uva-dare (digital academic repository) postpartum urinary ... · postpartum urinary retention (pur)...

UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)

UvA-DARE (Digital Academic Repository)

Postpartum urinary retentionRisk factors, clinical impact and managementMulder, F.E.M.

Link to publication

Citation for published version (APA):Mulder, F. E. M. (2017). Postpartum urinary retention: Risk factors, clinical impact and management.

General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s),other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).

Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, statingyour reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Askthe Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam,The Netherlands. You will be contacted as soon as possible.

Download date: 13 Jan 2020

https://dare.uva.nl/personal/pure/en/publications/postpartum-urinary-retention(3c84db95-51b2-4e32-838c-d006382290e3).html

POSTPARTUMURINARYRETENTIONIMPACT AND MANAGEMENTRISK FACTORS, CLINICAL

FEMKE E.M. MULDER

Postpartum urinary retentionRisk factors, clinical impact

and management

Femke Elisabeth Maria Mulder

Layout design: Jornt van Dijk, PersoonlijkProefschrift.nl

Cover design: Maaike van Oudenaarden-Mulder ISBN: 978-94-028-0853-7 Printed by: Ipskamp Printers, www.proefschriften.net

© 2017 F.E.M. Mulder

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, without the prior permission of the author. Printing of this thesis was financially supported by: Academisch Medisch Centrum, Spaarne Gasthuis, Chipsoft BV, Wellspect, Coloplast BV, Urogyn BV and IQ Medical Ventures BV.

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

geboren te Leiderdorp

PROMOTIECOMMISSIE

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

Faculteit der Geneeskunde

Voor mijn kinderen,

van jullie leer ik meer dan wetenschappelijk kan worden aangetoond

TABLE OF CONTENTS

Chapter 1 General introduction and outline of the thesis 8

PART I RISK FACTORS FOR POSTPARTUM URINARY RETENTION 22

Chapter 2 Risk factors for postpartum urinary retention: a systematic review and meta-analysis.British Journal of Obstetrics and Gynaecology 2012

24

Chapter 3 Delivery related risk factors for covert postpartum urinary retention after vaginal delivery. International Urogynecology Journal 2016

38

PART II ADVERSE EFFECTS OF INADEQUATE VOIDING AFTER DELIVERY 50

Chapter 4 Postpartum urinary retention: a systematic review of adverse effects and management. International Urogynecology Journal 2014

52

Chapter 5 Long term lower urinary tract symptoms of asymptomatic postpartum urinary retention: a prospective case control study. International Urogynecology Journal 2017

70

PART III POSTPARTUM BLADDER MANAGEMENT 86

Chapter 6 Reliability of measurement of the post void residual volume with a portable BladderScan® in the postpartum period. Submitted

88

Chapter 7 Intermittent versus indwelling catheterization in women with overt postpartum urinary retention: a randomized clinical trial. International Urogynecology Journal 2017

102

Chapter 8 General discussion and future implications 116

Chapter 9 Summary 126

Chapter 10 Nederlandse samenvatting 132

Addendum List of authors and affiliations 144

List of publications 148

PhD portfolio 152

Dankwoord 156

Curriculum Vitae 162

1CHAPTER

General Introduction

10

Chapter 1

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).23 While screening for abnormal PVRV is not standard postpartum care in the majority of departments, covert PUR is therefore often not recognised and only observed when actively looked for, for example in case of scientific purposes.27-31 Incidences vary extensively for both covert PUR (0.4% up to 45%)24,29,32,33 and overt PUR (0.45% to 12%).34,35 These variations in incidence are mainly the result of varying definitions.

First, variation exists in what is regarded as an abnormal residual volume. The used cut-off values to define ‘abnormal or inadequate’ voiding for covert PUR vary between 100 and 200 mL. Second, the timing of PVRV measurements can result in variations of

11


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 pregnancyDuring 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 factorsVarious 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

1

12

Chapter 1

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

Although the relationship between pregnancy, delivery and voiding dysfunctions like urinary incontinence later in life have been well described1-4 and the potential (long term) consequences of bladder overdistension have been identified before,54-59 postpartum urinary retention is generally not defined as a clinically important condition.60 Despite the fact that even a single episode of bladder overdistension can significantly reduce contractility of the detrusor muscle and can lead to micturition and rarely bladder rupture or kidney damage,58,59,61 preventing inadequate bladder emptying in the puerperium is still not a high priority in postpartum care. Reports on adverse effects of inadequate bladder emptying after delivery mostly deal with the problem of prolonged postpartum

13


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

DiagnosticsThe 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.

1

14

Chapter 1

ManagementAlthough 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 studyIn 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 second aim of this thesis is to evaluate the clinical impact of incomplete voiding after delivery. The third aim of this thesis is to optimise postpartum bladder care by evaluating diagnostics and treatment for PUR.

Outline of this thesisIn order to answer the formerly mentioned questions, we will conduct several studies concerning postpartum urinary retention. In the first part of this thesis we will concentrate on risk factors for PUR. This will start with a systematic review of literature on risk factors for postpartum urinary retention of which results will be described in chapter 2. The outcomes of this systematic research will be used in order to design a prospective

15


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.

1

16

Chapter 1

REFERENCES1. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of parity

on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol. 2001;98(6):1004-1010.

2. Wesnes SL, Hunskaar S, Bo K, Rortveit G. The effect of urinary incontinence status during pregnancy and delivery mode on incontinence postpartum. A cohort study. BJOG. 2009;116(5):700-707.

3. Brown SJ, Donath S, Macarthur C, McDonald EA, Krastev AH. Urinary incontinence in nulliparous women before and during pregnancy: prevalence, incidence, and associated risk factors. Int Urogynecol J. 2010;21(2):193-202.

4. Altman D, Ekstrom A, Gustafsson C, Lopez A, Falconer C, Zetterstrom J. Risk of urinary incontinence after childbirth: a 10-year prospective cohort study. Obstet Gynecol. 2006;108(4):873-878.

5. Mason L, Glenn S, Walton I, Hughes C. Women’s reluctance to seek help for stress incontinence during pregnancy and following childbirth. Midwifery. 2001;17(3):212-221.

6. Van Brummen HJ, Bruinse HW, Van de Pol G, Heintz AP, Van der Vaart CH. What is the effect of overactive bladder symptoms on woman’s quality of life during and after first pregnancy? BJU Int. 2006;97(2):296-300.

7. Cerruto MA, D’Elia C, Aloisi A, Fabrello M, Artibani W. Prevalence, Incidence and Obstetric Factors’ Impact on Female Urinary Incontinence in Europe: A Systematic Review. Urol Int. 2012.

8. Samuelsson E, Victor A, Tibblin G. A population study of urinary incontinence and nocturia among women aged 20-59 years. Prevalence, well-being and wish for treatment. Acta Obstet Gynecol Scand. 1997;76(1):74-80.

9. Bartoli S, Aguzzi G, Tarricone R. Impact on quality of life of urinary incontinence and overactive bladder: a systematic literature review. Urology. 2010;75(3):491-500.

10. Kim S, Harvey MA, Johnston S. A review of the epidemiology and pathophysiology of pelvic floor dysfunction: do racial differences matter? J Obstet Gynaecol Can. 2005;27(3):251-259.

11. Arrue M, Ibanez L, Paredes J, et al. Stress urinary incontinence six months after first vaginal delivery. European Journal of Obstetrics Gynecology and Reproductive Biology. 2010;150:210-214.

12. van der Vaart CH, de Leeuw JR, Roovers JP, Heintz AP. The effect of urinary incontinence and overactive bladder symptoms on quality of life in young women. BJU Int. 2002;90(6):544-549.

13. Pizzoferrato AC, Fauconnier A, Bader G, de Tayrac R, Fort J, Fritel X. Is prenatal urethral descent a risk factor for urinary incontinence during pregnancy and the postpartum period? Int Urogynecol J. 2016;27(7):1003-1011.

14. Wijma J, Potters AE, de Wolf BT, Tinga DJ, Aarnoudse JG. Anatomical and functional changes in the lower urinary tract following spontaneous vaginal delivery. BJOG. 2003;110(7):658-663.

15. Miller JM, Low LK, Zielinski R, Smith AR, DeLancey JO, Brandon C. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol. 2015;213(2):188 e181-188 e111.

17


16. Rogers RG, Leeman LL. Postpartum genitourinary changes. Urol Clin North Am. 2007;34(1):13-21.

17. Durnea CM, Khashan AS, Kenny LC, et al. What is to blame for postnatal pelvic floor dysfunction in primiparous women-Pre-pregnancy or intrapartum risk factors? Eur J Obstet Gynecol Reprod Biol. 2017;214:36-43.

18. Durnea CM, Khashan AS, Kenny LC, Tabirca SS, O’Reilly BA. The role of prepregnancy pelvic floor dysfunction in postnatal pelvic morbidity in primiparous women. Int Urogynecol J. 2014;25(10):1363-1374.

19. Serati M, Rizk D, Salvatore S. Vaginal birth and pelvic floor dysfunction revisited: Can cesarean delivery be protective? Int Urogynecol J. 2016;27(1):1-2.

20. Boyle R, Hay-Smith EJ, Cody JD, Morkved S. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2012;10:CD007471.

21. Bo K, Hilde G, Tennfjord MK, Engh ME. Does episiotomy influence vaginal resting pressure, pelvic floor muscle strength and endurance, and prevalence of urinary incontinence 6 weeks postpartum? Neurourol Urodyn. 2017;36(3):683-686.

22. Rogers RG, Ninivaggio C, Gallagher K, Borders AN, Qualls C, Leeman LM. Pelvic floor symptoms and quality of life changes during first pregnancy: a prospective cohort study. Int Urogynecol J. 2017.

23. 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.

24. Hee P, Lose G, Beier-Holgersen R, Engdahl E, Falkenlove P. Postpartum voiding in the primiparous after vaginal delivery. International Urogynecology Journal. 1992;3(2):95-99.

25. Groutz A, Gordon D, Wolman I, Jaffa A, Kupferminc MJ, Lessing JB. Persistent postpartum urinary retention in contemporary obstetric practice. Definition, prevalence and clinical implications. J Reprod Med. 2001;46(1):44-48.

26. Chai AH, Wong T, Mak HL, Cheon C, Yip SK, Wong AS. Prevalence and associated risk factors of retention of urine after caesarean section. Int Urogynecol J. 2008;19(4):537-542.

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

28. Zakaria NH, Nusee Z, Ab RJ, et al. Overt and covert postpartum urinary retention, risk factors and complications - A cohort study at Hospital Tengku Ampuan Afzan (HTAA), Kuantan, Pahang, Malaysia. 2012;Conference: 10th International Scientific Congress of the Royal College of Obstetricians and Gynaecologists, Conference Publication:109-110.

29. 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.

30. Liang CC, Chang SD, Chang YL, Chen SH, Chueh HY, Cheng PJ. Postpartum urinary retention after cesarean delivery. Int J Gynaecol Obstet. 2007;99(3):229-232.

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

1

18

Chapter 1

32. Ramsay IN, Torbet TE. Incidence of abnormal voiding parameters in the immediate postpartum period. Neurourol Urodyn. 1993;12(2):179-183.

33. 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.

34. 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.

35. Liang CC, Chang SD, Wong SY, Chang YL, Cheng PJ. Effects of postoperative analgesia on postpartum urinary retention in women undergoing cesarean delivery. J Obstet Gynaecol Res. 2010;36(5):991-995.

36. Lee SN, Lee CP, Tang OS, Wong WM. Postpartum urinary retention. Int J Gynaecol Obstet. 1999;66(3):287-288.

37. Muellner S. Physiological bladder changes during pregnancy and the puerperium. J Urol. 1938;41:691.

38. Iosif S, Ingemarsson I, Ulmsten U. Urodynamic studies in normal pregnancy and in puerperium. Am J Obstet Gynecol. 1980;137(6):696-700.

39. Beydoun SN. Morphologic changes in the renal tract in pregnancy. Clin Obstet Gynecol. 1985;28(2):249-256.

40. Liang CC, Lin YH, Chen TC, Chang SD. How antepartum and postpartum acute urinary retention affects the function and structure of the rat bladder. Int Urogynecol J. 2014;25(8):1105-1113.

41. Conrad KP, Jeyabalan A, Danielson LA, Kerchner LJ, Novak J. Role of relaxin in maternal renal vasodilation of pregnancy. Ann N Y Acad Sci. 2005;1041:147-154.

42. Rechberger T, Uldbjerg N, Oxlund H. Connective tissue changes in the cervix during normal pregnancy and pregnancy complicated by cervical incompetence. Obstet Gynecol. 1988;71(4):563-567.

43. Qayyum MA, Fatani JA, Abbas MO. Degeneration of adrenergic nerves in the urinary bladder during pregnancy. Acta Anat (Basel). 1989;136(4):303-305.

44. Tammela T. Postoperative urinary retention--why the patient cannot void. Scand J Urol Nephrol Suppl. 1995;175:75-77.

45. Morrison JF. The excitability of the micturition reflex. Scand J Urol Nephrol Suppl. 1995;175:21-25.

46. Buchanan J, Beckmann M. Postpartum voiding dysfunction: Identifying the risk factors. Aust N Z J Obstet Gynaecol. 2013.

47. Caughey AB, Lyell D, Handler SJ, Cheng YW, Knight S. What factors are associated with postpartum urinary retention? Conference: 2011 31st Annual Meeting of the Society for Maternal-Fetal Medicine: The Pregnancy Meeting San Francisco, CA United States. Conference Publication:S79.

48. Snooks SJ, Swash M, Mathers SE, Henry MM. Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. Br J Surg. 1990;77(12):1358-1360.

19


49. Tetzschner T, Sorensen M, Jonsson L, Lose G, Christiansen J. Delivery and pudendal nerve function. Acta Obstet Gynecol Scand. 1997;76(4):324-331.

50. 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.

51. Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2005(4):CD000331.

52. Foon R, Toozs-Hobson P, Millns P, Kilby M. The impact of anesthesia and mode of delivery on the urinary bladder in the postdelivery period. Int J Gynaecol Obstet. 2010;110(2):114-117.

53. Weiniger CF, Yaghmour H, Nadjari M, et al. Walking reduces the post-void residual volume in parturients with epidural analgesia for labor: a randomized-controlled study. Acta Anaesthesiol Scand. 2009;53(5):665-672.

54. Bross S, Schumacher S, Scheepe JR, et al. Effects of acute urinary bladder overdistension on bladder response during sacral neurostimulation. Eur Urol. 1999;36(4):354-359.

55. Klarskov P, Andersen JT, Asmussen CF, et al. Acute urinary retention in women: a prospective study of 18 consecutive cases. Scand J Urol Nephrol. 1987;21(1):29-31.

56. Madersbacher H, Cardozo L, Chapple C, et al. What are the causes and consequences of bladder overdistension? ICI-RS 2011. Neurourol Urodyn. 2012;31(3):317-321.

57. Darrah DM, Griebling TL, Silverstein JH. Postoperative urinary retention. Anesthesiol Clin. 2009;27(3):465-484.

58. Mustonen S, Ala-Houhala IO, Tammela TL. Long-term renal dysfunction in patients with acute urinary retention. Scand J Urol Nephrol. 2001;35(1):44-48.

59. Mustonen S, Ala-Houhala IO, Turjanmaa V, Tammela TL. Effect of acute urinary retention on glomerular filtration rate. Clin Nephrol. 2001;56(1):81-82.

60. Zaki MM, Pandit M, Jackson S. National survey for intrapartum and postpartum bladder care: assessing the need for guidelines. BJOG. 2004;111(8):874-876.

61. Mustonen S, Ala-Houhala I, Tammela TL. Proteinuria and renal function during and after acute urinary retention. J Urol. 1999;161(6):1781-1784.

62. Kibel AS, Staskin DR, Grigoriev VE. Intraperitoneal bladder rupture after normal vaginal delivery. J Urol. 1995;153(3 Pt 1):725-727.

63. Roberts C, Oligbo N, Swinhoe J. Spontaneous bladder rupture following normal vaginal delivery: a postpartum emergency. BJOG. 1996;103(4):381-382.

64. Kekre AN, Kekre N, Nath V, Seshadri L. Spontaneous rupture of the urinary bladder in the puerperium. Aust N Z J Obstet Gynaecol. 1997;37(4):473-474.

65. Wandabwa J, Otim T, Kiondo P. Spontaneous rupture of bladder in puerperium. Afr Health Sci. 2004;4(2):138-139.

66. Duenas-Garcia OF, Rico H, Gorbea-Sanchez V, Herrerias-Canedo T. Bladder rupture caused by postpartum urinary retention. Obstet Gynecol. 2008;112(2 Pt 2):481-482.

67. Png KS, Chong YL, Ng CK. Two cases of intraperitoneal bladder rupture following vaginal delivery. Singapore Med J. 2008;49(11):327-329.

68. Gaikwad PR, Sharma S, Kanitkar SV, Kachane T. Spontaneous rupture of the urinary bladder in the puerperium. Journal of Obstetrics and Gynecology of India. 2011;61:208-209.

1

20

Chapter 1

69. Humburg J, Holzgreve W, Hoesli I. Prolonged postpartum urinary retention: the importance of asking the right questions at the right time. Gynecol Obstet Invest. 2007;64(2):69-71.

70. Humburg J, Troeger C, Holzgreve W, Hoesli I. Risk factors in prolonged postpartum urinary retention: an analysis of six cases. Arch Gynecol Obstet. 2011;283(2):179-183.

71. Valsky DV, Anteby EY, Hiller N, Amsalem H, Yagel S, Hochner-Celnikier D. Postpartum pubic separation associated with prolonged urinary retention following spontaneous delivery. Acta Obstet Gynecol Scand. 2006;85(10):1267-1269.

72. Watson WJ. Prolonged postpartum urinary retention. Mil Med. 1991;156(9):502-503.

73. Hakenberg OW, Ryall RL, Langlois SL, Marshall VR. The estimation of bladder volume by sonocystography. J Urol. 1983;130(2):249-251.

74. Abdel-Fattah M, Barrington JW. The accuracy of Bardscan: a new tool for the measurement of the bladder volume. J Obstet Gynaecol. 2005;25(2):186-188.

75. Bano F, Arunkalaivanan AS, Barrington JW. Comparison between bladderscan, real-time ultrasound and suprapubic catheterisation in the measurement of female residual bladder volume. J Obstet Gynaecol. 2004;24(6):694-695.

76. Bent AE, Nahhas DE, McLennan MT. Portable ultrasound determination of urinary residual volume. Int Urogynecol J. 1997;8(4):200-202.

77. Fuse H, Yokoyama T, Muraishi Y, Katayama T. Measurement of residual urine volume using a portable ultrasound instrument. Int Urol Nephrol. 1996;28(5):633-637.

78. Barrington JW, Edwards G, Ashcroft M, Adekanmi O. Measurement of bladder volume following cesarean section using bladderscan. Int Urogynecol J. 2001;12(6):373-374.

79. Pallis LM, Wilson M. Ultrasound assessment of bladder volume: is it valid after delivery? Aust N Z J Obstet Gynaecol. 2003;43(6):453-456.

80. Lukasse M, Cederkvist HR, Rosseland LA. Reliability of an automatic ultrasound system for detecting postpartum urinary retention after vaginal birth. Acta Obstet Gynecol Scand. 2007:1-5.

81. Van Os AF, Van der Linden PJ. Reliability of an automatic ultrasound system in the post partum period in measuring urinary retention. Acta Obstet Gynecol Scand. 2006;85(5):604-607.

82. Mehta S, Anger J. Evaluation and Management of Postpartum Urinary Retention. Current Bladder Dysfunction Reports. 2012;7:260-263.

83. 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.

84. Patel MI, Watts W, Grant A. The optimal form of urinary drainage after acute retention of urine. BJU Int. 2001;88(1):26-29.

85. Carr D, Cook V. Intrapartum and postnatal bladder care: A survey of midwives’ current practice. Neurourology and Urodynamics. 39th Annual Meeting of the International Continence Society San Francisco, CA United States. Conference Publication:898-899.

86. Hilton P. Bladder drainage: a survey of practices among gynaecologists in the British Isles. Br J Obstet Gynaecol. 1988;95(11):1178-1189.

21


87. Hakvoort RA, Burger MP, Emanuel MH, Roovers JP. A nationwide survey to measure practice variation of catheterisation management in patients undergoing vaginal prolapse surgery. Int Urogynecol J. 2009;20(7):813-818.

88. Rivard C, Awad M, Liebermann M, et al. Bladder drainage during labor: a randomized controlled trial. J Obstet Gynaecol Res. 2012;38(8):1046-1051.

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.

1

RISK FACTORS FOR POSTPARTUM URINARY RETENTION

2CHAPTER

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

26

Chapter 2

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.

Conclusions:Instrumental delivery, epidural analgesia, episiotomy and parity are statistical significant clinical prognostic factors for overt PUR. The same factors have been identified for covert PUR, however without statistical significance. Uniformity in definitions in future research is essential to create a prognostic model.

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.

2

28

Chapter 2

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 (OR) and 95% confidence intervals (CI) from each two-by-two table and constructed forest plots using Review Manager version 5.0.2. To quantify heterogeneity, i.e. to determine the proportion of total variance between different studies explained by heterogeneity, the I² with a Chi² test was used to calculate p-values. A fixed-effect model was used when heterogeneity was low to moderate (I² < 50%). When homogeneity was rejected and thus heterogeneity was substantial too high, we used a random effect model (I² ≥ 50%).16

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 2,3,5,7,8,11-13,19 and 4 were retrospective studies (Figure 1).4,10,17,18

Figure 1: Literature identification and study selection

MEDLINE (n = 289)

Scre

enin

g In

clude

d El

igib

ility

Id

entif

icatio

n

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)


2

30

Chapter 2

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 PUR2-4,17,18 and five studies for covert PUR,5,7,8,12,13 epidural analgesia in seven studies for overt PUR2-4,10,17-19 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 (I2 = 19%, pooled OR 11.9) and episiotomy (I2 = 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.

