (PUR) is a common puerperal condition and is defined as the inability to (completely) void after giving birth. Yip et al were the first to make a distinction between overt (symptomatic) and covert (asymptomatic) PUR.1_{They classified}

overt PUR as “the inability to void spontaneously within six hours after vaginal delivery or six hours after removal of an indwelling bladder catheter after caesarean section, requiring catheterization”. Covert PUR was classified as “a post void residual bladder volume (PVRV) of ≥ 150 ml after spontaneous micturition, verified by ultrasound or catheterization”. Numerous authors have adopted these definitions.2-5

After pelvic organ prolapse surgery, urinary retention is a common complication for which patients are routinely screened, as missing this diagnosis may result in severe morbidity such as renal failure. A recent study showed that intermittent catheterization is a better alternative than indwelling catheterization in order to reduce the incidence of bacteriuria and urinary tract infections in women with inadequate bladder emptying after vaginal prolapse surgery.6

Despite our knowledge of urinary retention after surgery, little is known about postpartum pathophysiology and management for postpartum urinary retention. Although in case of overt PUR, management is obviously essential (i.e. catheterization), for covert PUR this necessity is not clear. While reported prevalences for covert postpartum urinary retention vary widely (1.5% - 45%),7,8_{consequences of this condition are still debated.}1,7

As screening for post void residual volumes after delivery is seldom part of standard postpartum care, management of covert PUR only ‘exists’ in study designs. In order to evaluate the clinical need for treatment of covert PUR, clinical factors related to PUR have to be identified. Prognostic factors that are associated with postpartum urinary retention are duration of labour, instrumental assisted delivery, episiotomies, birth weight, parity and epidural anaesthesia.4,5,8-13_{While these potential risk factors seem highly related, it}

is necessary to evaluate independent prognostic factors and thus whether patients with multiple clinical risk factors have an increased risk to get PUR.

The aim of this review was to identify and quantify clinical factors that can predict the occurrence of postpartum urinary retention and to quantify their influence as independent risk factor.

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MATERIAL AND METHODS

We performed a systematic search of the electronic databases MEDLINE (OVID) from 1948 and EMBASE (OVID) from 1980 to September 2011 to identify publications about postpartum urinary retention. No language restrictions were applied. We excluded animal studies by using double negation (i.e. in MEDLINE: not animals/ not humans/). The search strategy consisted of free-text words (tw) and Subject Headings (MeSH, SH: command /) related to (1) urinary retention (bladder retention, bladder- and voiding functions or dysfunctions) and (2) delivery, the postpartum period, and obstetric procedures that enhance the chance of urinary retention (i.e. episiotomy, caesarean, anaesthesia). Synonyms for 1 and 2 were combined with the boolean operator “or”, whereas search sets 1 and 2 were combined with the boolean operator “and” (Appendix for the MEDLINE search strategy).14

The search included an iterative process to refine the search strategy through adding search terms as new relevant citations were identified. The bibliographic records retrieved were downloaded and imported into Reference Manager® software (version 12.0) to deduplicate, store and analyse the search results.

Inclusion criteria were studies that reported women diagnosed with postpartum urinary retention or women with an abnormal post void residual volume. Patients with pre-existing kidney disease or urinary tract problems were excluded. Only papers presenting original work regarding urinary retention postpartum were included. Also papers with urinary retention as a secondary outcome were used for analysis. Only peer-reviewed articles were included.

Two authors (FM and MS) independently assessed eligibility of studies and extracted available data. To assess the quality of all included studies, the STROBE guidelines were used.15_{Any disagreements between the two reviewers were resolved through discussion.}

For the included studies, a two-by-two table was created to classify potential risk factors for PUR. When we were not able to construct a two-by-two table due to missing data, we contacted the authors of the original paper for additional data. We calculated Odds Ratios

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29 RESULTS

The OVID Medline search (1948 – Sept 2011) retrieved 306 records of which 289 were unique, whereas the EMBASE search (1980 – Sept 2011) retrieved 605 records. In total 696 unique records were obtained from MEDLINE and EMBASE (Figure 1).14_{For data}

extraction a total of 23 original papers met the inclusion criteria were selected in this systematic review for analysis.

