EXPLANATION FOR QUESTION 24

 QUESTION 24

This patient has postpartum urinary retention, which is the inability to void 2:6 hours after vaginal delivery (or �6 hours after

catheter removal following cesarean delivery) Risk factors include primiparity, regional neuraxial anesthesia (eg, epidural

anesthesia), and pudenda! nerve injury from prolonged labor (perinea! stretching and swelling) The combination results in an inability

to sense the need to void, loss of the micturition reflex, bladder atony (eg, palpably overdistended bladder with suprapubic fullness

and tenderness), and urinary retention. Overflow incontinence (eg, involuntary dribbling of urine) can occur due to bladder pressure

rising above urethral pressure.

Urethral catheterization is required for both diagnosis and treatment, particularly in patients who are unable to void (Choice B) A

postvoid residual volume of �150 ml is consistent with urinary retention. Urethral catheterization decompresses the bladder,

preventing upper urinary tract damage from urine reflux or increased pressure Symptoms are self-limited, and most patients regain

bladder function after catheterization.

(Choice A) Antibiotics are administered if the patient has clinical features of a urinary tract infection (UTI), including suprapubic

tenderness (as in this patient). However, patients with a UTI also typically have fever and urinary frequency, but not urinary retention.

(Choice C) Oxybutynin, an anticholinergic, inhibits smooth muscle contractions, promoting bladder relaxation in the treatment of

overactive bladder (ie, urgency due to detrusor spasm). This therapy would worsen urinary retention in this patient

(Choice D) A pessary is used to manage stress incontinence and pelvic organ prolapse by stabilizing the pelvic floor. Although this

patient may have some pelvic floor laxity from her recent delivery, her incontinence is due to overflow from pudenda! nerve injury and

bladder atony, not urethral hypermobility.

(Choice E) Suprapubic catheter placement is a more invasive procedure and is therefore typically performed only when urethral

catheterization is contraindicated (eg, urethral injury or stricture). This patient had recent urethral catheterization (suggesting no

stricture) and has no perinea! or vaginal lacerations (suggesting no urethral injury).

Educational objective:

Patients with postpartum urinary retention, the inability to void �6 hours after vaginal delivery, may have dribbling of urine from

overflow incontinence. Urethral catheterization is indicated for diagnosis and treatment.