Table 1: Definitions of covert postpartum urinary retention

Author PVRV Time after delivery

No studied patients

No of PUR patients

Prevalence of PUR

Andolf ≥ 150 ml 72 h 539 8 1.5%

Demaria ≥ 100 ml 72 h 154 55 36%

Hee ≥ 100 ml after 1st void 51 23 45%

Ismael ≥ 150 ml 48 h 100 37 37%

Kekre ≥ 150 ml after 1st void 771 82 10.6%

Liang ≥ 150 ml 6 h 605 101 16.7%

31


Study or SubgroupCarleyChing-ChungFedorkowMusselwhiteTeo

Total (95% CI)Total eventsHeterogeneity: Tau² = 0.22; Chi² = 13.36, df = 4 (P = 0.010); I² = 70%Test for overall effect: Z = 3.44 (P = 0.0006)

Events348955

618

202

Total238

133814913

7464

16627

Events1725218812

163

Total323

154872632010

86

11230

Weight20.7%23.9%22.8%15.9%16.6%

100.0%

M-H, Random, 95% CI3.00 [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 RatioM-H, Random, 95% CI

0.01 0.1 1 10 100

Study or SubgroupCarleyChing-ChungGlavindMusselwhiteTeo

Total (95% CI)Total eventsHeterogeneity: Tau² = 0.90; Chi² = 30.46, df = 4 (P < 0.00001); I² = 87%Test for overall effect: Z = 3.41 (P = 0.0007)

Events3847

75

15

112

Total370243122

5634

825

Events1367

58915

189

Total191

264315272028

116

6505

Weight21.3%22.9%17.2%19.0%19.6%

100.0%

M-H, Random, 95% CI1.57 [0.81, 3.02]

9.22 [6.18, 13.76]18.53 [5.79, 59.29]

2.14 [0.83, 5.48]5.32 [2.23, 12.66]

4.84 [1.95, 12.01]

Episiotomy/vaginal tear Intact perineum Odds Ratio Odds RatioM-H, Random, 95% CI

0.01 0.1 1 10 100

Study or SubgroupCarleyChing-ChungFedorkowGlavindMusselwhiteOlofssonTeo

Total (95% CI)Total eventsHeterogeneity: Tau² = 0.47; Chi² = 19.59, df = 6 (P = 0.003); I² = 69%Test for overall effect: Z = 6.26 (P < 0.00001)

Events503470

46

2722

213

Total401122

16702185

591000

48

18517

Events1

8068

8838

194

Total160

27645474146420252364

112

14363

Weight7.1%

20.3%16.3%12.5%15.9%12.6%15.4%

100.0%

M-H, Random, 95% CI22.65 [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 RatioM-H, Random, 95% CI

0.01 0.1 1 10 100


Total (95% CI)Total eventsHeterogeneity: Chi² = 3.69, df = 4 (P = 0.45); I² = 0%Test for overall effect: Z = 9.67 (P < 0.00001)

Events2419

49

16

72

Total87

170136

7435

502

Events2795

88514

229

Total474

271615132010

115

6828

Weight23.2%38.0%

4.9%20.3%13.6%

100.0%

M-H, Fixed, 95% CI6.31 [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 RatioM-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

2

32

Chapter 2

Study or SubgroupAndolfKekreLiang


Events7

4871

126

Total223407281

911

Events1

3675

112

Total316364324

1004

Weight5.2%

44.2%50.5%

100.0%

M-H, Random, 95% CI10.21 [1.25, 83.57]

1.22 [0.77, 1.92]1.12 [0.77, 1.63]

1.31 [0.79, 2.15]

Primiparous Multiparous Odds Ratio Odds RatioM-H, Random, 95% CI

0.01 0.1 1 10 100

Study or SubgroupDemariaHeeKekre


Events301161

102

Total9734

494

625

Events251223

60

Total5717

277

351

Weight35.7%26.0%38.3%

100.0%

M-H, Random, 95% CI0.57 [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 RatioM-H, Random, 95% CI

0.01 0.1 1 10 100

Study or SubgroupAndolfIsmail


Events4

10

14

Total9523

118

Events4

27

31

Total444

77

521

Weight40.7%59.3%

100.0%

M-H, Random, 95% CI4.84 [1.19, 19.69]

1.42 [0.55, 3.68]

2.34 [0.72, 7.65]

Epidural No epidural Odds Ratio Odds RatioM-H, Random, 95% CI

0.01 0.1 1 10 100

Study or SubgroupAndolfDemariaHeeIsmailKekre


Events2772

24

42

Total32331411

152

242

Events6

48163560

165

Total5071213789

619

1373

Weight14.7%23.1%19.1%15.2%27.9%

100.0%

M-H, Random, 95% CI5.57 [1.08, 28.76]0.41 [0.16, 1.02]1.31 [0.38, 4.50]0.34 [0.07, 1.68]1.75 [1.05, 2.91]

1.10 [0.46, 2.62]

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

0.01 0.1 1 10 100

Figure 3: Risk factors for covert Postpartum Urinary Retention

Figure 3d Primiparous vs multiparous for covert PUR

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



Events241949

16

72

Total87

1701367435

502

Events27958

8514

229

Total474

271615132010115

6828

Weight23.2%38.0%4.9%

20.3%13.6%

100.0%

M-H, Fixed, 95% CI6.31 [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]


0.01 0.1 1 10 100



Events241949

16

72

Total87

1701367435

502

Events27958

8514

229

Total474

271615132010115

6828

Weight23.2%38.0%4.9%

20.3%13.6%

100.0%

M-H, Fixed, 95% CI6.31 [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]


0.01 0.1 1 10 100

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.

2

34

Chapter 2

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.

In conclusion our meta-analyses show that instrumental delivery, epidural analgesia, parity and episiotomy can be identified as clinical risk factors for overt or covert postpartum urinary retention. Since especially in studies concerning covert PUR homogeneity is lacking, uniformity in definitions is necessary for future studies with multivariate analysis.

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.




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.


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.


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.

2

36

Chapter 2


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.


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 correlation with obstetric parameters. J Reprod Med. 2004;49(12):960-964.

37


2

3CHAPTER

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

F.E.M. Mulder K. Oude RengerinkJ.A.M. van der PostR.A. Hakvoort J.P.W.R. Roovers

Delivery related risk factors for covert postpartum urinary retention after vaginal delivery

40

Chapter 3

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.

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 over-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.

3

42

Chapter 3


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.

43


RESULTS

Between September 2010 and January 2013 data of 930 women was obtained, of which the PVRV of 745 (80%) could be used in the analysis. Of 165 women there was no documentation of the PVRV. We excluded 20 women, because they had a twin pregnancy.

Patient characteristics are shown in Table 1. The mean age of women was 31 years, median parity was 2, and 13% (94/745) of women underwent an instrumental delivery (all instrumental deliveries were vacuum extractions).

The first voided volume was measured in 439 women, with a median of 320 mL (Table 2). Measurement of the first voided volume was not performed routinely and not when the first void took place during showering. The median PVRV was 140 mL, the 75th percentile was 250 mL and the 95th percentile 540 mL. (Figure 1) For ease of interpretation and use in practice we rounded these values for use in the regression model, where we used 150 mL (value often used in literature), 250 mL (75th percentile) and 500 mL as outcomes.

Table 3 shows the univariable regression analyses, using the 150 mL, 250 mL and 500 mL cut off values. Primiparity, duration of labour, duration of second stage of labour, opioid analgesia (i.e. intramuscular morphine or intravenous remifantanil), epidural analgesia, instrumental delivery, birth weight, vaginal tears requiring suturing, episiotomy and augmentation were univariably associated with covert PUR (PVRV ≥ 150 mL).

After selection of possible risk factors through univariable regression, multivariate analysis revealed epidural analgesia, birth weight and episiotomy as independent risk factors for PVRV ≥ 150 mL (Table 4). For the cut off value of PVRV ≥ 250 mL, opioid analgesia, birth weight, epidural analgesia and episiotomy were risk factors. Using a PVRV ≥ 500 mL, opioid analgesia, epidural analgesia and episiotomy were significant risk factors.

Table 1: Baseline characteristics (n=745)

Maternal age (years), mean (range) 31 (16 - 46)

BMI (kg/m2), median (range) 24 (16 - 64)

Parity, median (range) 1,8 ( 1 - 8)

Spontaneous vaginal delivery, n (%) 651 (87%)

Instrumental delivery, n (%) 94 (13%)

Epidural analgesia, n (%) 141 (19%)

Opioid analgesia, n (%) 121 (16%)

Episiotomy, n (%) 131 (18%)

3

44

Chapter 3

Table 2: Univariable regression analysis

Clinical factor Number of cases

PVRV ≥ 150 mL PVRV ≥ 250 mL PVRV ≥ 500 mL OR 95% CI OR 95% CI OR 95% CI

Maternal age (per year) 745 1,01 0,99 - 1,04 1,03 0,98 - 1,03 1,03 0,97 - 1,08

BMI (per kg/m2) 625 0,99 0,96 - 1,01 0,98 0,95 - 1,01 1,00 0,95 - 1,05

Primiparous (yes/no) 745 1,63 1,22 - 2,18 1,46 1,05 - 2,03 2,56 1,39 - 4,73

Duration of labour (per minute) 724 1,00 1,00 - 1,00 1,00 1,00 - 1,00 1,00 1,00 - 1,00

Duration 2nd stage (per minute) 738 1,01 1,01- 1,02 1,01 1,01 - 1,02 1,01 1,00 - 1,02

Augmentation (yes/no) 745 1,30 0,97 - 1,73 1,20 0,87 - 1,67 1,17 0,65 - 2,08

Opioid analgesia (yes/no) 745 1,39 0,93 - 2,08 2,04 1,32 - 3,14 3,59 1,72 - 7,50

Epidural (yes/no) 745 2,57 1,75 - 3,77 2,08 1,41 - 3,06 2,88 1,57 - 5,26

Instrumental delivery (yes/no) 745 2,49 1,58 - 3,92 1,89 1,20 - 2,97 3,34 1,75 - 6,41

Birthweight (per 100 grams) 744 1,04 1,01 - 1,06 1,05 1,02 - 1,07 1,03 0,99 - 1,08

Vaginal tears (yes/no) 745 1,58 1,17 - 2,14 1,46 1,03 - 2,07 3,26 1,50 - 7,04

Episiotomy (yes/no) 745 2,39 1,61 - 3,53 2,83 1,91 - 4,19 5,07 2,81 - 9,17Figure 1: PVRV measurements

Number of patients

PVRV in mL

Figure 1: PVRV measurements

Number of patients

PVRV in mL


Number of patients

PVRV in mL


45


DISCUSSION

This multivariate regression analysis shows that episiotomy, epidural analgesia and birth weight are independent risk factors for covert postpartum urinary retention (PVRV ≥ 150 mL). The 75th percentile of measured PVRV in all women was 250 mL; for this cut off value, opioid analgesia, birth weight, epidural analgesia and episiotomy were identified as independent risk factors.

Our applied lower limit of 150 mL for the diagnosis of covert PUR is in line with literature 1,16.The use of this cut off facilitates comparison to other studies.1,8,14 Although we have conducted a large cross-sectional study with data of over 700 women on covert PUR after vaginal delivery, this study has some potential limitations which need discussion.

First, selection bias may have occurred as women with complicated deliveries (i.e. extreme premature deliveries, postpartum hemorrhage, severe pre-eclampsia) were not always screened for PVRV. However we have no reasons to believe that voiding mechanisms would be different in this (small) group of woman with severe pregnancy related complications and therefore believe our results can be generalized. In order to confirm our hypothesis, we plan to perform an external validation.

Second, the use of a BladderScan® as measurement technique of post-voiding residual bladder volume has often been discussed. Still, the validation studies that have been

Table 3: Multivariable regression analysis

PVRV ≥ 150 mL PVRV ≥ 250 mL PVRV ≥ 500 mL Clinical factor OR 95% CI OR 95% CI OR 95% CI

Primiparous (yes/no) 1,26 0,83 - 1,81 1,13 0,75 - 1,70 1,60 0,77 - 3,33

Duration of labour (per minute) 1,00 1,00 - 1,00 1,00 1,00 - 1,00 1,00 1,00 - 1,00

Duration 2nd stage (per minute) 1,00 1,00 - 1,01 1,01 1,00 - 1,01 1,00 0,98 - 1,01

Opioid analgesia (yes/no) 1,18 0,77 - 1,81 1,86* 1,18 - 2,94 3,19* 1,46 - 6,98

Epidural analgesia (yes/no) 2,08* 1,36 - 3,19 2,07* 1,32 - 3,26 3,54* 1,64 - 7,64

Instrumental delivery (yes/no) 1,35 0,78 - 2,34 0,85 0,48 - 1,49 1,15 0,52 - 2,52

Birthweight (per 100 grams) 1,03* 1,01 - 1,06 1,04* 1,01 - 1,07 1,03 0,97 - 1,08

Vaginal tears (yes/no) 1,07 0,76 - 1,52 0,86 0,57 - 1,29 1,53 0,64 - 3,68

Episiotomy (yes/no) 1,67* 1,02 - 2,71 2,53* 1,53 - 4,20 3,72* 1,71 - 8,08

Clinical factors with p < 0,20 in univariable analysis (table 3) were included in the multivariable model (maternal age, BMI en augmentation were not included) * = P < 0,05

3

46

Chapter 3

performed suggest that with such devices reliable measurements are obtained directly postpartum, while no statistical significant differences were found between abdominal measurement and catheterization. 17-20 In our department, a modern 3D model was used (BladderScan® BVI 9400, Verathon, IJsselstein) and, above this, the nursing staff was extensively trained. Therefore, all measures were taken to achieve optimal reliability of measurements.

One of the largest studies concerning this subject is a recent study from Buchanan et al. which found primiparity and large perineal tears as well as cesarean sections to be independent predictors.8 Although this was a large study group it cannot be easily compared to ours due to a high percentage of women undergoing caesarean section and a relatively number of women receiving regional anesthesia. As no information is given in this study about catheters placement protocols under these circumstances, it is hard to compare this study to ours because we did not include women after cesarean section nor regional anesthesia. However, the finding of perineal tears as a predictor is in line with our study and several others.

While in our large cohort the median PVRV was 140 mL, the 75th percentile 250 mL and the 95th percentile 540 mL, we believe that the currently used definition created by Yip et al should be re-evaluated. However, in order to generate a different definition for covert PUR, it is important to know more about the clinical consequences for different cut-off values of PVRV.

Our study shows that opioid analgesia, epidural analgesia and episiotomy are risk factors for a PVRV that exceeds 500 mL. Although the exact pathophysiological background of PUR is still unclear, many hypotheses have been generated, including anatomical changes21, enlargement of bladder capacity22 and hormonal changes during pregnancy23. Obviously, vaginal delivery is an anatomically and functionally traumatic event as it influences not only the anatomy and pelvic floor muscles24 but also has effects on pudendal nerve conduction25,26 and possibly causing obstructive peri-urethral and vulvar edema. Our results show that episiotomy, epidural analgesia and birth weight independently influence postpartum bladder function negatively. The (sutured) episiotomy as a predictor is likely to exert its effect through the development of pain and a subsequent disturbance in bladder sensitivity but also central inhibition of bladder function.27-29

It is rational to presume that the more extreme change in anatomy in primiparous women is different from the more adapted pelvic floor of multiparous women. It is likely that the first situation results in more pain. From this mechanical point of view, it is as likely that the birth of neonates with a larger birth weight can cause more trauma, subsequently resulting in a more painful delivery with the eventual inhibitory effect on bladder function. Last, the finding of epidural analgesia as a predictor for abnormal PVRV as an expression of

47


decreased bladder function was not surprising7,30 as it directly affects (bladder) sensitivity and contractility.

Keeping these hypotheses in mind, one can understand how these clinical factors might cause an abnormal PVRV. Although several authors have shown that residual volumes often normalize spontaneously, 1,2,5,14 data on long term and adverse effects are still missing. A recent systematic review on adverse effects of postpartum urinary retention shows that literature is insufficient to state that covert PUR harmless.10 Future research should therefore also focus on clinical consequences and long term adverse effects related to the occurrence of covert PUR.

CONCLUSIONS

Episiotomy, epidural analgesia and birth weight are independent risk factors for covert PUR. We suggest to re-evaluate the current definition and cut-off values of covert PUR data on clinical consequences of abnormal PVRV become available.

3

48

Chapter 3

REFERENCES


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







9. Salemnic Y, Gold R, Toov JH, et al. Prevalence, obstetric risk factors and natural history of asymptomatic postpartum urinary retention after first vaginal delivery-a prospective study of 200 primipara women. Journal of Urology. 2012;Conference: 2012 Annual Meeting of the American Urological Association.

10. Mulder FE, Hakvoort RA, Schoffelmeer MA, Limpens J, Van der Post JA, Roovers JP. Postpartum urinary retention: a systematic review of adverse effects and management. Int Urogynecol J. 2014;25(12):1605-1612.



13. Lewis JM, Yalla SV, Stanitski KE, Sullivan MP. Spectrum of urodynamic abnormalities and renal function changes in adult men with non-neurogenic urinary retention. Neurourol Urodyn. 2012;31(4):544-548.


15. Mulder FE, Schoffelmeer MA, Hakvoort RA, et al. Risk factors for postpartum urinary retention: a systematic review and meta-analysis. BJOG. 2012;119(12):1440-1446.

16. 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.


49


18. 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.

19. Barrington JW, Edwards G, Ashcroft M, Adekanmi O. Measurement of bladder volume following cesarean section using bladderscan. Int Urogynecol J 2001;12(6):373-374.






25. Lien KC, Morgan DM, DeLancey JO, Ashton-Miller JA. Pudendal nerve stretch during vaginal birth: a 3D computer simulation. Am J Obstet Gynecol. 2005;192(5):1669-1676.

26. Sajadi KP, Lin DL, Steward JE, et al. Pudendal nerve stretch reduces external urethral sphincter activity in rats. J Urol. 2012;188(4):1389-1395.

27. Blok BF, Sturms LM, Holstege G. Brain activation during micturition in women. Brain. 1998;121 ( Pt 11):2033-2042.

28. Morrison JF. The excitability of the micturition reflex. Scand J Urol Nephrol Suppl. 1995;175:21-25.

29. Tammela T. Postoperative urinary retention--why the patient cannot void. Scand J Urol Nephrol Suppl. 1995;175:75-77.

30. Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2005(4):CD000331.

3

IIPART

ADVERSE EFFECTS OF INADEQUATE VOIDING AFTER DELIVERY

4CHAPTER

International Urogynecology Journal (2014) 25:1605-1612.

F.E.M. MulderR.A. HakvoortM.A. SchoffelmeerJ. LimpensJ.A.M. van der PostJ.P.W.R. Roovers

Postpartum urinary retention: a systematic review of adverse effects and management

54

Chapter 4

ABSTRACT

Background: Postpartum urinary retention (PUR) is a well-known condition after childbirth. Often clinicians assume this condition is transient, either through belief or by not being aware of the occurrence as measurement of post voiding residual volume (PVRV) is often not routine. However, long lasting urinary retention is a serious condition that needs management in order to prevent urogenital tract morbidity.

Objectives: By performing a systematic review on adverse effects of postpartum urinary retention and management of this condition, we aimed to identify the necessity for diagnosing this condition in the puerperium and to evaluate whether treatment is required.

Methods: We searched for all studies on PUR in OVID MEDLINE, OVID EMBASE, and ongoing Trial registers. Two reviewers independently screened and extracted the data.

Results: Twenty four papers were included in this review. Limited data on adverse effects demonstrate the potential morbidity, like micturition symptoms and sporadically spontaneous bladder ruptures, related to PUR.

Conclusions: Based on current literature, evidence stating that PUR is harmless is missing. Future research should focus on management strategies for overt PUR and long term consequences of covert PUR. Until these results are available, clinicians should be aware of the potential consequences and therefore keep trying to identify patients at risk for PUR and patients with the actual condition.

55

Systematic review of adverse effects and management of postpartum urinary retention

INTRODUCTION

Postpartum urinary retention (PUR) is a common phenomenon in the puerperium, with prevalences varying between 1.5% up to 45%.1-4 In literature often a distinction is made between patients who cannot void at all (overt postpartum urinary retention) and those that can void but experience an abnormal post-voiding residual bladder volumes (covert PUR). This distinction was first made by Yip et al who defined 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”.1 Covert PUR was classified as “a post void residual bladder volume (PVRV) of ≥ 150 mL after spontaneous micturition, verified by ultrasound or catheterization”. These definitions have been adopted afterwards by several authors.4-8

Long term and adverse effects of postpartum urinary retention have not been identified yet, therefore, screening for increased PVRV is often not part of standard postpartum care. This is in contrast to patients after (gynaecological) surgery, where screening for urinary retention has often become part of routine postoperative care.9-13

In patients with persistent urinary retention (for example due to pelvic masses, benign prostate hyperplasia or postoperative), long term micturition problems, due to detrusor failure, and even kidney failure due to renal obstruction, anuria and hydronephrosis have been described.14-17 In addition, persistent micturition problems have been described after a single episode of detrusor overdistention.18,19

Although the pathophysiology remains unelucidated, various factors have found to be of influence from which several hypotheses on the cause of postpartum urinary retention have arisen. Regarding bladder physiology Muellner et al. showed that the capacity of the bladder increases during pregnancy.20 Iosif et al. performed urodynamic tests in pregnant and postpartum women, showing adaptations of urethral length and urethral closure pressures during pregnancy.21 This physiologic increase of the length of the urethra as well as the increase of the maximum urethral pressure and urethral closure pressure is responsible for a protection against urinary incontinence in pregnancy.21 Vaginal delivery can directly traumatize pelvic floor muscles and its innervations, which is likely to result in decreased bladder sensibility.22 Moreover, it causes peri-urethral and vulvar edema which may also result in PUR by obstruction. Although no comparisons have been made, it is feasible that the mode of delivery (vaginal delivery versus cesarean section) also affect the bladder function.

Finally, hormonal changes may influence the function of the bladder during pregnancy and in the puerperium. Recently, Liang and colleagues explored hormone levels in rats with and without postpartum urinary retention; they found that rats with postpartum urinary retention had increased progesterone levels, resulting in shorter intervals between

4

56

Chapter 4

contraction of the bladder muscle cells, lower mean voided volumes and increased residual volumes.23

While in the puerperium morbidity related to postpartum urinary retention is not well documented and possibly underreported, the potential damage of enduring retention and the uncertainty about actual incidence does not exempt clinicians to be vigilant about the occurrence of retention.

In addition, the lack of screening for PUR or (abnormal) PVRV in the postpartum period also causes practice variations in daily clinical practice and management after delivery which may cause under or overtreatment of patients.24

The aim of this review is to provide an answer whether postpartum urinary retention needs to be diagnosed and whether an intervention is needed. This would be true in case a clear relationship would exist between the existence of PUR and morbidity of the urogenital tract. To establish a possible relationship, a review was performed of the available literature on the incidence of adverse effects of overt and covert PUR and the need for interventions in women who suffer from it.

57



A medical librarian (JL) performed a systematic literature search in MEDLINE (OVID, from 1948), EMBASE (OVID, from 1980), PubMed (the publisher[sb]-fraction which contains publications ahead of print, not yet included in OVID MEDLINE) and ongoing Trial registers (http://clinicaltrials.gov/) to identify publications about PUR. The latest update was November 11th 2013. No language restrictions were applied and animal studies were safely excluded by double negation. The search strategy consisted of free-text words and Subject Headings related to (1) urinary retention and (2) delivery, postpartum period or obstetric procedures that enhance the chance of urinary retention (See Appendix for the entire MEDLINE search strategy).25 The search included an iterative process, for each database, to refine the search strategy through incorporation of new search terms as new relevant citations were identified, i.e. by checking reference lists and citing articles using ISI Web of Science. The bibliographic records retrieved were downloaded and imported into Reference Manager® software (version 12.0) to deduplicate, store and analyze the search results.

Included papers involved original data on women diagnosed with postpartum urinary retention (after vaginal delivery or cesarean section) as well as women with an ‘abnormal’ PVRV (as defined by the author). Also papers with urinary retention as a secondary outcome were used for analysis. If data were inconclusive or insufficient, authors were contacted.

After identifying all available papers on PUR, manuscripts reporting on adverse events and treatment were selected and used in the final analysis.

Two authors (FM and MS) independently assessed all the potential studies that were identified as a result of the search strategy for inclusion. The STROBE guideline was used in order to evaluate the quality of included studies.26 Any disagreements between the two reviewers were resolved through discussion.

4

http://clinicaltrials.gov/

58

Chapter 4

RESULTS

The systematic search identified 909 unique papers on PUR of which 24 were eligible for data extraction. (Figure 1)

On overt PUR, 10 prospective studies1,4-7,27-31 were found as well as 6 retrospective studies.8,32-35,36 Three studies reported on protracted or prolonged PUR.37-39 On covert PUR, 14 prospective studies were identified.1-4,7,30,40-47

We identified all papers that reported on any complication potentially related to PUR, like micturition problems, urinary tract infections or incontinence.

Considering overt PUR, three studies reported on adverse effects.2,4,48 Two authors evaluated long term consequences, both four years after delivery. Andolf et al. reviewed ten PUR patients with a questionnaire. Three out of ten patients experienced occasional voiding problems but the study was too small to claim that urinary symptoms in patients Figure 1: Literature identification and study selection

MEDLINE (n = 343)

Scre

enin

g In

clude

d El

igib

ility

Id

entif

icatio

n

EMBASE (n = 835)

Records after duplicates removed (n = 909)

Records screened by title and/or abstract

(n = 273)

Records excluded (n = 185)

Full-text articles assessed for eligibility

(n = 95)

Full-text articles excluded (n=71) - No original data (n = 71)

Studies included in data synthesis

(n = 24)

PubMed Publisher

(n = 6)


59


diagnosed with PUR are not increased compared to the general population.2 Yip and colleagues reviewed patients with and without PUR four years after the (vaginal) index delivery. Of the 394 telephonically contacted patients, 73 patients had earlier been diagnosed with PUR. No distinction was made between women with overt or covert PUR. No statistical significance for urinary stress incontinence was found between patients with and without PUR patients (71% vs 61%).48 Another group evaluated women three months after having gone through an episode of PUR by uroflowmetry and a questionnaire on subjective symptoms.4 One of the two overt PUR patients had voiding dysfunctions (not otherwise specified), the other patient did not show urodynamic disturbances nor was symptomatic.

Another defined entity regarding overt PUR came forward from literature: urinary retention lasting for longer than 3 days and requiring catheterization for a longer period. This is called prolonged, persistent or chronic postpartum urinary retention and was described by five authors.32,37,38,39,49-51 Concerning adverse effects, Groutz et al. performed urodynamic investigation in 48 out of 55 women with prolonged PUR, 3-39 months after delivery; 10% was diagnosed with stress incontinence and 8% with overactive bladder signs.37 Humburg and colleagues presented two cases of patients with prolonged PUR, resulting in suprapubic catheterization and antibiotic treatment for urinary tract infections.39 No comparison with women without prolonged PUR was made.