Studies, in which a two by two table could not be constructed, were excluded. Missing data were verified by contacting the authors of the original articles. In total, eight authors were contacted. Four authors send additional data, this allowing construction of a two by two table. Three authors responded that their data were no longer available and one author did not respond despite several reminders. Only studies with complete datasets per risk factor were included in the analysis.

A distinction was made between overt and covert PUR. The data of 13 studies could finally be used for a meta-analysis.2-5,7,8,10-13,17-19_{Of these studies, 9 were prospective}

studies 2,3,5,7,8,11-13,19Figure 1: Literature identification and study selection _{and 4 were retrospective studies (Figure 1).}4,10,17,18

MEDLINE (n = 289) Sc reen in g Inc lude d El igib ilit y Id en tif icat ion EMBASE (n = 605)

Records after duplicates removed (n = 696)

Records screened (n =198 )

Records excluded (n =110 )

Full-text articles assessed for eligibility

(n = 88 )

Full-text articles excluded (n=66) - No original data (n = 66) Studies included in qualitative synthesis (n = 23 ) Studies included in quantitative synthesis (meta-analysis) (n = 13 )

Papers excluded from final analysis (n = 10) - Insufficient data to construct 2x2 table (n=10)

Figure 1: Literature identification and study selection

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Parity was reported on in five studies for overt PUR 3,4,10,17,18_{and in three studies for covert}

PUR.5,8,11_{Instrumental delivery was reported on in five studies for overt PUR}2-4,17,18_{and five}

studies for covert PUR,5,7,8,12,13_{epidural analgesia in seven studies for overt PUR}2-4,10,17-19_and

two studies for covert PUR. 8,12_{Episiotomy and/or vaginal tears were reported in five studies}

for overt PUR2-4,17,18_{and three for covert PUR.}5,7,13

The definitions for covert PUR varied largely between studies. Time of PVRV measurement varied between 6 to 72 hours after delivery. Post void residual volumes varied between 100 – 200 mL. An overview of the definitions used for covert PUR is shown in Table 1.

Instrumental delivery was associated with a statistically significant higher incidence of overt PUR than non-instrumental delivery, with a pooled Odds Ratio of 4.5 (95% CI 3.3 – 6.1) (Figure 2a). In all studies the incidence of overt PUR was higher for women with epidural analgesia (OR 7.7, 95% CI 4.1 – 14.5), women with an episiotomy (OR 4.8, 95% CI 2.0 – 12.0) and primiparous women (OR 2.4, 95% CI 1.5 – 4.0) (Figure 2b, 2c, 2d). Although heterogeneity was substantial between studies for parity, epidural analgesia and episiotomy (69% - 88%), results were statistically significant. When removing the studies with non-significant 95% confidence intervals from the meta-analysis,4,10,17_{we found a considerable lower heterogeneity for parity}

(I2_{= 0%, pooled OR 3.5), epidural analgesia (I}2_{= 19%, pooled OR 11.9) and episiotomy (I}2₌

33%, pooled OR 9.0).

For covert PUR, the heterogeneity between studies was substantial (Figure 3). For instrumental delivery versus non-instrumental deliveries, the pooled OR for covert PUR was 1.1 (95% CI 0.5 – 2.6). Two studies studying the effect of epidural analgesia showed an OR of 1.2 and 4.7 respectively, in favour of no epidural analgesia (pooled OR 2.3, 95% CI 0.7 – 7.7). The association between episiotomy and covert PUR was mixed (pooled OR 1.5, 95% CI 0.8 – 2.2), as well as the comparison between parity and covert PUR (OR 1.3, 95% CI 0.8 – 2.2).

Due to the absence of studies with multivariate analyses, we were unable to explore which clinical factors have been identified as independent risk factors. Consequently we could not quantify the effect of the various risk factors and evaluate whether multiple prognostic factors in one patient result in an increased risk to be diagnosed with postpartum urinary retention.

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31

Study or Subgroup Carley Ching-Chung Fedorkow Musselwhite Teo Total (95% CI) Total events

Heterogeneity: Tau² = 0.22; Chi² = 13.36, df = 4 (P = 0.010); I² = 70% Test for overall effect: Z = 3.44 (P = 0.0006)

Events 34 89 55 6 18 202 Total 238 1338 14913 74 64 16627 Events 17 25 21 88 12 163 Total 323 1548 7263 2010 86 11230 Weight 20.7% 23.9% 22.8% 15.9% 16.6% 100.0% M-H, Random, 95% CI 3.00 [1.63, 5.51] 4.34 [2.77, 6.81] 1.28 [0.77, 2.11] 1.93 [0.81, 4.56] 2.41 [1.07, 5.47] 2.42 [1.46, 4.02]

Primiparous Multiparous Odds Ratio Odds Ratio M-H, Random, 95% CI 0.01 0.1 1 10 100 Study or Subgroup Carley Ching-Chung Glavind Musselwhite Teo Total (95% CI) Total events

Heterogeneity: Tau² = 0.90; Chi² = 30.46, df = 4 (P < 0.00001); I² = 87% Test for overall effect: Z = 3.41 (P = 0.0007)

Episiotomy/vaginal tear Intact perineum Odds Ratio Odds Ratio M-H, Random, 95% CI 0.01 0.1 1 10 100 Study or Subgroup Carley Ching-Chung Fedorkow Glavind Musselwhite Olofsson Teo Total (95% CI) Total events

Heterogeneity: Tau² = 0.47; Chi² = 19.59, df = 6 (P = 0.003); I² = 69% Test for overall effect: Z = 6.26 (P < 0.00001)

Events 50 34 70 4 6 27 22 213 Total 401 122 16702 185 59 1000 48 18517 Events 1 80 6 8 88 3 8 194 Total 160 2764 5474 1464 2025 2364 112 14363 Weight 7.1% 20.3% 16.3% 12.5% 15.9% 12.6% 15.4% 100.0% M-H, Random, 95% CI 22.65 [3.10, 165.41] 12.96 [8.23, 20.41] 3.84 [1.67, 8.83] 4.02 [1.20, 13.49] 2.49 [1.04, 5.95] 21.84 [6.61, 72.15] 11.00 [4.40, 27.50] 7.66 [4.05, 14.47]

Epidural No epidural Odds Ratio Odds Ratio M-H, Random, 95% CI 0.01 0.1 1 10 100 Study or Subgroup Carley Ching-Chung Glavind Musselwhite Teo Total (95% CI) Total events

Heterogeneity: Chi² = 3.69, df = 4 (P = 0.45); I² = 0% Test for overall effect: Z = 9.67 (P < 0.00001)

Events 24 19 4 9 16 72 Total 87 170 136 74 35 502 Events 27 95 8 85 14 229 Total 474 2716 1513 2010 115 6828 Weight 23.2% 38.0% 4.9% 20.3% 13.6% 100.0% M-H, Fixed, 95% CI 6.31 [3.43, 11.61] 3.47 [2.07, 5.83] 5.70 [1.69, 19.18] 3.14 [1.51, 6.51] 6.08 [2.55, 14.48] 4.52 [3.33, 6.14]

Instrumental delivery Non-instrumental delivery Odds Ratio Odds Ratio M-H, Fixed, 95% CI

0.01 0.1 1 10 100

Figure 2: Risk factors for overt Postpartum Urinary Retention

Figure 2a Instrumental delivery vs non-instrumental delivery for overt PUR

Figure 2b Epidural analgesia vs no epidural analgesia for overt PUR

Figure 2c Episiotomy and/or vaginal tear vs no episiotomy and/or vaginal tear for overt PUR

Figure 2d Primiparous vs multiparous for overt PUR

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Study or Subgroup Andolf Kekre Liang Events 7 48 71 Total 223 407 281 Events 1 36 75 Total 316 364 324 Weight 5.2% 44.2% 50.5% M-H, Random, 95% CI 10.21 [1.25, 83.57] 1.22 [0.77, 1.92] 1.12 [0.77, 1.63]

Primiparous Multiparous Odds Ratio Odds Ratio M-H, Random, 95% CI Study or Subgroup Demaria Hee Kekre Total (95% CI) Total events

Events 30 11 61 102 Total 97 34 494 625 Events 25 12 23 60 Total 57 17 277 351 Weight 35.7% 26.0% 38.3% 100.0% M-H, Random, 95% CI 0.57 [0.29, 1.13] 0.20 [0.06, 0.71] 1.56 [0.94, 2.58] 0.64 [0.22, 1.82]

Episiotomy/vaginal tear Intact perineum Odds Ratio Odds Ratio M-H, Random, 95% CI 0.01 0.1 1 10 100 Study or Subgroup Andolf Ismail Total (95% CI) Total events