Most authors supported the opinion that covert PUR is ephemeral and no treatment is necessary. Possibly as a consequence, no papers were found on management of covert PUR. Therefore, in contrast with overt PUR where the indication for treatment is more clear, groups have been able to scrutinize covert PUR in its natural course. Five authors studied the PVRV repeatedly after initial diagnosis of covert PUR, showing that in 96-100% of cases, PVRV normalized within 2 to 5 days after delivery.1,3,4,46,36 In nine papers the post void residual volume was only measured once in order to diagnose PUR.2,7,30,40-45 (Table 2)

Regarding negative effects of covert PUR, three of the thirteen included studies mention adverse effects.2,45,46 Andolf et al. included patients with a PVRV > 150 mL on the third day postpartum and re-evaluated them at day four and day five postpartum as well as four years after delivery. None of the patients had an increased PVRV at day five postpartum, indicating PUR is a transient condition. At the four years follow-up, three patients (30%) reported occasional voiding problems (urgency and stress incontinence); however, in this study no differentiation between overt and covert PUR was made and a control group of women without PUR was missing.2

Lee et al. evaluated 256 patients at the second day after vaginal delivery. 36 patients had PVRV exceeding 200 mL. 42% of these patients had symptoms of voiding dysfunction at that time (urinary frequency, dysuria, incontinence, sensation of incomplete emptying or

4

60

Chapter 4

difficulty voiding as defined by the authors). At the fifth day, 1.8% of all patients (4/228) still had a PVRV > 200 mL. Of these four patients none had symptoms of voiding dysfunction. In total, 92% of the patients with covert PUR recovered spontaneously.46 Eleven authors did not report adverse effects.

With respect to adverse effects, several cases have been published on spontaneous bladder ruptures after vaginal delivery.52-57 Although no information is available on the micturition of these women after giving birth, it is possible that this severe and detrimental

Table 1. Treatment and recovery overt PUR

Author Prevalence PUR Initial treatement Time of treatment Longest

treatment

Carley 0.45%CIC and CAD (not specified)

45% < 48 hours; 29% < 72 hours; 25% self catheterization

45 days

Ching Chung 3.97%CIC followed

by CAD98% < 72 hours 10 days

Fedorkow 0.34%CIC and CAD (not specified)

* *

Foon 2.50% CAD * *

Glavind 0.70% CIC47% < 24 hours; 33% < 48 hours;

20% self catheterization21 days

Kekre 0.30% CAD 100% < 48 hours N/A

Liang (2007) 7.40%CIC followed

by CAD65% 1x CIC; 23% 2x CIC; 11% CAD 48 hours

Liang (2010) 12.0%CIC followed

by CAD83% < 24 hours; 11% < 48 hours;

5% < 72 hoursat hospital discharge

Musselwhite 4.70% * * *

Olofsson 0.89% CAD 27% < 72 hours; 53% < 14 days > 14 days

Rizvi 0.14% CAD Median time: 72 hours 148 hours

Teo 0.20%CIC and CAD (not specified)

Median time: 19 days 85 days

Yip (1997) 4.90% CAD * *

Lee (1961) 8.0% CIC followed by

CAD* *

Sherline 3.0% CAD Median time: 52 hours 96 hours

* no data available

61


urologic complication is related to postpartum urinary retention. However, no cases of spontaneous bladder rupture have been recorded in cohort studies on PUR.

Although the necessity of management for overt PUR is indisputable (i.e. catheterization), clinical guidelines are missing. Concerning studies reporting on overt PUR, the treatment protocol was mentioned in 13 papers.1,4-8,27-33 Six authors reported that treatment of overt PUR started with indwelling catheterization, with time varying from 24 up to 72 hours.1,4,8,27,28 One author only used intermittent catheterization5, while in four studies, after initial treatment with intermittent catheterization, indwelling catheterization after 24 hours was started.6,7,29,30 In two studies both interventions were applied.32,33 Spontaneous micturition occurred in all included patients, with catheterization time varying from 24 hours up to 45 days.5,34 An overview of differences in management strategies is presented in Table 1.

Table 2: Natural course covert PUR

Author Time Prevalence PUR Natural course covert PUR

Ramsay mean 72 h 0.4% *

Andolf 72 h 1.5% *

Lee (1999) 24 h 14% Day 5: 98% PVRV < 200ml.

Yip 24 h 9.7% Day 4: 100% PVRV < 150ml.

Kekre after 1st void 10%Day 2: 98% PVRV < 150ml.

2 patients overt PUR: CAD 48hours

Hee after 1st void 45%Day 3: 92% PVRV < 100ml. Day 5: 96% PVRV < 100ml.

Chai 6 h 3.4% Measurements not repeated

Weissman 42 h 7.5% Measurements not repeated

Demaria 72 h 36% Measurements not repeated

Ismael 48 h 37% Measurements not repeated

Liang (2007) 6 h 16.7%All patients catheterized ;

no information on natural course

Van Os 6 h 32%All patients catheterized ;


Lee (1961) <18h 8%All patients catheterized ;


Buchanan 4 h 5.1 % Day 4: 97% PVRV < 150 m.

* no data available

4

62

Chapter 4

DISCUSSION

This systematic review shows that postpartum urinary retention is a frequent condition in the puerperium and that there is no evidence indicating it is harmless.

Literature on adverse effects of postpartum urinary retention shows that covert PUR often is a transient condition. However, due to the absence of control groups (patients with normal post void residual volumes), there is little to say about the relationship between the attributed risk of covert PUR on later development of micturition symptoms. Although spontaneous bladder rupture is rarely described in case reports, this complication is absent in cohort studies.

Regarding negative and harmful effects related to covert PUR, we believe current evidence is deficient to declare PUR is a physiologic condition, while, in general, follow up periods have been short and no comparisons with well-voiding subject have been made.

For overt PUR, three authors evaluated adverse effects.1,2,4 The follow up period in the study of Kekre et al. was limited to three months and contained only two patients of which one was lost to follow up.4 Although Yip et al. and Andolf et al. reviewed patients four year after the diagnosis of PUR, due to low numbers of patients and definition we believe these results are too limited to state that PUR does not give any long term problems.2,48 The revised group of patients with PUR in Andolfs study was very small (n=12) and different inclusion criteria were used. In addition, no difference was made in patients with overt and covert PUR.2 Yip et al. were able to reassess a large numbers of patients by telephonic interviews four years after the diagnosis of PUR.48 Although they did make a comparison between patients with and without PUR, again no distinction was made between overt and covert PUR. In addition, no validated questionnaires were used and women were allowed to answer only parts of the used questionnaire. We believe data are therefore insufficient to state that overt PUR does not have long term consequences.

Considering covert PUR, three authors reported on negative effects.2,45,46 Lee et al identified that 42% of women with covert PUR the second day after delivery had voiding problems (not otherwise specified). At the fifth day, four patients still had an increased PVRV, but were ‘asymptomatic’. No further information was given regarding characteristics of these patients. Andolf and collegues identified patients with a PVRV > 150mL at the third day postpartum. All patients had normal voiding parameters within several days. They found no differences regarding urinary symptoms comparing patients with PUR to the general population.

The majority of authors studying covert PUR had no follow up regarding adverse effects; clinical studies with long term follow up and associations with control groups of patients

63


with normal voiding parameters were missing. In the absence of sufficiently powered and properly designed studies we therefore believe that a true statement about the benign character of covert PUR is not possible. Future research on covert PUR should not only include comparisons with normal controls, but also focus on long term adverse effects. In addition, validated questionnaires should be used. Until results of such studies are available, patients who are at risk for covert PUR should be monitored closely.58

Bladder overdistention can reduce contractility of the detrusor muscle and can create micturition symptoms. Therefore, in women with overt postpartum urinary retention, timely recognition and treatment by catheterization is essential in order to prevent this disorder.18,19 However, our review shows that standardized diagnostics and management for overt PUR is lacking. Further, a large variation exists in catheterization protocols (intermittent versus indwelling catheterization as well as duration of catheterization).1,5,6,27,34

While catheterization after (vaginal) surgery and acute urinary retention is well evaluated in clinical studies, evidence for indwelling or intermittent catheterization in postpartum patients is missing. Different studies conclude that intermittent catheterization is preferred over indwelling catheterization as primary treatment.8,59 This is in line with a recent Cochrane review on postoperative acute urinary retention in adults, that shows restricted evidence in favour of clean intermittent catheterization (CIC); it is associated with a lower risk of bacteriuria than indwelling catheterization.60,61 The same conclusion is drawn by two authors studying women during labour.62,63 However, no comparison between different catheterization methods has been made for overt PUR. We therefore believe a study comparing both techniques is needed.

Regarding treatment for covert PUR, consensus is lacking. Studies conducted on this subject are restricted to repeated measurements of the PVRV and the so-called natural course.

While most patients were able to void sufficiently, authors conclude that covert PUR is transient and therefore self-limiting.1-4 28,29,42,44 However, a normal PVRV after initially increased residual volume does not guarantee the absence of symptoms and complications. While information on complications due to covert PUR is insufficient, we believe the statement that covert PUR does not need treatment, can only be justified when expectant management is compared to an intervention. In the meantime, there is insufficient evidence advising routine screening of all postpartum women after spontaneous micturition.

Our study has some weaknesses that have to be acknowledged. First, due to the variety in cut-off values and definitions used in the included studies, it is not possible to generate incidences of adverse effects. The variation in time of measurement of the PVRV (from six up to 72 hours postpartum) and multiple diagnostic instruments (ultrasound,

4

64

Chapter 4

catheterization) make it difficult to compare results and therefore produce absolute numbers on the potential negative effects of PUR. This limitation is consequently the result of the included studies. We therefore plead to use the definitions generated by Yip et al.1 When one could agree on the terminology, reported prevalences can be compared more easily and future study results can be used for meta-analysis.

Secondly, as treatment options contrast extensively between studies, sufficient evidence to constitute a treatment guideline for PUR is missing.

Future research should therefore focus on adverse effects of PUR, catheterization methods in women with overt PUR and the necessity for screening and treatment of covert PUR. Although we have not been able to generate recommendations for daily clinical practice, we believe our review shows that overt and covert postpartum urinary retention cannot be disregarded and until results of future research are available should be considered a serious condition.

65


CONCLUSIONS

Postpartum urinary retention is a frequently diagnosed condition in the postpartum period. While only few studies scrutinized adverse effects of overt and covert PUR, evidence that PUR is without danger of long term adverse effects is insufficient. Although not statistically significant, data show increased urinary problems in patients with PUR. Case reports on spontaneous bladder ruptures after vaginal delivery imply that urinary retention can be detrimental.

Consequently, future research should focus more on short and long term consequences of postpartum urinary retention, catheterization methods for overt PUR and the necessity of treatment for covert PUR. Although until these results are available PUR should be regarded as a serious condition, we don’t recommend routinely screening for increased PVRV.

4

66

Chapter 4

REFERENCES1. 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.


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


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



8. Rizvi RM, Khan ZS, Khan Z. Diagnosis and management of postpartum urinary retention. Int J Gynaecol Obstet. 2005;91(1):71-72.

9. Hakvoort RA, Dijkgraaf MG, Burger MP, Emanuel MH, Roovers JP. Predicting short-term urinary retention after vaginal prolapse surgery. Neurourol Urodyn. 2009;28(3):225-228.

10. Fitzgerald MP, Kulkarni N, Fenner D. Postoperative resolution of urinary retention in patients with advanced pelvic organ prolapse. Am J Obstet Gynecol. 2000;183(6):1361-1363.

11. Sokol AI, Jelovsek JE, Walters MD, Paraiso MF, Barber MD. Incidence and predictors of prolonged urinary retention after TVT with and without concurrent prolapse surgery. Am J Obstet Gynecol. 2005;192(5):1537-1543.

12. Smorgick N, DeLancey J, Patzkowsky K, Advincula A, Song A, As-Sanie S. Risk factors for postoperative urinary retention after laparoscopic and robotic hysterectomy for benign indications. Obstetrics & Gynecology. 2012;120(3):581-586.

13. Stallard S, Prescott S. Postoperative urinary retention in general surgical patients. Br J Surg. 1988;75(11):1141-1143.



16. Abe T, Shinno Y, Kawakura K, Moriya K. Acute renal failure occurring from urinary retention due to a mullerian duct cyst. Int J Urol. 2000;7(2):69-71.


67









25. 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.

26. 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.

27. 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.

28. Foon R, Toozs-Hobson P, Millns P, Kilby M. The impact of anesthesia and mode of delivery on the urinary bladder in the postdelivery period. Int J Gynaecol Obstet. 2010;110(2):114-117.

29. Liang CC, Chang SD, Wong SY, Chang YL, Cheng PJ. Effects of postoperative analgesia on postpartum urinary retention in women undergoing cesarean delivery. J Obstet Gynaecol Res. 2010;36(5):991-995.

30. Lee J. Management of postpartum urinary retention. Obstet Gynecol. 1961;17:464-471.

31. Sherline DM, Danforth DN. Effects of labor, delivery, and anesthesia on postpartum bladder function. Obstet Gynecol. 1962;19:808-813.

32. 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.

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



4

68

Chapter 4



38. Groutz A, Levin I, Gold R, Pauzner D, Lessing JB, Gordon D. Protracted postpartum urinary retention: the importance of early diagnosis and timely intervention. Neurourol Urodyn. 2011;30(1):83-86.

39. Humburg J, Holzgreve W, Hoesli I. Prolonged postpartum urinary retention: the importance of asking the right questions at the right time. Gynecol Obstet Invest. 2007;64(2):69-71.

40. Chai AH, Wong T, Mak HL, Cheon C, Yip SK, Wong AS. Prevalence and associated risk factors of retention of urine after caesarean section. Int Urogynecol J. 2008;19(4):537-542.

41. Weissman A, Grisaru D, Shenhav M, Peyser RM, Jaffa AJ. Postpartum surveillance of urinary retention by ultrasonography: the effect of epidural analgesia. Ultrasound Obstet Gynecol. 1995;6(2):130-134.




45. Ramsay IN, Torbet TE. Incidence of abnormal voiding parameters in the immediate postpartum period. Neurourol Urodyn. 1993;12(2):179-183.


47. 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.


49. TJ J, B T, N T, JD T. Chronic Urinary Retention Postpartum. Aust N Z J Obstet Gynaecol. 1990;30(4):364-366.

50. Humburg J, Troeger C, Holzgreve W, Hoesli I. Risk factors in prolonged postpartum urinary retention: an analysis of six cases. Arch Gynecol Obstet. 2011;283(2):179-183.


52. Duenas-Garcia OF, Rico H, Gorbea-Sanchez V, Herrerias-Canedo T. Bladder rupture caused by postpartum urinary retention. Obstet Gynecol. 2008;112(2 Pt 2):481-482.

53. Gaikwad PR, Sharma S, Kanitkar SV, Kachane T. Spontaneous rupture of the urinary bladder in the puerperium. Journal of Obstetrics and Gynecology of India. 2011;61:208-209.

54. Png KS, Chong YL, Ng CK. Two cases of intraperitoneal bladder rupture following vaginal delivery. Singapore Med J. 2008;49(11):327-329.

69


55. Roberts C, Oligbo N, Swinhoe J. Spontaneous bladder rupture following normal vaginal delivery: a postpartum emergency. Br J Obstet Gynaecol. 1996;103(4):381-382.

56. Kekre AN, Kekre N, Nath V, Seshadri L. Spontaneous rupture of the urinary bladder in the puerperium. Aust N Z J Obstet Gynaecol. 1997;37(4):473-474.

57. Wandabwa J, Otim T, Kiondo P. Spontaneous rupture of bladder in puerperium. Afr Health Sci. 2004;4(2):138-139.


59. Yip SK, Sahota D, Pang MW, Day L. Postpartum urinary retention. Obstet Gynecol. 2005;106(3):602-606.

60. Niel-Weise BS, van den Broek PJ. Urinary catheter policies for short-term bladder drainage in adults. Cochrane Database Syst Rev. 2005(3):CD004203.


62. 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.

63. Millet L, Shaha S, Bartholomew ML. Rates of bacteriuria in laboring women with epidural analgesia: continuous vs intermittent bladder catheterization. Am J Obstet Gynecol. 2012;206(4):316-317.

4

5CHAPTER

International Urogynecology Journal (2017) : accepted for publication. (Epub ahead of print)

F.E.M. MulderR.A. HakvoortJ.P. de Bruin E.W. JanszenJ.A.M. van der PostJ.P.W.R. Roovers

Long term lower urinary tract symptoms of asymptomatic postpartum urinary retention: a prospective case control study

72

Chapter 5

ABSTRACT

Background:Covert (asymptomatic) Postpartum Urinary Retention(PUR) is defined as post void residual volume (PVRV) ≥ 150 mL. Although often supposed to be a common and harmless phenomenon, no data are available on the potential long term micturition problems of increased PVRV after vaginal delivery.

Methods: PVRV after the 1st spontaneous void postpartum was measured with a portable scanning device after vaginal delivery. Micturition symptoms were compared using validated questionnaires between women with PVRV < 150 mL and ≥ 150 mL until one year after delivery. Women with PVRV ≥ 150 mL were followed until complete bladder emptying was achieved.

Results:Data of 105 patients with PVRV < 150 mL and 119 with PVRV ≥ 150 mL were available for analysis. 75% of all included patients had PVRV ≥ 250 mL. Primiparous patients had PVRV ≥ 150 mL more often (p < 0.02). 92% of women with PVRV ≥ 150 mL after delivery were able to adequately empty their bladder within 4 days. One year after delivery no statistical significant differences were found.

Conclusions: Covert PUR according to the definition of PVRV ≥ 150 mL, is a common and transient phenomenon which does not result in more lower urinary tract symptoms one year after delivery. While the current definition is not useful to identify postpartum women with pathology, we suggest to change the definition of covert PUR into: “PVRV ≥ 500 mL after the first spontaneous void after (vaginal) delivery”. This cut-off value is the value at which some women do need more time to normalize emptying of the bladder. The exact clinical implications of covert PUR need to be further studied in this subcategory of women.

73

Long term micturition problems of covert postpartum urinary retention

INTRODUCTION

Postpartum urinary retention (PUR) is a frequently occurring condition in women.1-3 Two types of PUR can be distinguished; overt (symptomatic) PUR, i.e. the inability to void spontaneously after delivery and covert (asymptomatic) PUR, defined as abnormal post void residual volumes (PVRV) after micturition. By definition, the last form remains unrecognized when screening for residual volumes is not part of standard postpartum care.

Therefore, the true prevalence of covert PUR is unknown4-6 and possibly the reason that little is known about its natural course and potential long-term adverse effects.

The development of PUR is likely to be multifactorial; anatomical changes caused by delivery such as bladder descent through pushing and pain due to birth related pelvic floor trauma might disturb normal voiding by either causing obstruction, loss of awareness of bladder filling and inhibition of micturition. The possibility of the influence of these factors in the observed impairment of voiding might be reflected by the observation that the occurrence of PUR is higher in patients with epidural analgesia, episiotomy and higher birth weight.6,7

Based on limited data about its transient natural course some have hypothesized that covert PUR is a physiological phenomenon related to delivery.1,8,9 Several authors have indeed shown that elevated PVRV’s generally normalise within days.1,6,9 Still, even a single episode of bladder overdistension can create prolonged micturition problems and, rarely, even kidney failure.10,11 Yet, no studies examined the bladder function of these women with covert PUR in the long term.

The question arises in which respect the puerperal lower urinary tract differs functionally from non-pregnant women.4,9 Together with the fact that one out of three parous women suffer from urinary incontinence and micturition problems in the first year after delivery,12 it seems relevant to study not only the normalization of PVRV’s directly postpartum but also the influence of covert PUR on bladder function and micturition symptoms in the longer term.

To study these potential long-term effects of incomplete bladder emptying postpartum and to evaluate if the current definition is sufficient to discriminate between physiology and pathology, a prospective cohort study was performed in women with and without covert PUR throughout the first year after their vaginal delivery.

5

74

Chapter 5

MATERIALS AND METHODS

A prospective observational study was performed between August 2011 and June 2013 in 6 teaching hospitals in the Netherlands. The study was approved by the medical ethical committee of the Academic Medical Centre in Amsterdam, the Netherlands (MEC AMC 10/277) and all participating centres. The study was registered in the Dutch Trial Registry (NTR 3118).

During the study period, the PVRV of women who had delivered vaginally was measured routinely after the first spontaneous void with a portable non-invasive transabdominal bladder ultrasound device (BVI 9400 BladderScan®, Verathon Medical Europe, Ijsselstein, the Netherlands). When patients were able to void on a toilet, the quantity of the first micturition was measured. In case women voided while showering no measurement of the quantity of the first void could be obtained. Written informed consent was obtained from all patients. Patients with and without a PVRV ≥ 150 ml were included. Women with a PVRV ≥ 150 ml were included in the study group while women with a PVRV < 150 ml acted as controls.

Initially women were asked to participate after PVRV was measured. While the majority of women declined participation in this way, later on the protocol was changed to the possibility to also inform, and obtain informed consent from patients before delivery.

Patients < 18 years, patients with insufficient knowledge of Dutch language and patients with preexisting kidney or bladder problems were excluded from the study.

MeasurementsAll women with PVRV ≥ 150 mL were re-evaluated on day 4 after delivery (day of delivery was set at day 0) and measured repeatedly until a residual volume of < 150 ml was reached. In case PVRV was still more than 150 ml at day 4, measurements were repeated at day 7 and weekly afterwards.

To assess the presence of micturition symptoms all patients were asked to complete the Dutch validated short version of the urogenital distress inventory (UDI-6) at the day of delivery as well as on the 4th, 7th, 30th, 90th day and 1 year after delivery.13,14

The UDI-6 is a six item validated questionnaire used to identify symptoms associated with lower urinary tract dysfunction. The UDI questionnaires have previously been translated and validated in Dutch and are broadly accepted by urogynaecologic clinicians in the Netherlands.14,15 Questionnaires were analysed using a four-point scale. This results in scores, in which higher scores indicate more severe symptoms.16 (Figure 1)

75


The UDI-6 can be divided into three domains: the first domain (questions 1 and 2) measures irritative symptoms like frequency and urgency, the second domain (questions 3 and 4) measures incontinence symptoms and the third domain (questions 5 and 6) measures obstructive symptoms.

Data and statistical analysisIt was hypothesized that women diagnosed with covert PUR would have micturition problems more frequently one year after delivery than women with a PVRV < 150 mL.

A difference of 8 points at the total score of the UDI-6 was considered to be clinically relevant.17 To achieve a power of 90% for detecting a significant difference with an α of 0.05 using a 2-sided unpaired t-test a total of 86 patients with asymptomatic urinary retention was needed for evaluation. During the study period the drop-out rate was higher than anticipated. Therefore, the total number of patients was raised to 120 in each group.

Patient characteristics and the prevalence of micturition symptoms were compared between patients with and without covert PUR using an unpaired Student’s t-test for continuous variables, a Mann–Whitney U-test in case of non-parametric distribution or a Pearson’s chi-square test for dichotomous variables (SPSS, IBM, version 23). We compared total mean scores of the total UDI-6 scores between both groups. Univariate and multivariate logistic regression was used to identify confounding factors. Statistical significance was determined by chi-square testing. A p-value of < 0.05 was used as the statistical significance level.

1. How much are you bothered by frequent urination?0 = not at all, 1 = slightly, 2 = moderately, and 3 = greatly.

2. How much are you bothered by leakage related to feeling of urgency?0 = not at all, 1 = slightly, 2 = moderately, and 3 = greatly.

3. How much are you bothered by leakage related to activity, coughing, or sneezing?0 = not at all, 1 = slightly, 2 = moderately, and 3 = greatly.

4. How much are you bothered by small amounts of leakage (drops)?0 = not at all, 1 = slightly, 2 = moderately, and 3 = greatly.

5. How much are you bothered by difficulty emptying bladder?0 = not at all, 1 = slightly, 2 = moderately, and 3 = greatly.

6. How much are you bothered by pain or discomfort in lower abdominal or genital area?0 = not at all, 1 = slightly, 2 = moderately, and 3 = greatly.

Figure 1: UDI-6 questionnaire

5

76

Chapter 5

In order to evaluate the contemporary definition of covert PUR (i.e. PVRV ≥ 150 mL after spontaneous micturition), as defined by Yip et al in 1997,4 the 75th and 95th percentile of the measured PVRVs in women with PVRV ≥ 150 mL was calculated to assess the current classification.

We also evaluated median UDI-6 total and domain scores for PVRV ≥ 250 mL and PVRV ≥ 500 mL. These cut-off values were based on a previous study in which the median PVRV of an unselected cohort of 745 patients was 140 mL and the 75th and 95th percentile were respectively 250 mL and 540 mL.18 As the currently used cut-off value, i.e. PVRV ≥ 150 mL, might be too low to discriminate between pathology and physiology, we believed adding these values would be clinically relevant.

77


RESULTS

A total of 241 patients were included: 122 patients with a PVRV ≥ 150 ml and 119 patients with PVRV < 150 ml. Of these patients data of respectively 119 and 105 patients could be used in final analysis, due to incomplete data.

Table 1 shows the baseline characteristics of the included patients. A PVRV ≥ 150 mL was more common among primiparous women as compared to multiparous women. Univariate regression analysis showed that only ‘any analgesia’ was a potential confounder with an OR 1.87 (95% CI 1.116 – 3.138). All other clinical factors were not statistically significant. In the multivariate regression analysis, no independent confounding factors remained.

The median voided volume was 370 mL (100 – 1100 mL) in women with PVRV < 150 mL and 350 mL (50 - 1900 mL) in women with PVRV ≥ 150 mL and did not differ significantly. The median PVRV in the total group was 175 mL and 300 mL in the group of women with a PVRV ≥ 150 mL. The 75th percentile of PVRV in the total study group was 303 mL and the 95th percentile was 549 mL. In patients with PVRV ≥ 150 mL, a total of 83 women had PVRV ≥ 250 mL and 19 women had PVRV ≥ 500 mL. This represents 68% and 16% of women respectively in the study group of women with PVRV ≥ 150 mL.

Table 1: Patient Characteristics

Patient characteristics PVRV < 150 mL PVRV ≥ 150 mL p

Nulliparous (%) 43% 58% 0,02

Gestational age* 39,3 39,4 NS

Maternal age (years)* 32 31,6 NS

Time first stage (hours)† 5 6 NS

Time second stage (minutes)† 6 20 NS

Mean volume first void (mL)† 370 350 NS

Spontaneous vaginal delivery (%) 85% 84% NS

Assisted vaginal delivery (%) 15% 16% NS

Birth Weight (grams)* 3373 3237 NS

Any analgesia (%) 35% 41% NS

Epidural analgesia (% of total patients) 16% 22% NS

Episiotomy (%) 18% 16% NS

* mean † median NS non-significant

5

78

Chapter 5

Women with PVRV ≥ 150 mL were re-evaluated at day 4 after delivery. At day 4, 92% of these women were able to completely empty their bladder. The PVRV of 8 out of a total of 100 women that returned at this visit remained above 150 mL (160 – 480 mL). From these 8 women, 7 women were able to void completely at day 7 and the final patient had a PVRV < 150 mL at day 10 postpartum.

Table 2 lists the results of the UDI scores compared to women with PVRV ≥ 150 mL, presented as total scores and domain scores. For women with PVRV ≥ 150 mL, no statistical significant differences were found one year after delivery. Regarding domain scores, we found that the first questionnaire (day 0, i.e. day of delivery), women with PVRV ≥ 150 mL experienced more irritative symptoms (p < 0.001). For other differences in domain scores, no statistical significant difference was reached.

Results on the UDI scores for PVRV ≥ 250 mL and PVRV ≥ 500 mL are presented in Table 3; besides more stress symptoms in women with PVRV < 250 mL, no statistical significant differences were identified.


Tabl

e 2:

UD

I-6 s

core

s: w

omen

with

PVR

V <

150

mL

com

pare

d to

wom

en w

ith P

VRV

≥ 1

50 m

L

Da

y 0Da

y 4Da

y 7Da

y 30

Day 9

0Da

y 365

<150

mL

≥150

mL

p<1

50m

L≥1

50m

Lp

<150

mL

≥150

mL

p<1

50m

L≥1

50m

Lp

<150

mL

≥150

mL

p<1

50m

L≥1

50m

Lp

n=94

n=11

9n=

72n=

100

n=69

n=77

n=63

n=68

n=57

n=64

n=63

n=80

UD

I-6 to

tal s

core

*10

,8±1

4,5

11,4

±12,

60,

49±

11,2

8,6±

10,2

0,6

7,5±

7,6

9,4±

13,6

0,9

6,6±

9,2

6,1±

9,5

0,6

5,8±

8,7

8,0±

10,6

0,2

8,1±

11,1

9,8±

11,3

0,2

Irrita

tive

sym

ptom

s*

9,6±

18,7

13,6

±17,

40,

015

5,8±

11,2

7,5±

13,9

0,6

5,6±

10,9

7,6±

17,2

0,9

6,1±

11,8

3,9±

9,6

0,2

3,5±

8,2

6,3±

12,0

0,3

7,7±

14,3

10,4

±17,

50,

2

Stre

ss sy

mpt

oms*

11

,5±1

89,

0±15

,60,

27,

2±14

,55,

5±10

,90,

812

,6±1

5,8

8,0±

17,0

0,6

7,4±

12,9

7,1±

13,6

0,7

8,8±

14,8

10,1

±16,

40,

610

,6±1

6,7

10,6

±17,

00,

8

Obs

truct

ive

sym

ptom

s*

11,5

±20

11,8

±17,

50,

413

,9±1

8,5

12,7

±17,

40,

76,

6±9,

212

,6±1

6,3

0,8

6,4±

11,4

7,1±

12,9

0,8

5,0±

9,9

7,6±

11,8

0,2

6,1±

12,8

8,5±

15,2

0,2

*(m

ean

± S

D)

Tabl

e 3:

UD

I-6 s

core

s: w

omen

with

PVR

V <

250

mL

com

pare

d to

wom

en w

ith P

VRV

≥ 2

50 m

L

Day 0

Day 4

Day 7

Day 3

0Da

y 90

Day 3

65<

250m

L≥

250m

Lp

<25

0mL

≥25

0mL

p<

250m

L≥

250m

Lp

<25

0mL

≥25

0mL

p<

250m

L≥

250m

Lp

<25

0mL

≥25

0mL

p

n=13

5n=

78n=

107

n=65

n=96

n=50

n=85

n=46

n=77

n=44

n=92

n=51

UD

I-6 to

tal s

core

*11

,7±

14,2

10,2

±11

,90,

69,

3±9,

87,

8±10

,00,

27,

6±8,

110

,1±

15,4

0,9

6,6±

8,8

5,8±

10,3

0,3

7,2±

10,8

6,4±

7,8

0,7

9,4±

12,1

8,5±

9,6

0,9

Irrita

tive

sym

ptom

s*11

,4±

18,9

12,6

±16

,40,

27,

3±12

,95,

9±12

,60,

44,

9±9,

38,

3±19

,10,

75,

5±11

4,0±

10,1

0,3

4,8±

10,8

5,3±

10,0

0,5

9,6±

16,9

8,5±

14,7

0,9

Stre

ss s

ympt

oms*

12,1

±17

,66,

6±14

,50,

008

7,5±

14,2

4,0±

8,8

0,2

5,9±

11,6

8,7±

18,8

0,7

7,3±

12,7

7,3±

14,4

0,7

10,4

±17

,58,

0±11

,60,

912

±18

,58,

2±13

,10,

3

Obs

truct

ive

sym

ptom

s*11

,9±

18,8

11,3

±18

,30,

813

,1±

17,3

13,3

±18

,90,

812

,1±

15,2

13,3

±17

,50,

97,

1±12

,16,

2±12

,40,

66,

5±11

,56,

1±10

,20,

96,

7±14

,68,

8±13

,50,

1

<50

0mL

≥50

0mL

p<

500m

L≥

500m

Lp

<50

0mL

≥50

0mL

p<

500m

L≥

500m

Lp

<50

0mL

≥50

0mL

p<

500m

L≥

500m

Lp

n=19

4n=

19n=

157

n=15

n=13

1n=

15n=

117

n=14

n=11

1n=

10n=

132

n=11

UD

I-6 to

tal s

core

*11

,3±

13,6

9,4±

11,7

0,6

8,5±

9,3

11,5

±14

,80,

77,

5±8,

317

,0±

23,7

0,3

6,2±

8,6

7,14

±15

,60,

66,

9±9,

97,

2±8,

70,

69,

3±11

,47,

1±8,

90,

7

Irrita

tive

sym

ptom

s*11

,9±

18,3

10,5

±14

,90,

96,

5±12

,210

,0±

18,7

0,5

4,6±

8,8

18,9

±31

,40,

24,

7±9,

99,

5±19

,30,

94,

8±10

,46,

7±11

,70,

59,

5±16

,76,

1±8,

40,

9

Stre

ss s

ympt

oms*

10,6

±17

4,3±

12,2

0,07

6,4±

12,7

4,4±

9,9

0,6

6,1±

11,9

13,3

±28

,30,

67,

0±12

,44,

8±13

,80,

99,

6±16

8,3±

11,8

0,9

10,7

±17

,19,

1±13

,70,

9

Obs

truct

ive

sym

ptom

s*11

,5±

18,4

13,1

±21

,10,

712

,5±

16,8

20,0

±26

,10,

311

,8±

15,3

18,9

±20

,80,

27,

0±12

,07,

2±8,

70,

26,

3±10

,86,

7±14

,10,

77,

6±14

,26,

1±15

,40,

5

*(m

ean

± S

D)

5

80

Chapter 5

DISCUSSION

This study shows that many women experience inadequate voiding directly after vaginal delivery. Post void residual volumes up to 1000 mL have been measured in postpartum women after spontaneous micturition. 92% of women with PVRV > 150 mL after the first void was able to adequately empty their bladder the fourth day after vaginal delivery. Regarding long term micturition problems, one year after vaginal delivery, no statistical significant differences could be found in women with PVRV ≥ 150 mL as compared to women with PVRV < 150 mL.

Our study supports the findings in previous publications that covert PUR is a common phenomenon after vaginal delivery. Moreover, this study confirms that abnormal PVRVs after vaginal delivery ‘recover’ spontaneously after several days, as 92% of our population was able to empty their bladder sufficiently 4 days after delivery.1,6,9,19,20 The patients with prolonged PUR (i.e. persistent increased PVRVs after 4 days, n=8), we found no statistical significant differences in UDI total or domain scores or patient characteristics as compared to the control group.

In the group with PVRV ≥ 150 ml, 15% of women had a PVRV ranging from 150 to 250 ml, 69% (n=86) had a PVRV between 250 to 500 ml and 16% (n=19) of women had a PVRV above 500 ml. This implies that in clinical daily practice, a considerable percentage of women with high residual volumes remain unnoticed.

With a median PVRV of 175 mL after the first void in the total group and median PVRV of 300 mL in the group of women with a PVRV ≥ 150 mL, it is reasonable to assume that the cut-off value of 150 mL, as used by many authors1,4 and based on residual volumes in non-pregnant patients, may be too low to detect actual pathology. Many authors focus on abnormal post void residual volumes, however an internationally accepted definition with a clinically significant threshold values is missing.21 Although large PVRVs (≥ 200-300 mL) may suggest a higher incidence of lower urinary tract symptoms , evidence for using this measurement as a predictor is low.22 It seems reasonable to define adequate emptying of the bladder as a voided volume which is over 2/3 of the bladder capacity, indicating that residual volumes over 30% of the bladder volume could be abnormal. With non-pregnant females with bladder capacities around 400-500 mL, this would result in PVRV < 150 mL. However, as bladder volumes in pregnant and postpartum can reach and exceed 1000 mL, it is a reasonable assumption that limiting PVRVs to 150 mL after delivery is clinically irrelevant. Since over 15% of our patients had PVRV ≥ 500 mL, comparable to previous studies,18,19 we believe the cut-off value to detect potential pathology should be increased. We therefore suggest that the new definition of covert PUR should be: “covert or asymptomatic postpartum urinary retention (PUR) includes post void residual volume (PVRV) ≥ 500 mL after the first spontaneous void after (vaginal) delivery, measured by ultrasound or catheter”. This adjusted definition could help us to learn more about

81


potential LUTS related to inadequate bladder emptying after (vaginal) delivery and should therefore not only be a topic for future research but also be widely accepted by international expert societies and incorporated in daily clinical guidelines.

Our study is the first using a validated questionnaire to examine lower urinary tract symptoms (LUTS) in women with increased PVRV after the first spontaneous micturition following vaginal delivery.16 Previous studies have mainly focused on the prevalence and transient course of covert PUR.1,4,6 To our knowledge only Yip and colleagues published results on their evaluation of long term micturition problems in women with postpartum urinary retention, four years after childbirth.23 In this study, no significant differences in the occurrence of urinary incontinence were detected. However, a few remarks can be made. Besides the use of non-validated questionnaires, no distinction was made between women with covert or overt PUR. Although both phenomena refer to inadequate voiding after delivery, the pathophysiology of the inability to void (overt PUR) and incomplete bladder emptying (covert PUR) might be different, resulting in different management strategies and potential long term consequences.

The results of our study are also consistent with published studies on bothersome LUTS in women one year after delivery.24,25 In our total population, 42% of women experienced some bladder symptoms, with 12% bothersome irritative symptoms, 15% moderate to severe stress related complaints and 11% moderate to severe obstructive or discomfort symptoms. Although we have no information on the prevalence of LUTS before or during gestation in our patients, we believe our study population is a reliable representation of the general population.

Although the pathophysiology of urinary retention is still unknown and probably multifactorial, we can learn from our results. With a median first voided volume of 355 mL (± 263 mL) and a median PVRV of 174 mL (± 176 mL), women in our study showed a much higher bladder capacity than those found in non-pregnant females.22,26 While the majority of our patients showed large voided volumes, up to 1900 mL, we think it is reasonable that these findings reflect physiology of pregnancy, whereas pregnancy is characterized by drastic changes to several organs and organ systems. Not only are there anatomical changes like dilation of the ureters and calyces of the kidneys but also several functional changes like increased glomerular filtration and urinary output. The bladder capacity most likely adapts to these new functional requirements.27 The bladder, being attached to the growing uterus, has to adapt to this stretch and extra urine production in order to prevent overdistension and facilitate extra storage function. The latter possibly preventing bothersome frequency in order to maintain relatively normal daily activities of pregnant women.

Another factor can be the influence of hormonal changes. Progesterone and relaxin might be (partially) accountable. Relaxin is a peptide hormone of the insulin-like growth

5

82

Chapter 5

factor family and has been associated with collagen remodeling and adjustments of renal physiology and vasodilatation in normal pregnancy. 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.28 It is not unthinkable that relaxin has an effect on bladder characteristics too. Progesterone is a more known gestational hormone which is not only important in retaining pregnancy but also reduces urethral tone, peristalsis and contraction pressure of the bladder, potentially resulting in enlargement of bladder capacity in the puerperium.29

Some limitations of our study need to be discussed, first of all the large amount of incomplete questionnaires. Despite repeated invitations by (e-)mail or phone, numerous patients did not react to these reminders to respond. Initially our sample size calculation was based on 15% of dropouts. However, during the study period we experienced that up to 35% of included patients were lost to follow up. Therefore it was necessary to file an amendment in order to reach the required number of patients. Although we eventually were not able to collect the initially required 86 complete questionnaires one year after delivery per group, resulting in insufficient power of our data, we believe our results are reliable. We found no statistical significant differences between the patients who were lost to follow up and the patients who completed all questionnaires. Our sample size calculation was based on finding a difference of 8 points in the total UDI score. However, with a mean UDI total score of 8.1 ± 11.1 in women with PVRV < 150 mL and mean 9.8 ± 11.3 in patients with PVRV ≥ 150 mL, a difference of 8 points does not seem to be clinically relevant in this population, as the majority of women do not experience lower urinary tract symptoms, consistent with previous studies.24,30 It is possible that the group of women with complaints were more inclined to respond, in this way generating an information bias. However, the possible effect of this bias is considered to be small as the distribution of incomplete data was equal between the group with and without abnormal PVRV. We therefore believe that although there might be statistical underpower of our results, we have shown that PVRV ≥ 150 mL is not related with increased urinary related problems one year after delivery.

A second limitation could be the time of measurement of the PVRV. According to our study protocol this was performed after the first spontaneous void after delivery. In other studies this was done after 24 hours up to 72 hours after delivery, resulting in lower prevalences of covert PUR.4,19,20 Therefore it is possible that our results have overestimated the occurrence of abnormal PVRV. However, as most women who deliver vaginally leave the hospital within a few hours and the ability to void spontaneously is used as an indication for adequate bladder function, we believe that if the PVRV is measured, it is only feasible to do after the first spontaneous micturition. Another limitation could be the potential selection we have created by only including patients delivering in the hospital. This could possibly mean that we selected women who

83


have had more complicated deliveries, compared to women without medical history or medical indication to deliver in the hospital.

Last, we were not informed on our patient’s individual ‘normal’ PVRV and ‘normal’ UDI-6 scores before delivery and pregnancy. However, it seems unlikely that these otherwise healthy young women would have urinary retention related symptoms in their earlier life. We therefore believe this doesn’t influence our results to a great extent.

The results of our study confirm previous studies that covert PUR in women after vaginal delivery normalizes spontaneously within several days1,4,6,20 and that women with PVRV ≥ 150 mL don’t experience more lower urinary tract symptoms one year after delivery.

While we believe that the cut-off value of PVRV ≥ 150 mL is insufficient to distinguish between physiology and pathology and is based on limited data in non-pregnant patients, we suggest to adjust the definition of covert PUR and incorporate it into daily clinical practice. Women at risk for covert PUR, defined as PVRV ≥ 500 mL after the first spontaneous void after (vaginal) delivery, should be the focus of future research in order to learn whether these patients could benefit from screening and treatment.6,18

CONCLUSIONS

Covert PUR according to the definition of PVRV ≥ 150 mL, is a common and transient phenomenon after vaginal delivery which does not result in more lower urinary tract symptoms one year after delivery. While the current definition is not useful to identify postpartum those women who have pathology, we suggest to change the definition of covert PUR into: “post void residual volume ≥ 500 mL after the first spontaneous void after (vaginal) delivery”. This cut-off value is the value at which some women do need more time to normalize emptying of the bladder. The exact clinical implications of covert PUR need to be further studied in this subcategory of women.

5

84

Chapter 5

REFERENCES

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







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




12. van Brummen HJ, Bruinse HW, Van de Pol G, Heintz AP, van der Vaart CH. Bothersome lower urinary tract symptoms 1 year after first delivery: prevalence and the effect of childbirth. BJU Int. 2006;98(1):89-95.

13. Shumaker SA, Wyman JF, Uebersax JS, McClish D, Fantl JA. Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Qual Life Res. 1994;3(5):291-306.

14. Utomo E, Korfage IJ, Wildhagen MF, Steensma AB, Bangma CH, Blok BF. Validation of the urogenital distress inventory (UDI-6) and incontinence impact questionnaire (IIQ-7) in a Dutch population. Neurourol Urodyn. 2015 Jan;34(1):24-31

15. van der Vaart CH, de Leeuw JR, Roovers JP, Heintz AP. Measuring health-related quality of life in women with urogenital dysfunction: the urogenital distress inventory and incontinence impact questionnaire revisited. Neurourol Urodyn. 2003;22(2):97-104.

16. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn. 1995;14(2):131-139.

85


17. Barber MD, Spino C, Janz NK, et al. The minimum important differences for the urinary scales of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. Am J Obstet Gynecol. 2009;200(5):580-587.

18. Mulder FE, Rengerink KO, Van der Post JA, Hakvoort RA, Roovers JW. Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery. Int Urogynecol J. 2016 Jan;27(1):55-6

19. 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.


21. Asimakopoulos AD, De Nunzio C, Kocjancic E, Tubaro A, Rosier PF, Finazzi-Agro E. Measurement of post-void residual urine. Neurourol Urodyn. 2016;35(1):55-57.

22. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology. 2003;61(1):37-49.


24. van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH. Bothersome lower urinary tract symptoms 1 year after first delivery: prevalence and the effect of childbirth. BJU Int. 2006;98(1):89-95.

25. Viktrup L. The risk of lower urinary tract symptoms five years after the first delivery. Neurourol Urodyn. 2002;21(1):2-29.

26. Groutz A, Blaivas JG, Chaikin DC. Bladder outlet obstruction in women: definition and characteristics. Neurourol Urodyn. 2000;19(3):213-220.

27. Bakircioglu ME, Sievert KD, Lau A, Lin CS, Lue TF. The effect of pregnancy and delivery on the function and ultrastructure of the rat bladder and urethra. BJU Int. 2000;85(3):350-361.

28. Rechberger T, Uldbjerg N, Oxlund H. Connective tissue changes in the cervix during normal pregnancy and pregnancy complicated by cervical incompetence. Obstet Gynecol. 1988;71(4):563-567.

29. Beydoun SN. Morphologic changes in the renal tract in pregnancy. Clin Obstet Gynecol. 1985;28(2):249-256.


5

IIIPART

POSTPARTUM BLADDER MANAGEMENT

6CHAPTER

Submitted for publication.

F.E.M. Mulder S. van der Velde F. Pol M. Bos J. Schagen van Leeuwen V. Dietz R.A. Hakvoort J.P.W.R. Roovers

The accuracy of post void residual volumes after vaginal delivery: a prospective equivalence study to compare an automatic scanning device with transurethral catheterisation

90

Chapter 6

ABSTRACT

Background: Abnormal post void residual volumes (PVRV) after delivery are common in daily clinical practice. By using an automatic scanning device, unnecessary catheterizations can be prevented.

Objective: To determine the accuracy of post void residual volumes (PVRV) after vaginal delivery measured by an automatic scanning device through a comparison with transurethral catheterization.

Methods: This prospective observational equivalence study was performed in patients who delivered vaginally between June 2012 and May 2017 in three teaching hospitals in the Netherlands. After the first spontaneous void after vaginal delivery, the post void residual volume (PVRV) was measured with a portable automatic scanning device (BladderScan® BVI 9400).Directly afterwards, PVRV was measured by catheterization. Correlation between the two measurements was calculated using Spearman’s correlation coefficient and agreement plot. The primary outcome was to validate the correlation between the BladderScan® for measurement of PVRV after vaginal delivery, compared to the gold standard i.e. transurethral catheterization.

Results: Data of 407 patients could be used for final analysis. The median PVRV as measured by BladderScan® was 380 mL (± 261 mL, 0 - 999 mL), by catheterization this was 375 mL (± 315 mL, 0 - 1800 mL). The mean difference between measurements was -12.9 mL (± 178 mL). There was a very good correlation between the two methods (Spearman’s rho = 0.82, p < 0.001). Using a cut-off value of PVRV > 500 mL, the specificity and sensitivity were 85.4% and 85.6% respectively.

Conclusions: The BladderScan® (BVI 9400) measures precisely and reliably the PVRV after vaginal delivery and should be preferred over catheterization.

91

Validating the use of BladderScan® after vaginal delivery

INTRODUCTION

After delivery, abnormal post void residual volumes (PVRV) after spontaneous voiding attempts are encountered in up to 45% of women.1-5 This condition is also known as asymptomatic or covert postpartum urinary retention (PUR). Although evidence for long term clinical consequences of abnormal PVRV postpartum is missing, literature suggests that even a single episode of bladder overdistension can result in prolonged micturition problems, urinary tract infections and renal obstruction.6-9 Therefore, an accurate and timely diagnosis is important.

To measure PVRV, different techniques are available. Transurethral catheterisation is considered the ‘gold standard’ method for accurate measurement of bladder volume and PVRV. However, (real time) ultrasonography has proven to be a valid and reliable substitute.10,11 Nevertheless, the use of a regular ultrasound device requires specific expertise and training but also a mathematic calculation after measurement. This makes the method unsuitable for every day clinical use. In order to facilitate the recognition of urinary retention, automatic portable devices have been developed. In many fields of medicine, screening for PVRV with a portable BladderScan® device is part of routine care, for example in patients with neurogenic bladders, voiding dysfunction or after orthopaedic or uro(gynaeco)logical surgery.12-14 In this way unnecessary trans-urethral catheterisations can possibly be reduced.15,16 The effect of such measure could be the reduction of nosocomial infections, patient discomfort and healthcare costs.

However, the technique is not widely accepted. A reason for this could be that the portable bladder scanner might not only measure the volume of the bladder but also the (remaining bloody content of the) uterus and its pronounced vascularisation. While the reliability of the BladderScan® is confirmed in men as well as in non-pregnant women,17-19 its reliability in the puerperium remains inconclusive.20,21 Although several studies have compared portable bladder scanning devices with catheterisation, these studies were all small or validation was done for relatively high residuals. 4,22,23, 24,25 In order to determine the accuracy of the BladderScan® in women directly after vaginal a prospective equivalence study was conducted.

6

92

Chapter 6


Between June 2012 and May 2017, this study was conducted in three Dutch teaching hospitals. This study was approved by the medical committee of the Catharina Hospital in Eindhoven, the Netherlands (M11-1165) after which the two other centres followed its approval. Women were asked to participate in this study prior to their delivery, if they were ≥ 18 years old and were to deliver vaginally. Women were either counselled and included before the onset of labour or were asked to participate after having given birth. Written informed consent was obtained from all patients.