Events 4 10 14 Total 95 23 118 Events 4 27 31 Total 444 77 521 Weight 40.7% 59.3% 100.0% M-H, Random, 95% CI 4.84 [1.19, 19.69] 1.42 [0.55, 3.68] 2.34 [0.72, 7.65]

Epidural No epidural Odds Ratio Odds Ratio M-H, Random, 95% CI 0.01 0.1 1 10 100 Study or Subgroup Andolf Demaria Hee Ismail Kekre Total (95% CI) Total events

Odds Ratio Odds Ratio M-H, Random, 95% CI

0.01 0.1 1 10 100

Figure 3c Episiotomy and/or vaginal tear vs no episiotomy and/or vaginal tear for covert PUR Figure 3b Epidural analgesia vs no epidural analgesia for covert PUR

Figure 3a Instrumental delivery vs non-instrumental delivery for covert PUR

Study or Subgroup Carley Ching-Chung Glavind Musselwhite Teo Total (95% CI) Total events

Instrumental delivery Non-instrumental delivery Odds Ratio Odds Ratio M-H, Fixed, 95% CI 0.01 0.1 1 10 100 Study or Subgroup Carley Ching-Chung Glavind Musselwhite Teo Total (95% CI) Total events

Instrumental delivery Non-instrumental delivery Odds Ratio Odds Ratio M-H, Fixed, 95% CI

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33 DISCUSSION

Our review identified 23 published studies and identified a variety of clinical risk factors which can lead to postpartum urinary retention.8,20,21_{By systematically collecting available}

data and translating the results into odds ratios, we have created a supplement on available literature and daily clinical practice.

Regarding overt postpartum urinary retention, instrumental delivery was the only clinical factor with an excellent homogeneity. The other identified risk factors, parity, epidural analgesia and episiotomy, were obtained from studies that were highly heterogeneous in definition and cut-off values (I² = 69 - 87 %). This high heterogeneity was associated with the retrospective character of the studies,4,10,17_{because only the retrospective}

studies showed statistically non-significant odds ratios (Figure 2). Although removing the retrospective studies from the meta-analyses resulted in increased homogeneity (I²=0-33%), it did not alter the pooled odds ratios. Because in the current meta-analyses all point estimates show a positive correlation, we feel that including the retrospective studies is legitimate.

Concerning covert postpartum urinary retention, the included clinical prognostic factors were obtained from heterogeneous studies (Table 1). Although it were all prospective studies, point estimates for instrumental delivery and episiotomy appear on both sides off the no effect line (Figure 3a, 3c). Also epidural analgesia and primiparity had no statistical significant effect on covert PUR (Figure 3b, 3d). The diversity of our data makes it difficult to translate our results into guidelines for daily clinical practice. We still decided to present our data with pooled odds ratios because our meta-analyses illustrate this variety between studies and with that the need for uniformity in definitions for covert PUR.

The relationship between the different identified risk factors for covert and overt PUR is still indistinct. The question is whether instrumental delivery is a true risk factor or that this factor is confounded by other factors like prolonged labour, epidural analgesia, parity and episiotomy. Also the reasons to terminate labour could be a confounder. Future studies assessing all factors related to instrumental delivery are needed to answer the question whether instrumental delivery is a true risk factor or not.

Multivariate analysis would be a valuable addition to distinguish between confounders and independent prognostic factors. In 1996, Yip et al. conducted a study to assess the influence of obstetric factors on postpartum urinary retention. They performed a multivariate analysis and found that only duration of labour had a statistical significant influence on the prevalence of PUR.1_{Later they stated that a duration of labour longer}

than 700 minutes was predictive for PUR.22_{Because in other studies data on duration of}

labour were lacking, we have not been able to create a model for independent prognostic clinical factors for PUR and the results of Yip et al. stay unaltered.

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A way to identify independent risk factors and create a model for postpartum urinary retention would be to perform individual patient data meta-analysis (IPD). By analysing the original databases from each researcher and combining their data, one could create a reliable prognostic model. However, one would probably encounter the same problems for covert PUR as we did in our meta-analyses, because different authors have adopted different cut-off values, measurement methods and time points, next to a variety in registered patient information. Consequently, a uniform definition of PUR when conducting future studies is mandatory. These data enable creating a risk profile to identify women with increased risk on postpartum urinary retention and opens the possibility on intervention trials for covert PUR.