OutcomesThe primary outcome of this equivalence study was to determine the accuracy of the BladderScan® directly postpartum. In order to evaluate whether the BladderScan® can be used to detect abnormal or increased residual volumes in women after vaginal delivery, the PVRV as measured by BladderScan® was compared with the measurement of the PVRV collected by transurethral catheterisation. Measurements were done directly after the first void after vaginal delivery. The agreement between these measurements was calculated using Spearman’s rank correlation coefficient, using the following statistical cut-off values: 0 < r > 0.19 “very weak correlation”, 0.20 < r > 0.39 “weak correlation”, 0.40 < r > 0.59 “ moderate correlation” , 0.60 < r > 0.79 “strong correlation” and 0.80 < r > 1.0 “very strong correlations. In addition, an agreement plot was calculated. Second, we wanted to determine the sensibility and specificity of the device, using the cut-off value of 500 mL, while we believe this is a valid cut off to discriminate between physiology and pathology.26

MeasurementsPVRVs were measured with a portable bladder scanning device (BVI-9400 BladderScan®, Verathon Medical Europe, Ijsselstein, the Netherlands). After the first spontaneous micturition, bladder content was measured with the patient in supine position. Scanning was performed abdominally, two fingers above the symphysis pubis. Directly afterwards, the bladder was emptied with a single use catheter and the residual volume was collected and measured. Prior to the use of the BladderScan® nursing staff was trained by an expert from the manufacturer. In all hospitals the same new model was used. The BladderScan® has an upper limit of 999 mL: cases in which the apparatus showed “> 999 mL” were considered and analysed as being 999 mL. Pregnancy and delivery related data were obtained from electronic patient charts.

Sample size calculation The sample size was calculated based on equivalence between both methods. With an alpha of 0.05, power of 80%, standard deviation of 50 and an expected difference of 10% (+5% and -5%), it was calculated that at least total of 310 paired measurements were necessary.

93


Statistical analysis Measurements of post void urinary volume by BladderScan® and catheterisation were compared. For statistical analysis, SPSS version 24.0 (IBM) was used. Results of data were reported as a mean (in case of normal distribution) or a median (in case of abnormal distribution). In order to calculate the correlation, Bland-Altman plot, Spearman’s rank correlation coefficient and Wilcoxon signed rank test were used when appropriate. A p-value < 0.05 was considered to be statistically significant.

6

94

Chapter 6

RESULTS

Data of 407 patients could be used for final analysis. Table 1 shows the patient characteristics of the included patients.

The median volume of the catheterisation measurements was 375 mL (0 – 1800 mL), the 25th percentile was 150 mL and the 75th percentile was 600 mL. The median volume of the BladderScan® measurements was 380 mL (0 – 999 mL), with the 25th and 75th percentile being 200 mL and 567 mL respectively. The mean difference between the two measurements was -13 mL (SD ± 177 mL). These results are presented in Table 2.

The agreement between the two measurements methods are presented in a Bland-Altman plot, comparing BladderScan® volumes and catheterisation volumes, as presented in Figure 1. Spearman’s rank correlation coefficient calculation showed a close correlation of the BladderScan® with the catheterised bladder volumes (r = 0.82, p < 0.01).

Table 2: PVRV measurements

Bladderscan CatheterisationMinimum 0 mL 0 mL

Maximum > 999 mL 1800 mL

Median (± SD) 380 mL (± 261) 375 mL (± 315)

Mean Difference (± SD) -12,87 mL (± 178)

Table 1: Patient characteristics

Nulliparous 59%

Gestational age* 39.7 (weeks)

Maternal age* 30.5 years

Time first stage† 5.8 hours

Time second stage† 34 minutes

Spontaneous vaginal delivery 79%

Assisted vaginal delivery 21%

Birth Weight* 3430 grams

Any analgesia 66%

Epidural analgesia 44%

Vaginal rupture 42%

Episiotomy 49%

* mean † median

95


Figure 1: Correlation between residual volume measured by BladderScan® and by Catheterisation (dashed lines 95% CI)

Figure 2: Agreement plot (95% limits of agreement)

Resi

dual

vol

ume

mea

sure

d by

cat

hete

risati

on

Residual volume measured by Bladderscan

6

96

Chapter 6

The Spearman’s rank correlation coefficient was repeated after excluding extreme data ( i.e. BS > 999 mL only and BS > 999 mL plus catheterisation volume exceeding 1000 mL). With these restrictions outcomes remained similar, resulting in close correlation with r = 0.80 and r = 0.78 respectively.

An agreement plot with 95% confidence interval showing the mean average of measurement by BladderScan® and catheterisation compared to the difference between the measurements, is shown in figure 2. Here, a good agreement over the whole measurement reach of 0 - 1000 ml was found.

Table 3 shows the mean PVRV by BladderScan®, by catheterisation and the mean difference between these two measurements, categorised per 100 mL group (as measured with a BladderScan®).

In Table 4 the sensitivity and specificity are calculated using a PVRV ≥ 500 mL as a cut-off value.

Table 3: Median differences per category (per 100 mL)

BladderScan category per 100 mL n = Median PVRV

Bladderscan (± SD)Median PVRV

Catheterisation (± SD)Median difference (BS-CAD) (± SD)

0 – 100 mL 56 53 mL (±31) 60 (±68) -7 (±66)

101 – 200 mL 60 164 mL (±33) 195 (±211) -12 (±200)

201 – 300 mL 44 263 mL (±32) 212 (±132) 12 (±130)

301 – 400 mL 56 350 mL (±29) 350 (±139) 2 (±131)

401 – 500 mL 59 450 mL (±31) 450 mL (±164) 0 mL (±156)

501 – 600 mL 46 551 mL (±29) 575 mL (±211) -14 mL (±202)

601 – 700 mL 31 667 mL (±31) 690 mL (±210) 0 mL (±205)

701 – 800 mL 16 767 mL (±39) 800 mL (±137) -51 mL (±140)

801 - 900 mL 20 877 mL (±32) 830 mL (±228) 17 mL (±232)

901 – 999 mL 5 960 mL (±37) 875 mL (±147) 56 mL (±178)

Table 4: Sensitivity and specificity PVRV ≥ 500 mL

BladderScan < 500 mL BladderScan ≥ 500 mL Total

Catheterisation < 500 mL n = 229Specificity 85,4% n = 20 n = 249

Catheterisation ≥ 500 mL n = 39 n = 119Sensitivity 85,6% n = 158

Total n = 268 n = 139 n = 407

97


DISCUSSION

Based on our study results we conclude that the BladderScan® is an accurate and therefore valid alternative to the invasive measurements obtained by catheterisation in measuring PVRV directly after vaginal delivery.

By measuring the PVRVs in a large and non-selected group of women after vaginal delivery a high degree of agreement was found between the two measurement methods. This agreement was found in the whole range of PVRVs, which is known to be very wide directly post-partum.5,27 We believe this is sufficient evidence to support the use of the BladderScan® BVI-9400 after vaginal delivery. Measuring the post void residual volume is not part of standard postpartum care and various authors have shown that increased residual volumes often normalise within several days.27,28 However in daily clinical practice there is a need to identify abnormal PVRV, for instance when micturition produces very small portions of urine.

To minimise the risk of damage to the bladder an accurate and timely measurement of post void residual volumes is important to decide whether treatment should be started. In the absence of other techniques and because of a slight advantage that catheterisation is a measurement technique as well as a treatment, it has been the accepted gold standard for PVRV measurements. While it can cause considerable physical discomfort and inevitably increases the risk for urinary tract infections, non-invasive alternatives are nevertheless preferable.

However, evidence on the accuracy of non-invasive methods after delivery is scarce. Concerning automatic scanning devices, seven earlier studies reported on validity or reliability of measuring bladder volumes after delivery.4,20-25 However, the vast majority of these studies reported on a small patients sample in selected cases.21,24,29 Our study has a considerable larger sample size and was prospectively designed as an equivalence study to objectively assess accuracy of the BladderScan®. Further, this study was conducted in an unselected cohort of women, whereas other studies were potentially biased by including women who were at risk of having abnormal PVRV, women who were only catheterised in case PVRV exceeded 300 mL or women with and indwelling Foley catheter in situ which was clamped in order to measure bladder volumes.21,24,25 This inevitably leads to selection and therefore validation of the BladderScan® in higher regions of residual volumes.

Furthermore the PVRV of the patients in our study have all been measured using the same newer model, i.e. BVI 9400. To our knowledge this study is the first to determine the accuracy of this newer model. The earlier used previous models (BVI 3000 and BVI 6100) were, according to the manufacturer, inferior in discriminating bladder volumes from the uterus itself.

6

98

Chapter 6

A recurring thought is that an automatic scanning device could overestimate residual volumes as it would also measure the content of the uterus. However, others demonstrated by repetitive ultrasound after delivery that in the early puerperium the cavity of the uterus is generally empty, and fluid and debris are mostly seen in the middle puerperium (from the 7th day after delivery).30 In addition, it has been found that the median volume of the uterus after delivery is 22 cm3. This shows that the thoughts on overestimation of PVRV by the BladderScan® after delivery are non-evidence based and unfounded.31

Nevertheless, there are some limitations to our study that need to be addressed. First, there was a large group of nurses performing the measurements. Despite the ease of use and the structured training they all received before the study commenced, this still may have introduced variation in measurements. While we have no data on the measurements of the amount of different persons measuring for this study, inter-observer coefficients cannot be reproduced. Potentially with a smaller nursing staff or more extensive training, the performance of the BladderScan® would have been better. However, despite this we believe that the measurements done by a larger group of nurses reflects daily practice. Further, the effect of an inter-observer variation is expected to be small as a very strong correlation was found. The second limitation is that the time between the measurement with the Bladderscan® and catheterisation was often not recorded in patient files. Both transurethral catheterisation and scanning will only produce reliable values when the measurements are performed directly after micturition to minimise refilling due to continuing diuresis.32,33 Although, by protocol, the measurements had to be performed directly after each other we do not have data whether the protocol was violated. This would have been especially interesting in the cases were extreme differences were found between the two techniques, possibly resulting in a better correlation.

The importance of any measurement technique is that it is accurate in discriminating between patients who need to be treated and who do not. We have shown that this type of scanning device is suitable for all volume ranges. However, to minimalise overtreatment a valid cut-off value to discriminate physiology from pathology is essential. In current literature, asymptomatic postpartum urinary retention (covert PUR) is defined as a PVRV ≥ 150 mL after spontaneous micturition. Previously, we suggested to increase this cut-off value to PVRV ≥ 500 mL based on the high residual volumes found in a previous unselected cohort of women after vaginal delivery.5 With a median PVRV of 375 - 380 mL found in this study (± 216 - 315 mL) we believe that commonly used limit of 150 mL lies well within the physiological range and probably results to unnecessary management of a physiological phenomenon. Using the new cut-off value of PVRV ≥ 500 mL, we believe the BladderScan® can accurately be used in clinical daily practice, with a specificity of 85.4% and sensitivity of 85.6%. (Table 4)

99


CONCLUSIONS

The BladderScan® BVI 9400 is an accurate alternative to evaluate post void residual volumes after vaginal delivery and is preferred over trans-urethral catheterisation in order to reduce the risk on urinary tract infection and optimise patient comfort.

6

100

Chapter 6

REFERENCES





5. Mulder FE, Rengerink KO, Van der Post JA, Hakvoort RA, Roovers JW. Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery. Int Urogynecol J. 2016 Jan;27(1):55-6



8. Abe T, Shinno Y, Kawakura K, Moriya K. Acute renal failure occurring from urinary retention due to a mullerian duct cyst. Int J Urol. 2000;7(2):69-71.


10. Hakenberg OW, Ryall RL, Langlois SL, Marshall VR. The estimation of bladder volume by sonocystography. J Urol. 1983;130(2):249-251.

11. Bano F, Arunkalaivanan AS, Barrington JW. Comparison between bladderscan, real-time ultrasound and suprapubic catheterisation in the measurement of female residual bladder volume. J Obstet Gynaecol. 2004;24(6):694-695.

12. Hollman F, Wolterbeek N, Veen R. Risk Factors for Postoperative Urinary Retention in Men Undergoing Total Hip Arthroplasty. Orthopedics. 2015;38(6):e507-511.

13. Hakvoort RA, Dijkgraaf MG, Burger MP, Emanuel MH, Roovers JP. Predicting short-term urinary retention after vaginal prolapse surgery. Neurourol Urodyn. 2009;28(3):225-228.

14. Abdel-Fattah M, Barrington JW. The accuracy of Bardscan: a new tool for the measurement of the bladder volume. J Obstet Gynaecol. 2005;25(2):186-188.

15. Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters. Emerg Infect Dis. 2001;7(2):342-347.

16. Tambyah PA, Oon J. Catheter-associated urinary tract infection. Curr Opin Infect Dis. 2012;25(4):365-370.

17. Bent AE, Nahhas DE, McLennan MT. Portable ultrasound determination of urinary residual volume. Int Urogynecol J. 1997;8(4):200-202.

101


18. Goode PS, Locher JL, Bryant RL, Roth DL, Burgio KL. Measurement of postvoid residual urine with portable transabdominal bladder ultrasound scanner and urethral catheterization. Int Urogynecol J. 2000;11(5):296-300.

19. Fuse H, Yokoyama T, Muraishi Y, Katayama T. Measurement of residual urine volume using a portable ultrasound instrument. Int Urol Nephrol. 1996;28(5):633-637.

20. Mathew S, Horne AW, Murray LS, Tydeman G, McKinley CA. Are portable bladder scanning and real-time ultrasound accurate measures of bladder volume in postnatal women? J Obstet Gynaecol. 2007;27(6):564-567.

21. Barrington JW, Edwards G, Ashcroft M, Adekanmi O. Measurement of bladder volume following cesarean section using bladderscan. Int Urogynecol J. 2001;12(6):373-374.



24. Pallis LM, Wilson M. Ultrasound assessment of bladder volume: is it valid after delivery? Aust N Z J Obstet Gynaecol. 2003;43(6):453-456.

25. Nusee Z, Ibrahim N, Rus RM, Ismail H. Is portable three-dimensional ultrasound a valid technique for measurement of postpartum urinary bladder volume? Taiwan J Obstet Gynecol. 2014;53(1):12-16.

26. Mulder FEH, R.A., de Bruin JP, Janszen EW, van der Post JA, Roovers JP. Long term micturition problems of asymptomatic postpartum urinary retention: a prospective case control study. Int Urogynecol J 2017;accepted for publication



29. Weissman A, Grisaru D, Shenhav M, Peyser RM, Jaffa AJ. Postpartum surveillance of urinary retention by ultrasonography: the effect of epidural analgesia. Ultrasound Obstet Gynecol. 1995;6(2):130-134.

30. Mulic-Lutvica A, Bekuretsion M, Bakos O, Axelsson O. Ultrasonic evaluation of the uterus and uterine cavity after normal, vaginal delivery. Ultrasound Obstet Gynecol. 2001;18(5):491-498.

31. Belachew J, Axelsson O, Mulic-Lutvica A, Eurenius K. Longitudinal study of the uterine body and cavity with three-dimensional ultrasonography in the puerperium. Acta Obstet Gynecol Scand. 2012;91(10):1184-1190.

32. Cardozo L, A. C. Is disturbed bladder function after pregnancy normal? . Maternal and Child Health. 1993;18(6):180-183.

33. Klevmark B. Natural pressure-volume curves and conventional cystometry. Scand J Urol Nephrol Suppl. 1999;201:1-4.

6

7CHAPTER

F.E.M. Mulder R.A. Hakvoort J.P. de Bruin J.A.M. van der Post

J.P.W.R. Roovers

Comparing clean intermittent (CIC) versus transurethral indwelling catheterisation (TIC) for the treatment of overt urinary retention after vaginal delivery: a multicentre randomized controlled clinical trial

International Urogynecology Journal (2017): accepted for publication. (Epub ahead of print)

104

Chapter 7

ABSTRACT

Background:Overt postpartum urinary retention (PUR) is the inability to void after delivery and affects up to 7% of patients. Clean intermittent catheterization (CIC) and transurethral indwelling catheterization (TIC) are both standard treatments, but have not previously been com-pared. Clinical guidelines on postpartum bladder management are lacking.

Methods:A total of 85 patients were randomised for TIC (n=45) and CIC (n=40). In total 68 patients (34 patients with TIC and 34 patients with CIC) completed the UDI-6 questionnaire 3 months after delivery. Patients allocated to TIC had received an indwelling catheter in place for 24 h and if necessary, another catheter for 48 h. Patients with CIC were inter-mittently catheterized or taught to self-catheterize until adequate voiding with a post void residual volume (PVRV) of < 150 mL was achieved. The primary outcome was the presence of bothersome micturition symptoms as measured using the Dutch-validated Urogenital Distress Inventory (UDI-6).

Results:Only seven patients (10%) reported bothersome micturition problems 3 months after delivery. No significant differences in the occurrence of micturition symptoms were found. Median PVRV was 800 mL in the CIC group and 650 mL in the TIC group. PVRV was ≥ 1,000 mL in 24% of the patients. The median duration of catheterization was significantly shorter in the CIC group than in the TIC group (12 h vs. 24 h, p < 0,01). In patients with CIC, 35% required only one catheterization before complete bladder emptying occurred. The duration of treatment was not related to the initial PVRV. Both treatments were equally well accepted by the patients.

Conclusions:In patients with overt PUR, CIC is the preferred treatment as a considerable percentage of patients appear to be over-treated when the standard duration of TIC is 24 h. The occurrence of micturition symptoms is not associated with the catheterization method used. CIC is well tolerated in patients with overt PUR.

105

Cathetherisation methods for symptomatic postpartum urinary retention

INTRODUCTION

Postpartum urinary retention (PUR) is the inability to void spontaneously or adequately after delivery. It is a frequently occurring condition in the puerperium. In previous studies percentages varied from 12% to 45%.1-3 Women experiencing PUR can be subdivided into two clinically different groups; those who experience overt (symptomatic) PUR, i.e. the absolute inability to void spontaneously within several hours of delivery, and those with covert (asymptomatic) PUR who are able to void spontaneously but have increased post void residual volumes (PVRVs). Because of the overt nature of the problem, patients with symptomatic PUR are generally identified early, either because micturition is impossible or because of complaints such as abdominal pain or postpartum haemorrhage. Patients with covert PUR are more difficult to identify because spontaneous micturition does occur but the residual volume is high. In case of overt PUR, catheterization is considered to be required because bladder overdistension can potentially result in long-term problems including reduced detrusor contractility, urinary tract infections, hydronephrosis and even kidney failure. 4,5

With these potentially serious consequences, it is surprising that guidelines for the treatment of PUR are lacking. More than a decade ago the absence of evidence-based protocols on bladder care in the puerperium had already been addressed.6 However, until now no studies have been published that deal with the optimisation of treatment for this problem.6 Consequently, currently available recommendations regarding treatment of PUR are still not generally evidence-based.7-9 This absence of clarity results is an unwanted practice variation of overt PUR between different institutions.10-12

In many departments, patients are still treated by standard prolonged transurethral indwelling catheterization (TIC) for periods up to 72 hours. This is surprising as it is well known that indwelling catheterisation can cause significant discomfort and the chance of urinary tract infections increases significantly with every continuing day of catheterisation.13-15 Moreover, in different categories of patients with urinary retention, evidence is available that clean intermittent catheterisation results in faster normalization of micturition as compared to indwelling catheterisation.16-18

Whether this is also true in women with PUR after delivery is unknown. A randomized controlled trial was designed with the following aims: to safely prevent bladder overdistension in patients with PUR and concurrently reduce the duration of catheterization and to evaluate whether CIC is associated with less-severe micturition symptoms 3 months after delivery as compared with TIC.

7

106

Chapter 7

MATERIALS AND METHODS

Between January 2011 and June 2016 we performed a randomized controlled clinical in 5 teaching hospitals in the Netherlands. The study was approved by the medical ethical committee of the Academic Medical Centre in Amsterdam, the Netherlands (MEC AMC 10/187). Local approval was obtained in all participating centres. The trial was registered in the Dutch Trial Registry (NTR 2806).

During the study period, women aged 18 years and older, who were unable to void spontaneously within 6 hours after vaginal delivery, were asked to participate. After obtaining informed consent, patients were randomized between either (TIC) for 24 hours or (CIC).

Catherization protocolIn patients who were randomized for TIC, the catheter was removed after 24 hours. In case spontaneous voiding occurred, the post void residual volume was measured using a Bladderscan®(BVI 9400, Verathon, IJsselstein, the Netherlands). In case PVRV was less than 150 mL, no further treatment followed. When PVRV remained above 150 mL or if spontaneous voiding was not possible at all, an indwelling catheter was inserted again for an additional 48 hours. After removal of this indwelling catheter residual volume was measured again. When micturition was still not possible or in case of persistent abnormal PVRV’s, patients were instructed for CIC. In patients allocated to CIC the frequency of catheterisation depended on the residual bladder volume, i.e. PVRV ≥ 200 mL 2 times a day, PVRV ≥ 300 mL 3 times a day and PVRV ≥ 400 mL 4 times a day. As long as residual volumes remained above 150 mL, patients underwent repeated CIC or were instructed to perform CIC themselves. In case patients were discharged from the hospital and CIC was still required, they were asked to fill out a catheterisation diary at home in order to measure the frequency, duration of CIC and PVRV.

Urinary cultureIn case catheterisation, either CIC or TIC, was finished, a urine culture was sent to the laboratory. During the treatment, investigators were not informed about the results of this culture, while this culture was not part of routine clinical practice. By definition, cultures were regarded as positive when more than 105 colony forming units were observed.

OutcomesThe primary outcome was the presence of lower urinary tract symptoms three months after delivery. In order to assess these micturition related symptoms, all patients were asked to complete the Dutch validated short version of the urogenital distress inventory (UDI-6). 19,20 The UDI-6 is a six item validated questionnaire used to identify symptoms associated with lower urinary tract dysfunction. The UDI questionnaires are broadly accepted by urogynaecologic

107


clinics in the Netherlands. Questionnaires were analysed using a four-point scale resulting in total and domain scores, in which higher scores indicate more severe symptoms. 21,22 (Figure 1) Secondary outcomes were duration of catheterisation, bacteriuria and patient preference. To learn more on patient’s experience and preference, a questionnaire was developed. Patients were asked to give their opinion on different statements concerning the received treatment three months after delivery, for example “introduction of the catheter was painful, having urinary retention negatively influenced my postnatal period” and, in case of TIC, “I would have preferred to be randomized to CIC” and vice versa. The different statements could be scored from 1 (totally disagree) to 10 (totally agree). These scores were later categorized into disagree (score 1-4), neutral (score 5-6) and agree (score 7-10) and subsequently compared between the two groups CIC and TIC.

Sample size calculation A difference between both treatment groups of 6 points in the obstructive micturition domain (of the validated quality-of-life questionnaire) was considered to be a clinically relevant difference between both groups, based on non-inferiority. With a power of 80%, α level of 0.05, and a standard deviation of 3.75, the calculated sample size necessary is 68 (34 in each group) using a two-sided two-sample t-test. Assuming a drop out of 15 %, we planned to include 86 women in this study.

Randomization Computerized randomization tables, stratified in blocks and different sizes per hospital, were used for randomization. Because of the obvious difference between treatments blinding was not possible.

Statistical analysisThe data were analysed by intention to treat. To examine differences between groups, an unpaired Student’s t-test for continuous variables and a Fisher’s exact test for dichotomous variables was used. A Mann–Whitney U-test was performed to test nonparametric outcomes for statistical significance. Two-sided significance tests were used throughout. P < 0.05 was considered to be statistically significant. Statistics were performed using SPSS version 23.0 (IBM, SPSS)

7

108

Chapter 7

Figure 1. Consort flow chart

Table 1. Patient characteristics

Patient characteristics CIC (n=40) TIC (n=45) p

Nulliparous (%) 73% 76% NS

Gestational age* 39,9 39,7 NS

Maternal age (years)* 30,7 30,3 NS

BMI † 23 23 NS

Duration first stage (hours)† 7,5 8,0 NS

Duration second stage (minutes)† 50 38 NS

Induction of labour (%) 53% 60% NS

Spontaneous vaginal delivery (%) 63% 70% NS

Assisted vaginal delivery (%) 35% 29% NS

Birth Weight (grams)* 3568 3552 NS

Epidural analgesia (% of total patients) 53% 51% NS

Episiotomy (%) 50% 44% NS

Catheterization during labour (%) 65% 52% NS

First catheterized residual volume (mL)* 825 796 NS

* mean; † median; NS non-significant; CIC = clean intermittent catheterization; TIC = transurethral indwelling catheterization

109


RESULTS

Data from 85 patients were available for analysis, as shown in Figure 1. Of these 85 patients, 68 (34 in the TIC group and 34 in the CIC group) completed the UDI-6 questionnaire 3 months after delivery. The data from these patients were used to calculate the primary outcome. Baseline characteristics were not significantly different between the groups (Table 1). The median first urinary bladder volume was 800 mL (range 230–1,600 mL) in the CIC group and 650 mL (range 375–1,800 mL) in the TIC group. Micturition symptoms 3 months after delivery as expressed by the UDI domain scores concerning irritative symptoms, stress symptoms and obstructive symptoms did not significantly differ, as shown in Table 2.