Our study has some weaknesses that have to be acknowledged. First, we were not able to complete our collected data, although we contacted authors and even co-authors in case data were missing. However, of 67% of the included studies, the data set was complete, and of the remaining studies we still realized to collect the majority of data. Therefore we feel that missing data did not skew our results too much. In addition to our analysed risk factors, birth weight was also mentioned in two studies to be of significant influence on the prevalence of PUR.7,23_{As the authors were not able to provide original data on birth}

weight, we could not perform a meta-analysis for this factor.

Second, in our meta-analysis we decided to analyse all available data for covert PUR. Despite the high heterogeneity of the data (mainly caused by PVRV being measured at different time points after delivery) we feel that pooling available data provides valuable information about the different clinical prognostic factors for covert PUR. Therefore we used a random effect model to calculate pooled odds ratios. The paucity of current knowledge on this topic increases the clinical value of our review.

Finally, due to the inability to perform multivariate analysis, we have not been able to identify independent risk factors and quantify their individual influence. Therefore we cannot define a specific group of patients who are at risk for postpartum urinary retention and should, for example, be routinely screened after giving birth.

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35 REFERENCES

1. Yip SK, Brieger G, Hin LY, Chung T. Urinary retention in the post-partum period. The

relationship between obstetric factors and the post-partum post-void residual bladder volume.

Acta Obstet Gynecol Scand. 1997;76(7):667-672

2. Glavind K, Bjork J. Incidence and treatment of urinary retention postpartum. Int Urogynecol J. 2003;14(2):119-121.

3. Ching-Chung L, Shuenn-Dhy C, Ling-Hong T, Ching-Chang H, Chao-Lun C, Po-Jen C. Postpartum urinary retention: assessment of contributing factors and long-term clinical impact.

Aust N Z J Obstet Gynaecol. 2002;42(4):365-368.

4. Carley ME, Carley JM, Vasdev G, et al. Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. Am J Obstet Gynecol. 2002;187(2):430-433.

5. Kekre AN, Vijayanand S, Dasgupta R, Kekre N. Postpartum urinary retention after vaginal delivery. Int J Gynaecol Obstet. 2011;112(2):112-115.

6. Hakvoort R, Thijs S, Bouwmeester F, et al. Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for incomplete voiding after vaginal prolapse surgery: a multicentre randomised trial. BJOG. 2011(118):1055-1060.

7. Hee P, Lose G, Beier-Holgersen R, Engdahl E, Falkenlove P. Postpartum voiding in the primiparous after vaginal delivery. Int Urogynecol J. 1992;3(2):95-99.

8. Andolf E, Iosif CS, Jorgensen C, Rydhstrom H. Insidious urinary retention after vaginal delivery: prevalence and symptoms at follow-up in a population-based study. Gynecol Obstet Invest. 1994;38(1):51-53.

9. Yip SK, Hin LY, Chung TK. Effect of the duration of labor on postpartum postvoid residual bladder volume. Gynecol Obstet Invest. 1998;45(3):177-180.

10. Fedorkow DM, Drutz HP, Mainprize TC. Characteristics of patients with postpartum urinary retention. Int Urogynecol J. 1990;1:136-138.

11. Liang CC, Wong SY, Tsay PT, et al. The effect of epidural analgesia on postpartum urinary retention in women who deliver vaginally. Int J Obstet Anesth. 2002;11(3):164-169.

12. Ismail SI, Emery SJ. The prevalence of silent postpartum retention of urine in a heterogeneous cohort. J Obstet Gynaecol. 2008;28(5):504-507.

13. Demaria F, Amar N, Biau D, et al. Prospective 3D ultrasonographic evaluation of immediate postpartum urine retention volume in 100 women who delivered vaginally. Int Urogynecol J. 2004;15(4):281-285.

14. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-34.

15. Von EE, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-349.

16. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539-1558.

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17. Musselwhite KL, Faris P, Moore K, Berci D, King KM. Use of epidural anesthesia and the risk of acute postpartum urinary retention. Am J Obstet Gynecol. 2007;196(5):472-475.

18. Teo R, Punter J, Abrams K, Mayne C, Tincello D. Clinically overt postpartum urinary retention after vaginal delivery: a retrospective case-control study. Int Urogynecol J. 2007;18(5):521-524. 19. Olofsson CI, Ekblom AO, Ekman-Ordeberg GE, Irestedt LE. Post-partum urinary retention: a

comparison between two methods of epidural analgesia. Eur J Obstet Gynecol Reprod Biol. 1997;71(1):31-34.

20. Yip SK, Sahota D, Chang AM, Chung TK. Four-year follow-up of women who were diagnosed to have postpartum urinary retention. Am J Obstet Gynecol. 2002;187(3):648-652.

21. Watson WJ. Prolonged postpartum urinary retention. Mil Med. 1991;156(9):502-503. 22. Yip SK, Sahota D, Pang MW, Chang A. Screening test model using duration of labor for the

detection of postpartum urinary retention. Neurourol Urodyn. 2005;24(3):248-253. 23. Groutz A, Hadi E, Wolf Y, et al. Early postpartum voiding dysfunction: incidence and

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37

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International Urogynecology Journal (2016) 27:55-60.

F.E.M. Mulder

K. Oude Rengerink

J.A.M. van der Post

R.A. Hakvoort

J.P.W.R. Roovers

Delivery related risk factors for

covert postpartum urinary retention

after vaginal delivery

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ABSTRACT

Background:

Postpartum Urinary Retention (PUR) is a common consequence of bladder dysfunction after vaginal delivery. Patients with covert PUR are able to void spontaneously but have a post void residual bladder volume (PVRV) ≥ 150 mL. Incomplete bladder emptying may predispose to bladder dysfunction at later stage of life. This study aims to identify women with an increased risk of covert PUR.

Objectives:

A cross-sectional study was performed to identify independent delivery related risk factors for covert PUR after vaginal delivery.

Methods:

The PVRV of women who delivered vaginally was measured after the first spontaneous micturition with a portable bladderscanning device. A PVRV of 150 mL or more was defined as covert PUR. Through multivariate regression analysis, independent risk factors for covert PUR were identified.

Results:

Of 745 included women, 347 women (47%) were diagnosed with covert PUR (PVRV ≥ 150 mL), 197 women (26%) had a PVRV ≥ 250 mL (p75) and 50 women (7%) a PVRV ≥ 500 mL (p95). In multivariate regression analysis, episiotomy (OR 1.7, 95% CI 1.02 – 2.71), epidural analgesia (OR 2.08, 95% CI 1.36 – 3.19) and birth weight (OR 1.03, 95% CI 1.01 – 1.06) were independent risk factors for covert PUR. Opioid analgesia during labour (OR 3.19, 95% CI 1.46 - 6.98), epidural analgesia (OR 3.54, 95% CI 1.64 - 7.64) and episiotomy (OR 3.72, 95% CI 1.71 - 8.08) were risk factors for PVRV ≥ 500 mL.

Conclusions:

Episiotomy, epidural analgesia and birth weight are risk factors for covert PUR. We suggest that the current cut-off values for covert PUR should be re-evaluated when data on clinical consequences of abnormal PVRV become available.

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41

Risk factors for covert postpartum urinary retention

INTRODUCTION

In the puerperium, postpartum urinary retention (PUR) is a common finding which gives an increased risk for persistent urinary retention.1-6_{Reported prevalences for overt}

(symptomatic) PUR range from 0.3 to 4.7%, i.e. the inability to void spontaneous within 6 hours after vaginal delivery or removal of a catheter after a caesarean section.1,7_{For covert}

(asymptomatic) PUR, defined as a post void residual volume (PVRV) of at least 150 ml after spontaneous micturition, prevalences of even up to 45% are reported.2

Since Yip et al proposed a distinction between overt and covert PUR in 19971_{, many}

authors have adopted these definitions, which has led to a more consistent comparison between studies that deal with this common problem. The distinction between overt and covert PUR has clinical consequences. Whereas in women diagnosed with overt PUR bladder drainage is necessary , the necessity of bladder catheterization is debatable in covert PUR. Therefore overt PUR will always be recognized and covert PUR not. Numerous studies have reported spontaneous recovery after several days to normal PVRV in women with covert PUR.1,5,8,9_{A recent systematic review on adverse effects of postpartum urinary}

retention shows that literature is insufficient to state that covert PUR harmless.10_However

it is known that distension of the bladder, even in case of a single episode of over-distension, can lead to long-lasting voiding difficulties, recurrent urinary tract infections and, rarely, impaired renal function.11-13_{Sometimes long term catheterization may be}

indicated when retention persists or irreversible damage to the urogenital tract has occurred. Possibly, screening for covert PUR might be indicated to limit these risks.