Table 3 shows the time to adequate voiding in both groups. The median duration of catheterisation was 12 hours for CIC and 24 hours for TIC and was statistically significantly different between treatments (p < 0,01).

In the CIC group, 35% (n=13) of the included patients needed a single catheterisation only to regain adequate voiding. In total 78% of patients in the CIC group required a maximum of 4 catheterisations and had adequate voiding within 1 day. 84% (n=37) of the patients allocated to TIC was able to void adequately after 1 day of indwelling catheterisation. 7 patients (16%) required an indwelling catheter for another 48 hours. After 72 hours of indwelling catheterisation, only one patient needed to continue with CIC for one day. The median first catheterised volume for patients requiring one indwelling catheter was 600 mL (375-1800 mL). For patients requiring a second indwelling catheter this was 1000 mL (450-1500 mL).

In total 4 patients crossed over to the other treatment group: 3 patients who were allocated to CIC received an indwelling catheter; in 2 of these 3 patients because of vulvar oedema and pain. One patient experienced prolonged PUR after initially starting with CIC, and was treated with an indwelling catheter for 10 days and

Table 2. Results UDI-6 questionnaire 3 months postpartum

CIC (n=34 ) TIC (n=34 )Mean score SD Mean score SD p

UDI-6 total score 10,9 14,2 8,3 10,0 0,42

Irritative symptoms 11,1 17,9 9,09 13,3 0,63

Stress symptoms 12,4 19,4 9,6 15,6 0,55

Obstructive symptoms 9,3 19,8 6,1 10,1 0,45

CIC = clean intermittent catheterization; TIC = transurethral indwelling catheterization

7

110

Chapter 7

performed CIC for 28 days afterwards. The last patient requested for CIC after an indwelling catheter for 24 hours instead of receiving another indwelling catheter. Data of these patients were removed from Table 3.

The questionnaire on experience of the received treatment was answered by 28 patients of the TIC group and 26 patients of the CIC group. 21 patients of the TIC group and 16 patients of the CIC group filled out the statement “introduction of the catheter was painful”. 3 patients with CIC agreed (18%), 3 patients scored neutral (18%) and 10 patients disagreed (63%). Regarding TIC, none of the patients agreed, 3 out of 24 patients scored neutral (14%) and 18 out of 24 patients disagreed (86%), meaning the introduction was not painful. Results were not statistically different (p = 0,09). The statement “having urinary retention negatively influenced my postnatal period” was agreed by 9 out of 18 patients with CIC (50%), 1 patient scored neutral (6%) and 8 patients disagreed (44%). In the TIC group 4 out of 21 patients agreed (19%), 2 patients scored neutral (10%) and 15 patients disagreed (71%). No statistical difference was found (p = 0,12). The final statement “I would have preferred the other (not allocated) treatment” was acknowledged? agreed by 4 out of 26 patients with CIC (15%) and disagreed by 22 patients (85%). 6 out of 28 patients with TIC agreed this statement (21%), 4 patients scored neutral (14%) and 18 out of 28 patients disagreed (64%). No statistical differences were found (p = 0,09).

Table 3. Resumption of adequate voiding after treatement

Time to resumption of adequate voiding CIC (n=37) TIC (n=44) p

Within 24 hours postpartum 64,9% (n=24) - -

1 x CIC 35% (n=13) - -

2 x CIC 22% (n=8) - -

3 x CIC 8% (n=3) - -

At 24 hours postpartum 1 78,4% (n=29) 84,1% (n=37) -



After ≥ 72 hours postpartum 4 100% (n=37) 100% (n=44) -

Median duration of catheterisation 5 12 (0-768) 24 (24-72) 0,01

CIC = clean intermittent catheterization; TIC = transurethral indwelling catheterization; 1 in case of CIC: 4 times; 2 in case of CIC: 5 - 8 times; 3 in case of CIC: 9 - 12 times; 4 1 patient learned CIC after TIC. In 2 patients with CIC prolonged catheterisation was required; 5 in hours

111


DISCUSSION

In this study, we showed that in postpartum women with the inability to void spontaneously within 6 hours after vaginal delivery, the presence of micturition symptoms and patient preference regarding catheterization methods were similar for both regimens three months after delivery. Bladder emptying normalizes faster with clean intermittent catheterisation (CIC ) than with transurethral indwelling catheterisation (TIC).

In this study, we showed that in postpartum women unable to void spontaneously within 6 h of vaginal delivery, the presence of micturition symptoms and patient preference regarding catheterization method were similar for both regimens 3 months after delivery. Bladder emptying normalized earlier with CIC than with TIC.

The prevention of bladder overdistension is clearly the reason to screen and treat patients unable to void spontaneously. Assuming that these basic requirements are met by both treatments, we wanted to know whether the intermittent filling and emptying of the bladder, which mimics normal physiology, would be beneficial to the function of the bladder in the medium to longer term. Therefore, the primary outcome of this randomized controlled trial was the presence of bothersome micturition symptoms 3 months after vaginal delivery in patients requiring catheterization for overt PUR. Regarding total and domain scores from the UDI-6 questionnaire, no significant differences between the two catheterization methods were observed. This could have been related to the low incidence of micturition symptoms in our population. Only 10% (seven) of the included patients reported bothersome micturition problems 3 months after delivery (defined as a total UDI-6 score of ≥25 points). This low incidence is comparable to the rates found in previous studies.23-25 Our study shows that the functionality of the bladder in the postpartum period is hardly influenced by temporary (over)distension due to urinary retention

In our population, the median residual volume at the moment of catheterisation was 700 mL. 24% Of the included patients even had a residual volume of more than 1000 mL. Several authors have shown that acute urinary retention in other situations like post (spinal) analgesia, neurologic surgery or related to prostatic hyperplasia causes bladder overdistension that can lead to chronic impairment of the bladder’s capacity to (adequately) empty.26 Therefore, our hypothesis was that these patients would have a considerable risk for bladder overdistension, resulting in injury of the detrusor and as a consequence long term micturition problems.4,26 However, the course of PUR, even with the high residual volumes which were found, appeared to be relatively benign as PUR resolved after a maximum 72 hours in nearly all patients.27,28 This implies that the postpartum bladder is not only highly resilient but, to a certain extent, residual volumes might possibly be part of normal puerperal physiology.

7

112

Chapter 7

Our study has shown that by comparing two standard catheterisation methods in patients with symptomatic PUR, CIC is preferred over TIC. Regarding duration of catheterisation we found a statistical significant difference in favour of CIC, with a median catheterisation duration of 12 hours compared to 24 hours in patients with TIC (p < 0,01). We also observed that 35% of patients with CIC were able to void spontaneous and adequate after only a single catheterisation. The duration of catheterisation was not correlated with the initial bladder volume at the first catheterisation.

The advantage of intermittent catheterisation could be associated with the difference in bladder training. By intermittent drainage and filling of the bladder, the bladder is stimulated earlier to identify the difference between “full” and “empty”, leading to spontaneous voiding. In contrary, by placing an indwelling catheter, this bladder stimulation is postponed and bladder training delayed. While Lakeman et al have shown that even in patients after vaginal colporrhaphy, urinary retention is not related to bladder outlet obstruction,29 it is plausible that in patients with overt PUR disturbance of central inhibition due to pain has a larger role than for example peri-urethral oedema.

We observed that in our population CIC as well as TIC were well accepted by the study participants. This is important while in daily clinical practice, nursing and medical staff often believe that intermittent catheterisation postpartum is either too difficult or too bothersome, resulting in a frequent use of indwelling catheter. In our study, in 85% of patients with CIC and 64% of patient with TIC the allocated treatment was well tolerated. We have no information on duration of hospital admission due to urinary retention. However it is plausible that CIC can also be the more cost effective option. Taking into account that patients consenting to randomisation were willing to accept both catheterisation methods, our results show that CIC is a valid alternative for TIC.

A limitation of this study is the amount of missing urine cultures. Although collecting a urine sample after finishing catheterisation or in case of discharge from the hospital with CIC was part of the study protocol, data on bacteriuria were only available in 34% of included cases (10 patients with CIC and 19 patients with TIC). Therefore, we could not compare data on (asymptomatic) bacteriuria between the two treatment groups. However, previous studies have shown that the risk of (asymptomatic) bacteriuria is higher in patients receiving an indwelling catheter than in those undertaking CIC.16,30 As catheter-associated bacteriuria is a frequently diagnosed complication, the rationale for the benefits of CIC are interesting. It is known that bacterial infection can progress during catheterization, either directly due to insertion of the catheter or by colonization, as bacteria can ascend from the meatus of the urethra along the catheter (intraluminally and/or extraluminally).14,31 Also spontaneous resolution of bacteriuria has been described when spontaneous micturition, i.e. without a catheter, becomes possible. With CIC, the bladder is emptied so that potentially infected urine

113


does not pool in the bladder, and this is an advantage over TIC in which potentially infected foreign material remains in the bladder causing colonization.

Our results can be used to create future guidelines on postpartum bladder management. Evidence is needed to create protocols on bladder care in the puerperium, however no randomized studies have been published on this topic.6 Sathisyathasan and colleagues performed an audit in 40 randomly selected cases from the postnatal ward and showed poor compliance to the assessment and documentation of spontaneous micturition within 6 hours after delivery.32 Moreover in international guidelines on postpartum care, voiding problems after delivery are often not mentioned. One of the few opinion based recommendations on postpartum urinary retention can be found in the RCOG guideline on operative vaginal delivery and suggest that “timing and volume of the first void should be monitored and documented” and that “a post void residual volume should be measured if retention is suspected”. If PUR is present, placement of an indwelling catheter for 12 h is advised. 7 This study shows that there are no differences in longer term bothersome micturition symptoms, but duration of catheterisation is significantly shorter in patients with CIC compared to TIC for symptomatic PUR. Furthermore, duration of catheterisation seems not related to initially (high) residual volumes. Although we had insufficient data on cost effectiveness and bacteriuria, we would recommend that future guidelines and postpartum bladder care protocols include the results of this first randomized clinical trial and that CIC becomes the standard treatment for symptomatic PUR. In case the clinician believes there is a reason for TIC, for example if extensive periurethral lacerations are present that would make the introduction of a catheter painful or result in immobility of the patient, the indwelling catheter should be removed after 24 hours in order to evaluate whether spontaneous voiding is possible.

CONCLUSIONS

In patients with symptomatic PUR treated with either CIC or TIC, the prevalence of micturition-related symptoms does not differ between the two treatment methods. Patients with CIC regained spontaneous micturition significantly earlier than patients with TIC (12 vs. 24 h). CIC should therefore be the preferred treatment in patients with symptomatic PUR, regardless of the residual volume. If TIC is considered necessary, the indwelling catheter should be removed after a maximum of 24 h to start bladder training.

7

114

Chapter 7

REFERENCES







7. Operative Vaginal Delivery - RCOG Green-top guideline No 26. 2014.

8. Carr D, Cook V. Intrapartum and postnatal bladder care: A survey of midwives’ current practice. Neurourology and Urodynamics. 2009;Conference: 39th Annual Meeting of the International Continence Society San Francisco, CA United States. Conference Publication:898-899.

9. Demott K BD, Norman R, Ritchie G, Turnbull N, Adams C, Barry C, Byrom S, Elliman D, Marchant S, Mccandlish R, Mellows H, Neale C, Parkar M, Tait P, Taylor C Clinical Guidelines And Evidence Review For Post Natal Care: Routine Post Natal Care Of Recently Delivered Women And Their Babies. NICE Guideline. 2006.



12. 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 Pelvic Floor Dysfunct. 2007;18(5):521-524.

13. Perrin LC, Penfold C, McLeish A. A prospective randomized controlled trial comparing suprapubic with urethral catheterization in rectal surgery. Aust N Z J Surg. 1997;67(8):554-556.

14. Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters. Emerg Infect Dis. 2001;7(2):342-347.

15. Tambyah PA, Oon J. Catheter-associated urinary tract infection. Curr Opin Infect Dis. 2012;25(4):365-370.


115


17. Kamilya G, Seal SL, Mukherji J, Bhattacharyya SK, Hazra A. A randomized controlled trial comparing short versus long-term catheterization after uncomplicated vaginal prolapse surgery. J Obstet Gynaecol Res. 2010;36(1):154-158.

18. Glavind K, Morup L, Madsen H, Glavind J. A prospective, randomised, controlled trial comparing 3 hour and 24 hour postoperative removal of bladder catheter and vaginal pack following vaginal prolapse surgery. Acta Obstet Gynecol Scand. 2007;86(9):1122-1125.

19. Shumaker SA, Wyman JF, Uebersax JS, McClish D, Fantl JA. Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Qual Life Res. 1994;3(5):291-306.

20. Utomo E, Korfage IJ, Wildhagen MF, Steensma AB, Bangma CH, Blok BF. Validation of the urogenital distress inventory (UDI-6) and incontinence impact questionnaire (IIQ-7) in a Dutch population. Neurourol Urodyn. 2013.

21. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn. 1995;14(2):131-139.

22. van der Vaart CH, de Leeuw JR, Roovers JP, Heintz AP. Measuring health-related quality of life in women with urogenital dysfunction: the urogenital distress inventory and incontinence impact questionnaire revisited. Neurourol Urodyn. 2003;22(2):97-104.

23. van Brummen HJ, Bruinse HW, Van de Pol G, Heintz AP, van der Vaart CH. Bothersome lower urinary tract symptoms 1 year after first delivery: prevalence and the effect of childbirth. BJU Int. 2006;98(1):89-95.

24. Chan SS, Cheung RY, Yiu KW, Lee LL, Chung TK. Prevalence of urinary and fecal incontinence in Chinese women during and after their first pregnancy. Int Urogynecol J. 2013;24(9):1473-1479.

25. Groutz A, Rimon E, Peled S, et al. Cesarean section: does it really prevent the development of postpartum stress urinary incontinence? A prospective study of 363 women one year after their first delivery. Neurourol Urodyn. 2004;23(1):2-6.



28. Rizvi RM, Khan ZS, Khan Z. Diagnosis and management of postpartum urinary retention. Int J Gynaecol Obstet. 2005;91(1):71-72.

29. Lakeman MM, Hakvoort RA, Van de Weijer EP, Emanuel MH, Roovers JP. Anterior colporrhaphy does not induce bladder outlet obstruction. Int Urogynecol J. 2012;23(6):723-728.

30. Niel-Weise BS, van den Broek PJ. Urinary catheter policies for short-term bladder drainage in adults. Cochrane Database Syst Rev. 2005(3):CD004203.

31. Stamm WE. Catheter-associated urinary tract infections: epidemiology, pathogenesis, and prevention. Am J Med. 1991;91(3B):65S-71S.

32. Sathiyathasan S, Afors K, Ogunremi A, Sana Y. Audit of postpartum bladder care [abstract]. BJOG. 2013;120 Suppl s1:307.

7

8CHAPTER

General Discussion

118

Chapter 8

The work presented in this thesis reports on risk factors for and clinical impact, diagnosis and management of postpartum urinary retention.

OBJECTIVES OF THIS THESIS

The first objective of this thesis was to identify clinical risk factors for postpartum urinary retention. By performing a systematic literature search and meta-analysis, we were able to identify all known independent clinical prognostic factors for covert (asymptomatic) as well as overt (symptomatic) postpartum urinary retention (PUR). In order to prospectively confirm previously identified factors, we performed a prospective cross sectional study in a non-selected population.

The second objective was to study the clinical impact of inadequate voiding after delivery. Firstly, an extensive literature search was performed in order to assess adverse effects. Secondly, a prospective case control study was conducted to compare micturition related complaints in patients with increased post void residual volumes (PVRVs, i.e. covert PUR) to patients with adequate voiding one year after vaginal delivery.

The third objective was to evaluate diagnostic tools and treatment methods for voiding dysfunctions after vaginal delivery. In an effort to validate a device developed to determine PVRVs non-invasively, a comparative study was performed of a scanning device and transurethral catheterization. For evaluation of management of symptomatic PUR, i.e. the inability to void spontaneously, a randomized controlled trial was performed to compare two standard treatment methods for overt PUR i.e. transurethral indwelling catheterization (TIC) and clean intermittent catheterisation (CIC) in women with the inability to void after delivery. Data from these studies were intended to be used in evidence based guidelines.

119

General Discussion

MAIN CONCLUSIONS

First objective: identification of risk factors for postpartum urinary retentionIn order to learn which obstetric factors increase the risk for inadequate voiding after delivery, we performed an extensive literature search to identify known risk factors. This meta-analysis showed that nulliparity, instrumental delivery, epidural analgesia and episiotomy significantly increase the risk for overt PUR. We also found that due to heterogeneity in definitions, study designs and cut-off values, no statistical significant clinical factors could be found for covert PUR. The latter made us realize that current literature lacks uniformity in definitions for covert PUR and that standardization is needed in order to compare available data. While we also intended to evaluate obstetric factors for covert PUR, we conducted a large observational trial. By consequently measuring the post void residual volume (PVRV) directly following the first void of patients after vaginal delivery in our hospital, we were able to collect data from over 740 patients. With these data we were able by multivariate regression analysis to detect that episiotomy, epidural analgesia and birth weight are independent clinical factors for asymptomatic PUR. With these results we can identify patients with an increased risk for incomplete voiding after vaginal delivery.

Second objective: the clinical impact of postpartum urinary retentionBy systematically searching available literature, we found that PUR is frequently occurring in the postpartum period, affecting up to 45% of women after delivery.1 We also found that in many studies, patients with covert PUR regained adequate voiding within several days after delivery.2,3 However, since many authors have not evaluated (long term) voiding dysfunction in patients with PUR, evidence to state that PUR is therefore harmless is missing. With the knowledge that even a single episode of bladder overdistension can cause prolonged voiding dysfunction, we believed that data on adverse effects of covert PUR were essential to define whether covert PUR is a physiological condition or a serious complication. With this in mind, we designed a prospective comparative study to assess long term micturition problems in patients with inadequate voiding after vaginal delivery. With this prospective study we obtained information on voiding dysfunctions shortly after delivery with a follow up until one year after delivery in patients with covert PUR.4 We compared these data with patients who had adequate voiding, i.e. PVRV < 150 mL. Our results showed not only that increased PVRVs normalize quickly, with 92% of patients being able to void completely after 4 days after giving birth, but also that the incidence of micturition problems one year after delivery is low and not related to covert PUR. However, we also found that in the group of patients with PVRV ≥ 150 mL, 68% of patients had a PVRV ≥ 250 mL and 16% had a PVRV ≥ 500 mL, with a maximum of 1900 mL of residual volume after spontaneous micturition. We analysed patients with PVRV ≥ 500 mL separately, and found no statistical significant differences in the prevalence of micturition related symptoms. However this could also be explained by the fact that power was lacking to

8

120

Chapter 8

identify statistical differences in this group as a result of the small amount of patients with this large PVRV in our cohort.

Third objective: diagnostics and treatment for inadequate voiding after delivery We also examined whether the use of a non-invasive automatic scanning device is a valid alternative over catheterisation in postpartum patients. Although many clinicians doubted the reliability of the BladderScan® after delivery, stating that it also measures retaining fluids in the extended womb, our results show that it is a valid alternative and can prevent unnecessary catheterisations. We have shown that there was a very good correlation between PVRVs measured with the BladderScan compared to catheterisation.5 Before we designed and conducted our studies, puerperal bladder care differed significantly between hospitals; inserting an indwelling catheter standardly for 72 hours after delivery in patients with the inability to void was common practice in some of the participating hospitals. Our randomized controlled trial comparing clean intermittent catheterisation (CIC) with a transurethral indwelling catheter (TIC) for 24 hours in patients with overt PUR showed clear benefits in favour of CIC: time to resumption of spontaneous micturition was significantly shorter in patients with CIC, as in 35% of cases patients were able to void spontaneously after a single catheterisation.6 We also found that participating patients accepted both treatments well, based on the experience and preference questionnaire. The results of our study could be used in updating current (local) protocols and creating an evidence based guideline for overt postpartum urinary retention.

IMPLICATIONS AND FUTURE PERSPECTIVES

First objective: identification of risk factors for postpartum urinary retentionRegarding overt PUR, results of our meta-analysis showed that nulliparity, instrumental delivery, epidural analgesia and episiotomy are significant risk factors. The results of our multivariate regression analysis revealed that epidural analgesia, birth weight and episiotomy are risk factors for PVRV ≥ 150 mL after the first void after vaginal delivery. Our systematic review also showed that uniformity in definition regarding PUR is inadequate. In 1997, Yip et al. were the first to create a new definition for PUR, using the cut-off value of PVRV > 150 mL for covert PUR, while measuring the PVRV one day after delivery.7 Although an explanation for this arbitrary value is missing, it seems reasonable that this volume is based on (evidence based) guidelines used in urology, gynaecology and after surgery. Despite this created definitions, other authors still use different cut-off values and time intervals to measure the PVRV, varying from 100-200 mL and measurements after the first void to 72 hours after delivery.1,8,9 However, as many authors have shown physiological changes of the urogenital tract during pregnancy and the postpartum period,10-12 we believe these adaptations should be incorporated in a new definition of PUR. First of all, the time of PVRV measurement should be stratified. As the majority of women will be discharged within 24 hours after delivery, the most reliable and

121

General Discussion

reproducible time to measure the PVRV will be after the first void, merely as postpartum protocol requests women to void spontaneously before discharge. The second change in the definition should be a meaningful cut-off value. While in our study of 740 unselected women after vaginal delivery the median PVRV was 140 mL, the 75th percentile 250 mL and the 95th percentile PVRV > 500 mL, we believe that in order to discriminate between pathology and physiology, a PVRV ≥ 500 mL is a more reliable value. Regarding risk factors for PUR, we have shown that episiotomy, opioid and epidural analgesia are independent clinical factors for PVRV > 500 mL. Although statistically independent, it has been shown that women with epidural analgesia have an increased risk for episiotomy and instrumental delivery.13,14 Additionally it is known that women with epidural analgesia have more difficulties to void during labour and also experience these difficulties after delivery.15,16,17 Therefore clinical relationship between these different factors is foreseeable. Future research regarding risk factors for covert PUR should focus on patients at risk for PVRV > 500 mL and what can be done to prevent and treat these increased residual volumes.

Second objective: the clinical impact of postpartum urinary retentionIn our prospective study we found that voiding dysfunctions one year after vaginal delivery were not affected by abnormal post residual volumes following first micturition after giving birth.4 However, it is extraordinary to observe that postpartum the bladder can contain over 1000 mL of residual volume without causing voiding dysfunctions. We wondered how the function of the puerperal bladder can be so different in a non-pregnant situation and what causes this extreme adaptive capability.18 For example in postsurgical situations and patients with neurologic conditions it is known that urinary retention and bladder overdistension can cause long term voiding dysfunctions.19-21 We hypothesised that hormonal changes during pregnancy and in the puerperium could be related to this exceptional phenomenon. Although little is known on the relationship between hormonal changes during pregnancy and postpartum and the adaptive capacities of the bladder, we believe this could play a role in the relatively mild condition of PUR.22-25 For example the hypo-oestrogen status and the changes in relaxin levels might be of influence on the regenerative ability of the bladder after delivery, as it has been shown that relaxin levels are different in women with urinary incontinence during pregnancy.23,26 However it is still remarkable that pregnancy and delivery are well known risk factors voiding dysfunctions later in life but that inadequate bladder emptying after delivery doesn’t increase micturition problems. The latter could be caused by the lack of information on patients with residual volumes exceeding 500 mL or 1000 mL and how this affects the bladder function. It would also be interesting to evaluate the participating women for example 5 years after delivery or after menopause to learn the influence of inadequate voiding after delivery. We believe future research on postpartum urinary retention should therefore be threefold. First of all one needs to evaluate voiding dysfunctions in patients with PVRV ≥ 500 mL and ≥ 1000 mL, estimated to affect up to 9000 patients per year in the Netherlands, and compare these outcomes with not only pregnant women who void adequately but also

8

122

Chapter 8

with non-pregnant women. Secondly the need for catheterisation in these patients needs attention, to detect whether (a single) catheterisation of an increased residual volume affects micturition problems. Thirdly one needs to focus on the physiological characteristics of the puerperal bladder, regarding changes in hormonal levels, adaptations of the detrusor muscles and their innervations or whether there is a more mechanical origin, caused by the sudden increased abdominal space following emptying of the womb.