This cross-sectional study was performed to identify risk factors for covert PUR.

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MATERIAL AND METHODS

Between September 2010 and January 2013, data on the PVRV of women after vaginal delivery were collected in an academic hospital in the Netherlands. In this hospital, on average 1600 women per year give birth, with a caesarean section rate of 25%, resulting in 1200 vaginal deliveries each year. Women with an indication for prolonged catheterization because of their general condition were excluded, as well as women with a twin pregnancy. For women suffering severe foeto-maternal pathology, eligibility was judged by the nurse who took care of the patient after the delivery.

Of participating women the quantity of the first micturition was measured. If micturition on a toilet was not possible, women were given the opportunity to void while showering.

Within a maximum of 15 minutes after the first void the PVRV was measured with a portable non-invasive abdominal ultrasound device (BVI 9400 BladderScan®, Verathon Medical Europe, IJsselstein, the Netherlands). Nurses were trained in the appropriate use of the bladderscanning device. The PVRV was documented in the electronic patient chart as well as in a paper file. Potential clinical risk factors were identified based on literature1,14,15_{and were subsequently collected from (electronic) patient charts. The}

majority of the included factors are obligatory items in the patient chart, facilitating reliable documentation.

Women diagnosed with covert PUR were measured repeatedly until the PVRV was normal.

Using SPSS (IBM Statistics, version 20), with univariate regression analyses, clinical risk factors for the development of covert PUR were analysed. Analysis was performed for a PVRV cut off value of ≥ 150 mL, being the most common value in literature. After identifying the 75th and 95th percentile, analyses were also performed for the PVRV values related to these percentiles. Predictors with a p-value < 0.20 were included in a multivariate regression model. Associations between potential predictors and the outcome were reported as odds ratio’s with 95% confidence intervals.

Postpartum urinary retention: Risk factors, clinical impact and management - Thesis

UvA-DARE (Digital Academic Repository)

Postpartum urinary retention

Risk factors, clinical impact and management

Mulder, F.E.M.

Publication date

2017

Document Version

Final published version

License

Other

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Citation for published version (APA):

Mulder, F. E. M. (2017). Postpartum urinary retention: Risk factors, clinical impact and

management.

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POSTPARTUM

URINARY

RETENTION

IMPACT AND MANAGEMENT

Postpartum urinary retention

Risk factors, clinical impact

and management

Cover design:

Maaike van Oudenaarden-Mulder

ISBN:

978-94-028-0853-7

Postpartum urinary retention

Risk factors, clinical impact and management

ACADEMISCH PROEFSCHRIFT

Ter verkrijging van de graad van doctor

aan de Universiteit van Amsterdam

op gezag van de Rector Magnificus

prof. dr. ir. K.I.J. Maex

ten overstaan van een door het College voor Promoties ingestelde commissie,

in het openbaar te verdedigen in de Aula der Universiteit

op vrijdag 22 december 2017, te 11.00 uur

door

Femke Elisabeth Maria Mulder

Promotores:

Prof. dr. J.P.W.R. Roovers

AMC - UvA

Prof. dr. J.A.M. van der Post

AMC - UvA

Copromotor:

Dr. R.A. Hakvoort

Martini Ziekenhuis

Overige leden:

Prof. dr. M.Y. Bongers

Universiteit Maastricht

Prof. dr. S.E. Geerlings

AMC - UvA

Prof. dr. M.P. Laguna Pes

AMC - UvA

Prof. dr. E. Pajkrt

AMC - UvA

Dr. A. Vollebregt

Spaarne Gasthuis

Dr. M.I.J. Withagen

UMC Utrecht

Voor mijn kinderen,

van jullie leer ik meer dan wetenschappelijk kan worden aangetoond

TABLE OF CONTENTS

CLINICAL PROBLEM OF POSTPARTUM URINARY RETENTION

DEFINITIONS, ETIOLOGY AND CLINICAL FACTORS

11

CLINICAL IMPACT OF INCOMPLETE BLADDER EMPTYING

POST-PARTUM

13

OPTIMISING POSTPARTUM BLADDER CARE

OBJECTIVES AND OUTLINE OF THE THESIS