Third objective: diagnostics and treatment for inadequate voiding after deliveryWith the results of our prospective validation study, we have shown that the Bladderscan® BVI 9400 is a valid device to detect abnormal post void residual volumes in patients after vaginal delivery and can safely be used in daily clinical practice to prevent unnecessary catheterisations.5 With Spearman’s rank correlation coefficient of r = 0.82 and a sensitivity of 85.6 % and specificity of 85.4% for PVRV > 500 mL, we believe the Bladderscan® BVI 9400 should be used instead of catheterisation to diagnose inadequate voiding. It has the obvious advantage of not being an invasive diagnostic procedure without the risk of inducing infectious complications.

One can imagine that in patients with one or more risk factors for covert or asymptomatic PUR (i.e. episiotomy, epidural analgesia or birth weight > 4000 gram), the PVRV could be measured after the first void. In case this PVRV equals or exceeds 500 mL, the patient can be diagnosed with covert PUR. We would suggest to follow up these patients and repeat the PVRV measurement after the next void. In case increased residual volumes remain present, patients should be offered information (like micturition instructions, suggesting voiding every 4 hours and increased risk of urinary tract infections) and be re-evaluated after 3 or 4 days until the PVRV resolves. Patients diagnosed with overt PUR, i.e. the inability to void within 6 hours after vaginal delivery, should be offered intermittent catheterisation. After the catheterisations, a second voiding attempt should be advised within 6 hours. In case spontaneous voiding is still not possible, patients should be taught how to self-catheterise. This should be repeated until the patients is able to void spontaneously and residual volume is less than 150 mL. In case the obstetric caregiver has reasons to insert a transurethral indwelling catheter, for example in case of extreme vulvar oedema or peri urethral lacerations, this should be removed after a maximum of 24 hours in order to regain spontaneous micturition or when the patient is able to perform CIC in case oedema continues. In addition to the aims of this thesis, we repeatedly experienced that definitions and cut-off values for PUR used in literature varies to a great extent. This diversity directly influences the reproducibility of available data. In order to evaluate future data on postpartum urinary retention and reduce heterogeneity between studies, we believe definitions of overt and covert PUR should be redefined. Based on the results of our studies, which suggest that the current used cut-off values are too low to discriminate between physiology and pathology, we therefore suggest the following: “Overt or symptomatic Postpartum Urinary Retention is the inability to void

123

General Discussion

within 6 hours after (vaginal) delivery, requiring (intermittent) catheterisation”. “Covert or asymptomatic Postpartum Urinary Retention is an increased post void residual volume ≥ 500 mL after the first void after vaginal delivery”.

CONCLUDING MESSAGES

Voiding dysfunctions are common after childbirth. The lack of knowledge of the clinical impact of incomplete voiding after delivery and the absence of evidence based guidelines on management of postpartum voiding (of emptying) problems underline the need for this thesis.

First it was not only observed that incomplete bladder emptying after vaginal delivery resolves rather quickly, but also that the currently used cut-off values do not discriminate between physiology and pathology. We also concluded that an automatic scanning device is a valid non-invasive tool to identify increased post void residual bladder volume after vaginal delivery and to prevent unneeded catheterisations. Finally we concluded that clean intermittent catheterisation (CIC) is preferred over transurethral indwelling catheterisation (TIC) in patients with the inability to adequately empty the bladder after vaginal delivery.

To increase awareness of clinicians and to implement the outcomes, the results of our studies should be considered as scientific basis for an evidence based guideline to manage bladder emptying problems after vaginal delivery.

8

124

Chapter 8

REFERENCES 1. Hee P, Lose G, Beier-Holgersen R, Engdahl E, Falkenlove P. Postpartum voiding in the

primiparous after vaginal delivery. International Urogynecology Journal 1992; 3(2): 95-9.

2. Zakaria NH, Nusee Z, Ab RJ, et al. Overt and covert postpartum urinary retention, risk factors and complications - A cohort study at Hospital Tengku Ampuan Afzan (HTAA), Kuantan, Pahang, Malaysia. BJOG: An International Journal of Obstetrics and Gynaecology 2012; Conference: 10th International Scientific Congress of the Royal College of Obstetricians and Gynaecologists. Conference Publication: 109-10.

3. Buchanan J, Beckmann M. Postpartum voiding dysfunction: Identifying the risk factors. Aust N Z J Obstet Gynaecol 2013.

4. Mulder FE, Hakvoort RA, de Bruin JP, Janszen EW, van der Post JA, Roovers JP. Long term micturition problems of asymptomatic postpartum urinary retention: a prospective case control study. Int Urogynecol J 2017; accepted for publication. (Epub ahead of print)

5. Mulder FE, van der Velde S, Pol F, et al. The accuracy of post void residual volumes after vaginal delivery: a prospective equivalence study to compare an automatic scanning device with transurethral catheterisation. Submitted 2017.

6. Mulder FE, Hakvoort R, de Bruin J, van der Post J, Roovers J. Comparing clean intermittent (CIC) versus transurethral indwelling catheterisation (TIC) for the treatment of overt urinary retention after vaginal delivery: a multicentre randomized controlled clinical trial. Int Urogynecol J 2017; accepted for publication (Epub ahead of print)

7. 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): 667-72.

8. Lee SN, Lee CP, Tang OS, Wong WM. Postpartum urinary retention. Int J Gynaecol Obstet 1999; 66(3): 287-8.

9. 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): 365-8.

10. Iosif S, Ingemarsson I, Ulmsten U. Urodynamic studies in normal pregnancy and in puerperium. Am J Obstet Gynecol 1980; 137(6): 696-700.

11. Beydoun SN. Morphologic changes in the renal tract in pregnancy. Clin Obstet Gynecol 1985; 28(2): 249-56.

12. Bakircioglu ME, Sievert KD, Lau A, Lin CS, Lue TF. The effect of pregnancy and delivery on the function and ultrastructure of the rat bladder and urethra. BJU Int 2000; 85(3): 350-61.

13. Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev 2005; (4): CD000331.

14. Raisanen S, Vehvilainen-Julkunen K, Heinonen S. Need for and consequences of episiotomy in vaginal birth: a critical approach. Midwifery 2010; 26(3): 348-56.

15. Foon R, Toozs-Hobson P, Millns P, Kilby M. The impact of anesthesia and mode of delivery on the urinary bladder in the postdelivery period. Int J Gynaecol Obstet 2010; 110(2): 114-7.

16. 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): 472-5.

125

General Discussion

17. Weiniger CF, Yaghmour H, Nadjari M, et al. Walking reduces the post-void residual volume in parturients with epidural analgesia for labor: a randomized-controlled study. Acta Anaesthesiol Scand 2009; 53(5): 665-72.

18. Wijma J, Potters AE, de Wolf BT, Tinga DJ, Aarnoudse JG. Anatomical and functional changes in the lower urinary tract following spontaneous vaginal delivery. BJOG 2003; 110(7): 658-63.

19. Hakvoort RA, Dijkgraaf MG, Burger MP, Emanuel MH, Roovers JP. Predicting short-term urinary retention after vaginal prolapse surgery. Neurourol Urodyn 2009; 28(3): 225-8.

20. Steinberg BJ, Finamore PS, Sastry DN, Holzberg AS, Caraballo R, Echols KT. Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse. Int Urogynecol J 2010; 21(12): 1491-8.

21. Hollman F, Wolterbeek N, Veen R. Risk Factors for Postoperative Urinary Retention in Men Undergoing Total Hip Arthroplasty. Orthopedics 2015; 38(6): e507-11.

22. Liang CC, Lin YH, Chen TC, Chang SD. How antepartum and postpartum acute urinary retention affects the function and structure of the rat bladder. Int Urogynecol J 2014; 25(8): 1105-13.

23. Kristiansson P, Samuelsson E, von SB, Svardsudd K. Reproductive hormones and stress urinary incontinence in pregnancy. Acta Obstet Gynecol Scand 2001; 80(12): 1125-30.

24. Sangsawang B. Risk factors for the development of stress urinary incontinence during pregnancy in primigravidae: a review of the literature. Eur J Obstet Gynecol Reprod Biol 2014; 178: 27-34.

25. Harvey MA, Johnston SL, Davies GA. Mid-trimester serum relaxin concentrations and post-partum pelvic floor dysfunction. Acta Obstet Gynecol Scand 2008; 87(12): 1315-21.

26. Conrad KP, Jeyabalan A, Danielson LA, Kerchner LJ, Novak J. Role of relaxin in maternal renal vasodilation of pregnancy. Ann N Y Acad Sci 2005; 1041: 147-54.

8

9CHAPTER

Summary

128

Chapter 9

The work presented in this thesis reports on different aspects of postpartum urinary retention, i.e. risk factors, adverse effects, diagnostics and management, which can be used to optimise bladders care after delivery.

Chapter 1 is the general introduction and describes the aims and objectives of this thesis.

PART 1: RISK FACTORS FOR POSTPARTUM URINARY RETENTION

In chapter 2 we present the results of a systematic literature review on clinical risk factors for overt (symptomatic) and covert (asymptomatic) postpartum urinary retention. In total 23 observational studies with original data on PUR could be used for analysis. With data from 13 studies, we were able to perform a meta-analysis to identify independent factors for overt and covert PUR. After translating available data to odds ratio’s, we were conducted a meta-analysis for overt as well as covert PUR. The clinical factors instrumental delivery (pooled OR 4.52), epidural analgesia (pooled OR 7.66), episiotomy and/or vaginal tears (pooled OR 4.84) and parity (pooled OR 2.42) were all statistically significantly associated with overt PUR. Regarding covert PUR we found that the heterogeneity between studies was substantial (I2 between 50 – 83%), resulting in non-significance from the evaluated clinical factors (i.e. instrumental delivery, episiotomy, epidural analgesia and parity). We also concluded that the large heterogeneity between studies was a consequence of the use of different definitions and cut-off values, requiring more uniformity in definitions in order to compare future data.

In chapter 3 we describe the results from a prospective cross sectional study on clinical factors for covert PUR to assess clinical independent prognostic factors for covert PUR. Patients who delivered vaginally were included in the study. After the first micturition after vaginal delivery, the post void residual volume (PVRV) was measured with a portable non-invasive automatic scanning device (BladderScan® BVI 9400, Verathon Medical Europe, Ijsselstein, the Netherlands). These measurements were recorded in the electronic patient chart as well as on paper.

Data were obtained from 930 patients, and the PVRV of 745 patients could be used for final analysis. From these patients, the median first voided volume was 320 mL (range 0-1900 mL). The median PVRV was 140 mL (range 0 - >999 mL), with the 75th and 95th percentile being 250 mL and 540 mL. In 347 patients the PVRV was ≥ 150 mL. With available data a univariable regression analysis was performed for the cut-off values of PVRV ≥ 150 mL, 250 mL and 500 mL. First we created a selection of possible risk factors through univariable regression. This was followed by a multivariable regression analysis, showing that epidural analgesia, birth weight, and episiotomy were independent risk factors for PVRV ≥ 150 mL. Regarding PVRV ≥ 250 mL, birthweight, episiotomy and analgesia (epidural analgesia as well as opioid analgesia ) were independent factors. Episiotomy, opioid and epidural

129

Summary

analgesia were all statistical significant independent risk factors for PVRV ≥ 500 mL. Additionally, our data also gave an impression that the currently used cut-off value of 150 mL might be insufficient to discriminate between pathology and physiology. While in our large cohort the median PVRV after the first void was 140 mL, with a 75th percentile being PVRV ≥ 250 mL and the 95th percentile of PVRV ≥ 500 mL, we hypothesized that the definition of covert PUR should be topic of discussion to be adjusted when data on clinical consequences of abnormal PVRV after delivery become available.

PART 2: ADVERSE EFFECTS OF INADEQUATE VOIDING AFTER DELIVERY

Chapter 4 describes a systematic review which was performed to identify studies reporting on adverse effects of postpartum urinary retention and evaluate the need for diagnosing this condition.

After a systematic search of available literature, we identified 909 unique papers on PUR. Data from 24 publications were suitable for data extraction. 10 prospective and 6 retrospective studies reported on overt PUR and 14 prospective studies were identified regarding covert PUR. 3 studies discussed prolonged postpartum urinary retention.

The majority of papers did not report on adverse effects of PUR. Regarding overt PUR, we found 2 publications evaluating micturition related problems 4 years after delivery, suggesting there was no statistical significant difference between patients with or without PUR. We also found that in many studies, patients with covert PUR regained adequate voiding within several days after delivery. However, while many authors have not evaluated (long term) micturition related problems in patients with PUR, evidence to state that PUR is harmless is missing. With the knowledge that even a single episode of bladder overdistension can cause prolonged voiding dysfunction, we believed that data on adverse consequences of covert PUR are essential to define whether covert PUR is a physiological condition or a serious complication.

With this in mind, we designed a prospective comparative study to evaluate long term micturition problems in patients with inadequate voiding after vaginal delivery. These results are presented in chapter 5. With this multicentre study we obtained information on voiding dysfunctions shortly after delivery until one year after delivery in patients with covert PUR. We compared these data with patients who had adequate voiding, i.e. PVRV < 150 mL. Informed consent was obtained from all included patients. After the first micturition after vaginal delivery, the PVRV was measured with a portable non-invasive automatic scanning device, BladderScan® BVI 9400. All included patients were asked to fill out a validated questionnaire, the UDI-6, a short version of the urogenital distress inventory at the day of delivery as well as on the 4th, 7th, 30th, 90th day and 1 year after

9

130

Chapter 9

delivery. The results of the UDI-6 can be divided in three domains: irritative symptoms, incontinence symptoms and obstructive symptoms. We were able to include 241 patients of which data from 224 patients could be used for final analysis. Results of 119 patients with a PVRV ≥ 150 mL, i.e. covert PUR, were compared to result from 105 patients with PVRV < 150 mL. Baseline characteristics showed that inadequate voiding with PVRV ≥ 150 mL was more common in primiparous patients. The median voided volume was 370 mL (100 – 1100 mL) in women with PVRV < 150 mL and 350 mL (50-1900 mL) in women with PVRV ≥ 150 mL. In patients with covert PUR, 83 patients (68%) had PVRV ≥ 250 mL and 19 patients had a PVRV exceeding ≥ 500 mL (16%). 92% of patients with PVRV ≥ 150 mL had adequate voiding at the fourth day after giving birth. Regarding results of the UDI scores, we found no statistical significant differences in micturition related problems one year after delivery between patients with PVRV < 150 mL and PVRV ≥ 150 mL.

Our results show not only that increased PVRVs normalize quickly, with 92% of patients being able to void completely after 4 days after giving birth, but also that the incidence of micturition problems one year after delivery is low and not related to covert PUR. Although our results could suggest that covert PUR is a harmless and self-limiting condition after childbirth, we hypothesized that this might be related to the used definition. We believed that the currently used cut-off value of PRVR ≥ 150 mL is clinically irrelevant and insufficient to discriminate between physiology and pathology. Since 16% of our patients had PVRV ≥ 500 mL after the first void after vaginal delivery, we believe this is a more valid value to detect potential pathology. Therefore we suggested that the definition of covert PUR should be adjusted and should be “covert or asymptomatic postpartum urinary retention (PUR) includes post void residual volume (PVRV) ≥ 500 mL after the first spontaneous void after (vaginal) delivery, measured by ultrasound or catheter”.

PART 3: POSTPARTUM BLADDER MANAGEMENT

The final part of this thesis includes postpartum bladder care. In chapter 6 the results are shown from a prospective equivalence study concerning the accuracy of post void residual volumes measurements after vaginal delivery. While there is a need for a non-invasive method to detect inadequate voiding after delivery, the current belief in clinical daily practice is that the BladderScan® overestimates the bladder volume. This belief is based on the assumption that the apparatus cannot differentiate between fluid in the bladder and fluid in the involuting uterus, resulting overestimation of residual volumes and leading to unnecessary catheterisations. While previous studies only observed small patient samples or used older models, we conducted a multicentre prospective study to compare PVRV in patients after vaginal delivery measured with a BladderScan® BVI 9400 with the gold standard method of catheterisation. Data of a total of 407 patients could be used for final analysis. We found that the mean PVRV measured by the BladderScan® was 380 mL (0 – 999 mL) and by catheterisation 375 mL (0 – 1800

131

Summary

mL). The mean difference between the two measurements was -13 mL (SD ± 177 mL), resulting in a close correlation between the two methods with a Spearman’s rank correlation coefficient of r = 0.82 (p < 0.001). Using our suggestion from previous studies that the cut-off value to determine pathology should be increased to PVRV ≥ 500 mL, we also calculated the sensibility and specificity concerning this value, while we believe this could be a valid reason to catheterise in patients after spontaneous micturition.We found a specificity of 85.4% and sensitivity of 85.6% and could conclude that the BladderScan® BVI 9400 is an accurate instrument to measure PVRV after vaginal delivery.Chapter 7 shows the results of a randomised multicentre study comparing transurethral indwelling catheterisation (TIC) with clean intermittent catheterisation (CIC) for the treatment of patients with overt or symptomatic postpartum urinary retention, defined as the inability to void within 6 hours after vaginal delivery. These two management options are both standard treatment options but have never been compared before. Patients who were allocated to TIC received an indwelling catheter for 24 hours. After this period, they were stimulated to void spontaneously. In case this was not possible or in case the residual volume was ≥ 150 mL, a second indwelling catheter for 48 hours was inserted. Patients allocated to CIC were instructed to catheterise until PVRV < 150 mL. Our primary outcome was the presence of micturition related symptoms three months after delivery. 34 patients allocated to TIC and 34 patients allocated to CIC completed the validated UDI-6 questionnaire 3 months after delivery. We found no statistical significant differences between the two groups. However we did find that patients allocated to CIC regained spontaneous micturition significantly faster than patients treated with TIC (p < 0.01). In the CIC group, 35% of the patients required only a single catheterisation before adequate voiding returned. We could also rebut the assumption that intermittent catheterisation was a burden postpartum, as the majority of patients with CIC stated the treatment was well accepted. The results from this randomized trial can be used to create future evidence based guidelines on bladder management after vaginal delivery. In chapter 8 we discuss the results of all conducted studies and recommendations for clinical practice and future research are provided.

9

10CHAPTER

Nederlandse Samenvatting

134

Chapter 10

INLEIDING

Zwangerschap en bevalling zijn beiden geassocieerd met het ontstaan van bekkenbodem problemen, zoals urine incontinentie, vaginale prolaps (verzakking) en overactieve blaasklachten.1-6 De kans dat een vrouw tijdens haar leven te maken krijgt met (één van) deze klachten is hoog. De incidentie van blaas gerelateerde klachten varieert maar het cumulatieve risico ligt tussen de 26 en 69%.7,8 Onderzoek heeft aangetoond dat dit vaak een negatief effect heeft op de kwaliteit van leven.9-12

Omdat zowel zwangerschap als (vaginale) bevalling risico factoren zijn voor de ontwikkeling van mictie (plas) problemen gedurende het verdere leven, wordt veel onderzoek gedaan naar anatomische veranderingen of fysiologische aanpassingen tijdens de zwangerschap en bevalling.13-16 Ten aanzien van de preventie van (urine) incontinentie wordt onder andere gekeken naar de invloed van baringsposities, electieve keizersneden en prenatale bekkenbodem oefeningen.17-22

Er is echter weinig bekend over de relatie tussen mictie problemen en postpartum urine retentie (PUR), het niet (goed) kunnen plassen na de bevalling. In de kliniek worden twee verschillende vormen van PUR onderscheiden. Symptomatische PUR houdt in dat er geen spontane mictie plaatsvindt binnen 6 uur na de bevalling, waarbij catheterisatie nodig is. Daarnaast wordt asymptomatische PUR onderscheiden; hierbij is er spontane mictie maar blijft er een verhoogd residu (restvolume) (PVRV) achter in de blaas. Een veelgebruikte afkapwaarde hiervoor is PVRV ≥ 150 mL.

Het lijkt aannemelijk dat de oorsprong van mictie problemen later in het leven gerelateerd is aan de periode direct na de bevalling, wanneer het niet (goed) kunnen plassen vaak voorkomt. Daarom is het belangrijk om inzicht te krijgen in de klinische problemen van urineretentie na de bevalling, de invloed op het ontstaan van mictie klachten en de behandeling van incomplete blaaslediging.

Voor dit proefschrift is onderzoek gedaan naar vrouwen na een vaginale bevalling met zowel symptomatische als asymptomatische postpartum urineretentie.

135


SAMENVATTING

Hoofdstuk 1 is de algemene inleiding en geeft een beschrijving van de doelstellingen van dit proefschrift.

DEEL 1: RISICO FACTOREN VOOR POSTPARTUM URINE RETENTIE

In hoofdstuk 2 worden de resultaten van een systematisch literatuur onderzoek naar de klinische factoren voor symptomatische en asymptomatische urineretentie postpartum besproken.23 In totaal werden 23 observationele studies gevonden waarvan de data konden worden geanalyseerd. De resultaten van 13 studies konden worden gebruikt om een meta-analyse te verrichten met betrekking tot onafhankelijke risico factoren voor symptomatische en asymptomatische urineretentie postpartum. De volgende klinische factoren bleken onafhankelijk van invloed op het ontstaan van symptomatische urineretentie en waren allen statistisch significant: kunstverlossing (Odds Ratio 4.52), epidurale analgesie (ruggenprik) (OR 7.66), episiotomie (knip) of vaginale ruptuur (OR 4.84) en pariteit (OR 2.42). Met betrekking tot asymptomatische PUR bleek er grote heterogeniteit tussen de verschillende studies (I2 tussen 50-83%), wat resulteerde in niet significante factoren. Deze heterogeniteit lijkt met name te berusten op een grote diversiteit van gebruikte definities en afkapwaarden, waaruit geconcludeerd kan worden dat om toekomstige data goed te kunnen bestuderen, een universele definitie gewenst is.

In hoofdstuk 3 worden de resultaten beschreven van een prospectief cross-sectioneel onderzoek naar de invloed van klinische factoren op asymptomatische PUR bij vrouwen na een vaginale bevalling.24 Bij de geïncludeerde vrouwen werd het residu volume (PVRV) na de eerste spontane mictie na de bevalling gemeten met een non-invasief scan apparaat (BladderScan® BVI 9400, Verathon Medical Europe, Ijsselstein, the Netherlands). De resultaten van deze metingen werden gedocumenteerd in het elektronisch patiëntendossier en op papier. Er werden van 930 patiënten gegevens verkregen en de PVRV van 745 patiënten konden uiteindelijk gebruikt worden voor definitieve analyse. Van deze patiënten was het mediane volume van de eerste mictie 320 mL (tussen de 0 – 1900 mL). De mediane PVRV was 140 mL (tussen de 0 - ≥ 999 mL). De 75e en 95e percentiel waren 250 mL en 540 mL. 347 vrouwen hadden een PVRV ≥ 150 mL. Met de beschikbare data werd een regressie analyse verricht voor de afkapwaarden PVRV ≥ 150 mL, ≥ 250 mL en ≥ 500 mL. Na selectie van enkele klinische factoren met behulp van univariate regressie analyse werd een multivariate regressie analyse verricht. Deze toonde dat epidurale analgesie, geboortegewicht en episiotomie onafhankelijke risicofactoren zijn voor het ontstaan van een residu ≥ 150 mL. Voor PVRV ≥ 250 mL waren geboortegewicht, episiotomie en pijnstilling onafhankelijke

10

136

Chapter 10

factoren. De volgende factoren waren onafhankelijk van invloed op het ontstaan van een residu ≥ 500 mL: episiotomie, opioïde analgesie en epidurale analgesie.

Naar aanleiding van de bovengenoemde resultaten rees het idee dat de huidige afkapwaarde van 150 mL, welke veelvuldig wordt gebruikt in de definitie van asymptomatische PUR, onvoldoende is om te differentiëren tussen pathologie en fysiologie, aangezien in ons cohort een zeer groot deel van de vrouwen een verhoogd residu had: 25% had een residu ≥ 250 mL en 5% een residu ≥ 500 mL. We stelden daarom voor dat zodra informatie over de klinische consequenties van deze verhoogde residuen beschikbaar is, nagedacht moet worden over een aanpassing van de huidige definitie.

DEEL 2: NADELIGE EFFECTEN VAN INADEQUATE BLAASLEDIG-ING NA DE BEVALLING

Hoofdstuk 4 beschrijft een literatuur onderzoek waarbij gezocht is naar studies die de klinische consequenties van PUR beschrijven en rapporteren over de noodzaak dit probleem te diagnosticeren.25 Na een systematisch literatuur onderzoek werden 909 artikelen gevonden over postpartum urine retentie. Uiteindelijk konden de gegevens van 24 studies gebruikt worden voor verdere analyse; dit waren 10 prospectieve en 6 retrospectieve studies over symptomatische PUR en 14 prospectieve studies over asymptomatische urineretentie postpartum. 3 studies beschreven het fenomeen �verlengde� postpartum urineretentie.

In de meeste artikelen werd niet gesproken over de nadelige effecten of klinische gevolgen van PUR. Er werden 2 artikelen gevonden waarin gekeken werd naar mictieklachten 4 jaar postpartum; deze studies suggereerden dat er geen statistische verschillen waren in mictieklachten tussen patiënten met en zonder PUR. In een aantal artikelen over asymptomatische PUR werd het spontane fysiologische beloop van het verhoogde residu beschreven; de meeste patiënten in deze studies hadden binnen enkele dagen een optimale blaaslediging. Desondanks is er door gebrek aan literatuur geen bewijs gevonden dat postpartum urineretentie, zowel symptomatisch als asymptomatisch, een onschuldig fenomeen is. Aangezien bekend is dat zelfs een eenmalige episode van blaasoverrekking (blaas overdistensie) langdurige mictieklachten kan geven, is het nodig dat verder onderzoek gedaan wordt naar de klinische consequenties van asymptomatische PUR. Om dit verder te onderzoeken werd een prospectieve vergelijkende studie ontworpen om mictieklachten op de lange termijn te evalueren bij patiënten met inadequate en onvolledige mictie na de bevalling. De resultaten van deze studie worden besproken in hoofdstuk 5.

In deze multicenter studie werden gegevens vergeleken van vrouwen met adequate mictie (i.e. een residu < 150 mL) met vrouwen die een verhoogd residu hadden na spontane mictie (PVRV ≥ 150 mL).26

137


Het blaas residu werd bij vrouwen na een vaginale bevalling gemeten na de eerste mictie. Deze meting werd verricht door de verpleegkundige met een draagbaar non-invasief automatisch scanning apparaat, de BladderScan® (BVI 9400). Patiënten bij wie het residu ≥ 150 mL was, werden op dag 4, dag 7 en dag 10 na de bevalling opnieuw gebladderscand totdat het residu < 150 mL was. Aan alle patiënten die geïncludeerd werden, werd gevraagd om diverse vragenlijsten in te vullen; deze gevalideerde vragenlijst, de UDI-6 vragenlijst, is een verkorte versie van de ‘Urogenital Distress Inventory’ en bestaat uit een 6-tal vragen over mictieklachten. Deelnemende patiënten werd gevraagd de vragenlijsten in te vullen op de dag van de bevalling (dag 0) en op de 4e, 7e, 30e en 90e dag na de bevalling en tevens één jaar na de bevalling (dag 365).

De resultaten van de UDI-6 kunnen worden onderverdeeld in drie domeinen: irritatieve mictie symptomen, incontinentie symptomen en obstructieve mictie symptomen.

In totaal werden 241 patiënten geïncludeerd, waarvan de gegevens van 224 patiënten konden worden gebruikt in de analyses. De uitkomsten van 119 patiënten met asymptomatische retentie (i.e. PVRV ≥ 150 mL), werden vergeleken met de uitkomsten van 105 patiënten met complete blaaslediging (i.e. PVRV < 150 mL).

Asymptomatische PUR kwam vaker voor bij primipara. Het mediane volume van de eerste mictie was 370 mL (100 – 1100 mL) bij vrouwen met PVRV < 150 mL en 350 mL (50-1900 mL) bij vrouwen met PVRV ≥ 150 mL. 83 patiënten met asymptomatische PUR (68%) had een PVRV ≥ 250 mL en 19 patiënten hadden een PVRV ≥ 500 mL (16%). 92% van alle patiënten met een residu ≥ 150 mL na de bevalling had complete blaaslediging op de 4e dag na de bevalling.

Ten aanzien van de scores van de UDI vragenlijsten werden geen verschillen gevonden in mictie gerelateerde klachten tussen de beide patiënten groepen: zowel de totale scores als de domeinscores toonde geen statistisch significante verschillen 1 jaar na de bevalling.

Onze resultaten tonen aan dat een verhoogde residu na de bevalling snel herstelt, aangezien 92% van de patiënten binnen 4 dagen weer complete blaaslediging had. Daarnaast is de incidentie van mictieklachten 1 jaar postpartum laag en niet gerelateerd aan PUR.

Hoewel uit de resultaten van onze studie opgemaakt zou kunnen worden dat een verhoogd residu na spontane mictie na een vaginale bevalling een onschuldig fenomeen is, zou het ook kunnen dat dit ligt aan de gebruikte definitie. De huidige definitie met de afkapwaarde van PVRV ≥ 150 mL lijkt klinisch niet relevant en onvoldoende om te kunnen differentiëren tussen pathologie en fysiologie. Aangezien 16% van onze patiënten een PVRV ≥ 500 mL had na de eerste mictie na de bevalling, denken we dat dit een meer valide waarde is om eventuele pathologie te kunnen detecteren. Daarom hebben we

10

138

Chapter 10

voorgesteld om de huidige definitie van asymptomatische PUR aan te passen en te veranderen in “asymptomatische postpartum urineretentie wordt gedefinieerd als een PVRV ≥ 500 mL na de eerste spontane mictie na de (vaginale) bevalling, gemeten met een BladderScan® of echo”.

DEEL 3: POSTPARTUM BLAAS MANAGEMENT

Het laatste deel van dit proefschrift beschrijft blaas gerelateerde zorg na de bevalling. In hoofdstuk 6 worden de resultaten beschreven van een prospectieve vergelijkende studie waarbij gekeken is naar de betrouwbaarheid van het meten van de PVRV na een vaginale bevalling.27 Hoewel er in de kliniek behoefte is aan een non-invasieve methode om inadequate mictie na de bevalling op te sporen, is een veelgehoorde mening in de klinische praktijk dat de BladderScan® niet betrouwbaar is na de bevalling en een overschatting geeft van het blaasvolume. Dit geloof is gebaseerd op de aanname dat het apparaat niet kan differentiëren tussen vocht in de blaas en vocht in de uterus en zal leiden tot een onterecht verhoogd residu en onnodige catheterisatie. In de huidige literatuur ontbreekt voldoende bewijs voor deze aanname en zijn er slechts enkele vergelijkende studies gepubliceerd met ofwel kleine patiënten groepen ofwel oudere modellen scans. Daarom is een multicenter prospectieve studie verricht om de PVRV te vergelijken bij patiënten na een vaginale bevalling, gemeten met een BladderScan® (BVI 9400) en met eenmalige catheterisatie, de ‘gouden standaard’. In totaal konden de gegevens van 407 patiënten gebruikt worden voor de definitieve analyse. De gemiddelde (mean) PVRV gemeten met de BladderScan® was 380 mL (0 - 999 mL) en bij de catheterisatie 375 mL (0 - 1800 mL). Het gemiddelde verschil tussen de twee metingen was -13 mL (SD ± 177 mL), wat resulteerde in een goede correlatie tussen de twee methoden met een Spearman’s rank correlatie coëfficiënt van r = 0.82 (p < 0.001). Gebaseerd op de eerdere suggestie dat een PVRV ≥ 500 mL een betere afkapwaarde is om fysiologie van pathologie te kunnen onderscheiden, werden ook de sensitiviteit en specificiteit van deze afkapwaarde berekend, omdat een gemeten PVRV ≥ 500 mL een valide reden zou kunnen zijn om patiënten na spontane mictie te catheteriseren. Met een specificiteit van 85.4% en een sensitiviteit van 85.6% kan worden geconcludeerd dat de BladderScan® BVI 9400 een accuraat en betrouwbaar instrument is om de PVRV na een vaginale bevalling te meten.

Hoofdstuk 7 toont de resultaten van een multicenter gerandomiseerd onderzoek, waarbij gekeken is naar twee standaard behandelingen voor symptomatische urineretentie postpartum, gedefinieerd als het niet kunnen plassen binnen 6 uur na de bevalling (resulterend in een noodzaak tot catheterisatie).28 Zowel een transurethrale verblijfscatheter (catheter à demeure, CAD) als intermitterend catheteriseren (CIC) worden beiden als standaard behandeling gebruikt bij symptomatische PUR maar werden nooit eerder met elkaar vergeleken.

139


In de studie kregen geïncludeerde patiënten die gerandomiseerd (geloot) werden voor een verblijfscatheter deze catheter voor 24 uur. Indien na deze periode nog geen spontane mictie mogelijk was of indien het residu ≥ 150 mL was, werd een tweede verblijfscatheter voor 48 uur ingebracht. Bij patiënten die gerandomiseerd werden voor intermitterend catheteriseren gebeurde dit totdat er een residu < 150 mL was.

De primaire uitkomstmaat was de aanwezigheid van mictie gerelateerde klachten drie maanden na de bevalling, gebaseerd op uitkomsten van de UDI-6 vragenlijst.

In totaal werd deze UDI-6 vragenlijst door 34 patiënten met een CAD en 34 patiënten met CIC drie maanden postpartum ingevuld. Er werden geen statistisch significante verschillen gevonden in de totaalscores of domeinscores tussen beide patiënten groepen. Wel bleek dat patiënten die werden ingeloot voor intermitterend catheteriseren statistisch significant sneller weer spontaan konden plassen dan patiënten met een verblijfscatheter (p < 0.01). Bij 35% van de patiënten in de CIC groep was slechts één enkele catheterisatie nodig voordat adequate spontane mictie mogelijk was. Daarnaast kan de veelgehoorde aanname dat intermitterend catheteriseren bij kraamvrouwen niet mogelijk is of een te grote last is worden verworpen, aangezien de meerderheid van de patiënten aangaf intermitterend catheteriseren een niet belastende behandeling te vinden. De resultaten van deze gerandomiseerde studie kunnen gebruikt worden om toekomstige richtlijnen met betrekking tot mictie protocollen na een vaginale baring wetenschappelijk te ondersteunen.

Tenslotte worden in hoofdstuk 8 de resultaten van alle beschreven studies besproken en in een breder perspectief geplaatst. Daarnaast worden er aanbevelingen gedaan voor de dagelijkse praktijk en toekomstig wetenschappelijk onderzoek.

10

140

Chapter 10

CONCLUSIES

Postpartum urineretentie is een frequent voorkomend fenomeen na de bevalling. Het feit dat er weinig bekend is over de klinische consequenties van incomplete blaaslediging na de bevalling en richtlijnen gebaseerd op wetenschappelijk onderzoek ontbreken, onderstreept de noodzaak voor dit proefschrift.

De meerderheid van patiënten met een verhoogd residu na spontane mictie na een vaginale bevalling heeft binnen enkele dagen weer een adequate en complete blaaslediging. Een verhoogd residu lijkt daarmee een vaak passagère verschijnsel. Daarnaast lijken de huidige gebruikte definities voor asymptomatische urineretentie postpartum onvoldoende om te kunnen differentiëren tussen fysiologie en pathologie. Hierdoor is er nog onvoldoende bewijs om te kunnen stellen dat incomplete blaaslediging na de bevalling een onschuldige gebeurtenis is en zullen toekomstige studies zich moeten richten op patiënten met een residu > 500 mL na spontane mictie om de gevolgen binnen deze groep verder te bestuderen.

Verder is gebleken dat de BladderScan® BVI 9400 een betrouwbaar instrument is om een verhoogd residu na een vaginale bevalling te detecteren. Hiermee is het niet meer nodig om bij patiënten die verdacht worden van incomplete blaaslediging het residu middels catheterisatie te bepalen. Tenslotte werd aangetoond dat voor de behandeling van symptomatische urineretentie postpartum, bij patiënten die geen spontane mictie hebben binnen 6 uur na de bevalling, intermitterend catheteriseren (CIC) de voorkeur heeft boven het inbrengen van een verblijfscatheter (CAD). Niet alleen zorgt CIC voor een sneller herstel van spontane en adequate mictie, ook wordt deze behandeling goed geaccepteerd door de patiënten.

De uitkomsten van de studies kunnen gebruikt worden als een wetenschappelijk basis voor richtlijnen over incomplete blaaslediging en mictieprotocollen na een vaginale baring.

141


REFERENTIES1. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of parity

on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol. 2001;98(6):1004-1010.

2. Wesnes SL, Hunskaar S, Bo K, Rortveit G. The effect of urinary incontinence status during pregnancy and delivery mode on incontinence postpartum. A cohort study. BJOG. 2009;116(5):700-707.

3. Brown SJ, Donath S, Macarthur C, McDonald EA, Krastev AH. Urinary incontinence in nulliparous women before and during pregnancy: prevalence, incidence, and associated risk factors. Int Urogynecol J. 2010;21(2):193-202.

4. Altman D, Ekstrom A, Gustafsson C, Lopez A, Falconer C, Zetterstrom J. Risk of urinary incontinence after childbirth: a 10-year prospective cohort study. Obstet Gynecol. 2006;108(4):873-878.

5. Mason L, Glenn S, Walton I, Hughes C. Women’s reluctance to seek help for stress incontinence during pregnancy and following childbirth. Midwifery. 2001;17(3):212-221.


7. Cerruto MA, D’Elia C, Aloisi A, Fabrello M, Artibani W. Prevalence, Incidence and Obstetric Factors’ Impact on Female Urinary Incontinence in Europe: A Systematic Review. Urol Int. 2012.

8. Samuelsson E, Victor A, Tibblin G. A population study of urinary incontinence and nocturia among women aged 20-59 years. Prevalence, well-being and wish for treatment. Acta Obstet Gynecol Scand. 1997;76(1):74-80.

9. Bartoli S, Aguzzi G, Tarricone R. Impact on quality of life of urinary incontinence and overactive bladder: a systematic literature review. Urology. 2010;75(3):491-500.

10. Kim S, Harvey MA, Johnston S. A review of the epidemiology and pathophysiology of pelvic floor dysfunction: do racial differences matter? J Obstet Gynaecol Can. 2005;27(3):251-259.

11. Arrue M, Ibanez L, Paredes J, et al. Stress urinary incontinence six months after first vaginal delivery. European Journal of Obstetrics Gynecology and Reproductive Biology. 2010;150:210-214.

12. van der Vaart CH, de Leeuw JR, Roovers JP, Heintz AP. The effect of urinary incontinence and overactive bladder symptoms on quality of life in young women. BJU Int. 2002;90(6):544-549.

13. Pizzoferrato AC, Fauconnier A, Bader G, de Tayrac R, Fort J, Fritel X. Is prenatal urethral descent a risk factor for urinary incontinence during pregnancy and the postpartum period? Int Urogynecol J. 2016;27(7):1003-1011.

14. Wijma J, Potters AE, de Wolf BT, Tinga DJ, Aarnoudse JG. Anatomical and functional changes in the lower urinary tract following spontaneous vaginal delivery. BJOG. 2003;110(7):658-663.

15. Miller JM, Low LK, Zielinski R, Smith AR, DeLancey JO, Brandon C. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol. 2015;213(2):188 e181-188 e111.

10

142

Chapter 10

16. Rogers RG, Leeman LL. Postpartum genitourinary changes. Urol Clin North Am. 2007;34(1):13-21.

17. Durnea CM, Khashan AS, Kenny LC, et al. What is to blame for postnatal pelvic floor dysfunction in primiparous women-Pre-pregnancy or intrapartum risk factors? Eur J Obstet Gynecol Reprod Biol. 2017;214:36-43.

18. Durnea CM, Khashan AS, Kenny LC, Tabirca SS, O’Reilly BA. The role of prepregnancy pelvic floor dysfunction in postnatal pelvic morbidity in primiparous women. Int Urogynecol J. 2014;25(10):1363-1374.

19. Serati M, Rizk D, Salvatore S. Vaginal birth and pelvic floor dysfunction revisited: Can cesarean delivery be protective? Int Urogynecol J. 2016;27(1):1-2.

20. Boyle R, Hay-Smith EJ, Cody JD, Morkved S. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2012;10:CD007471.

21. Bo K, Hilde G, Tennfjord MK, Engh ME. Does episiotomy influence vaginal resting pressure, pelvic floor muscle strength and endurance, and prevalence of urinary incontinence 6 weeks postpartum? Neurourol Urodyn. 2017;36(3):683-686.

22. Rogers RG, Ninivaggio C, Gallagher K, Borders AN, Qualls C, Leeman LM. Pelvic floor symptoms and quality of life changes during first pregnancy: a prospective cohort study. Int Urogynecol J. 2017.


24. Mulder FE, Rengerink KO, Van der Post JA, Hakvoort RA, Roovers JW. Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery. Int Urogynecol J. 2015.


26. Mulder FE, Hakvoort RA, de Bruin JP, Janszen EW, van der Post JA, Roovers JP. Long term micturition problems of asymptomatic postpartum urinary retention: a prospective case control study. Int Urogynecol J 2017;accepted for publication (Epub ahead of print)

27. Mulder FE, van der Velde S, Pol F, et al. The accuracy of post void residual volumes after vaginal delivery: a prospective equivalence study to compare an automatic scanning device with transurethral catheterisation. Submitted 2017.

28. Mulder FE, Hakvoort RA, de Bruin JP, van der Post JA, Roovers JP. Comparing clean intermittent (CIC) versus transurethral indwelling catheterisation (TIC) for the treatment of overt urinary retention after vaginal delivery: a multicentre randomized controlled clinical trial. Int Urogynecol J. 2017;accepted for publication (Epub ahead of print)

143


10

AADDENDUM

List of Authors and Affiliations

List of Publications

PhD Portfolio

Dankwoord

Curriculum Vitae

146

Addendum

147


AUTHORS AND AFFILIATIONS

M. Bos Department of Obstetrics and Gynaecology, Antonius Hospital, Nieuwegein

J.P. de Bruin Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, ‘s Hertogenbosch

V. Dietz Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven

R.A. Hakvoort Department of Obstetrics and Gynaecology, Martini Hospital, Groningen

E.W. Janszen Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam

J. Limpens Medical Library, Academic Medical Center, Amsterdam

B.M.J. Mol The Robinson Institute, School of Medicine, University of Adelaide, Australia

The South Australian Health and Medical Research Institute, Adelaide, Australia

K. Oude Rengerink Julius Center for Health Sciences and Primary Car, University Medical Center, Utrecht

F. Pol Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven

J.A.M. van der Post Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam

J.P.W.R. Roovers Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam

J. Schagen van Leeuwen

Department of Obstetrics and Gynaecology, Antonius Hospital, Nieuwegein

M.A. Schoffelmeer Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam

S. van der Velde Department of Obstetrics and Gynaecology, Spaarne Hospital, Haarlem

A

AADDENDUM



PhD Portfolio

Dankwoord

Curriculum Vitae

150

Addendum

LIST OF PUBLICATIONS

Risk factors for postpartum urinary retention: a systematic review and meta-analysis.Mulder FE, Schoffelmeer MA, Hakvoort RA, Limpens J, Mol BW, van der Post JA, Roovers JP. British Journal of Obstetrics and Gynaecology, 2012;119:1440-6.

Postpartum urinary retention: a systematic review of adverse effects and management. Mulder FE, Hakvoort RA, Schoffelmeer MA, Limpens J, Van der Post JA, Roovers JP. International Urogynecology Journal, 2014;25:1605-12

Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery.Mulder FE, Rengerink KO, Van der Post JA, Hakvoort RA, Roovers JP. International Urogynecology Journal, 2016;27(1):55-60

Long term lower urinary tract symptoms of asymptomatic postpartum urinary retention: a prospective case control study.Mulder FE, Hakvoort RA, de Bruin JP, Janszen EW, van der Post JA, Roovers JP. International Urogynecology Journal, 2017, accepted for publication (Epub ahead of print)

Comparing clean intermittent (CIC) versus transurethral indwelling catheterisation (TIC) for the treatment of overt urinary retention after vaginal delivery: a multicentre randomized controlled clinical trial.Mulder FE, Hakvoort RA, de Bruin JP, van der Post JA, Roovers JP. International Urogynecology Journal, 2017, accepted for publication (Epub ahead of print)

Validation of an automatic ultrasound device (BladderScan®) to measure post void residual volumes in postpartum women - a prospective equivalence study.Mulder FE, van der Velde S, Pol F, Bos M, Schagen van Leeuwen J, Dietz V, Hakvoort RA, Roovers JP. Submitted

What’s a proper push? The Valsalva manoeuvre revisited.Mulder FE, Shek KL, Dietz HP.Australian and New Zealand Journal of Obstetrics and Gynaecology, 2012;52:282-5.

The Development of a New Medical Device for Standardized Episiotomy: A Pre-Clinical Validation Study. Mulder FE, Piersma D, Veersema S, van der Post JA, Roovers JP.Gynecologic and Obstetric Investigation, 2016;81:207-14.

151


Protocol for translabial 3D-ultrasonography for diagnosing levator defects (TRUDIL): a multicentre cohort study for estimating the diagnostic accuracy of translabial 3D-ultrasonography of the pelvic floor as compared to MR imaging.Notten KJ, Weemhoff M, Kluivers KB, Schweitzer KJ, Mulder FE, Stoker J, Beets-Tan RG, Futterer JJ, Vliegen RF, Evers JL, Link G, Bergmans MG, Kampschöer PH, Gondrie ET, van Gestel I, van Dooren I, Dirksen C, Smits LJ, Bossuyt PM, Roovers JP.BMC Womens Health, 2011 Jun3;11:23

Translabial three-dimensional ultrasonography compared with magnetic resonance imaging in detecting levator ani defects.Notten KJ, Kluivers KB, Futterer JJ, Schweitzer KJ, Stoker J, Mulder FE, Beets-Tan RG, Vliegen RF, Bossuyt PM, Kruitwagen RF, Roovers JP, Weemhoff M.Obstetrics and Gynecology, 2014;124:1190-7.

Levator hiatal area as a risk factor for cystocele recurrence after surgery: a prospective study. Vergeldt TF, Notten KJ, Weemhoff M, van Kuijk SM, Mulder FE, Beets-Tan RG, Vliegen RF, Gondrie ET, Bergmans MG, Roovers JP, Kluivers KB.British Journal of Obstetrics and Gynaecology, 2015;122:1130-7

Comparison of translabial 3D ultrasound with MRI for measuring levator hiatus biometry at rest. Vergeldt TF, Notten KJ, Stoker J, Fütterer JJ, Beets-Tan RG, Vliegen RF, Schweitzer KJ, Mulder FE, van Kuijk SM, Roovers JP, Kluivers KB. Ultrasound in Obstetrics and Gynecology, 2016 May; 47(5):636-41.

A

AADDENDUM



PhD Portfolio

Dankwoord

Curriculum Vitae

154

Addendum

PORTFOLIO PHD

Courses

2010 AMC World of Science 0.7 ECTS

2010 Pubmed 0.2 ECTS

2010 Basis Course Legislation and Organization for Clinical Research

0.9 ECTS

2010 Systematic reviews 0.3 ECTS

2011 Clinical data management 0.2 ECTS

2010 Practical Biostatistics 1.1 ECTS

2010 Clinical Epidemiology 1.1 ECTS

2010 Scientific writing in English 1.5 ECTS

2010 Reference manager 0.1 ECTS

Seminars, workshops and master classes

2010 – 2013 Weekly department lunch meetings 3.0 ECTS

2010 – 2013 Weekly journal club 3.0 ECTS

2010 – 2013 Weekly department seminars 3.0 ECTS

2010 Master class 3D Pelvic Floor Ultrasonography, Penrith, Australia

4.0 ECTS

Presentations

2013 38th Annual Meeting, International Urogynecological Association, Dublin, Ireland. Oral podium presentation: Intermittent versus indwelling catheterisation for symptomatic postpartum urinary retention: a randomized controlled clinical trial

0.5 ECTS

2017 Annual meeting, International Continence Society, Florence, Italy

0.5 ECTS

2017 Presentatie “Postpartum urine retentie” Werkgroep bekkenbodem, NVOG

0.5 ECTS

155

PhD Portfolio

(Inter)national conferences

2011 Annual meeting International Urogynaecological Association, Lisbon, Portugal

2016 Annual meeting European Urogynecological Association, Amsterdam

2017 Annual meeting International Continence Society, Florence, Italy

Tutoring, Mentoring

2010 Student mentoring/supervising scientific research project

1.0 ECTS


1.0 ECTS


1.0 ECTS

A

AADDENDUM



PhD Portfolio

Dankwoord

Curriculum Vitae

158

Addendum

DANKWOORD

En dan is het zover: tijd voor het dankwoord. Het meest gelezen gedeelte van een proefschrift. In gedachten heb ik dit stuk de afgelopen jaren al vele malen geschreven, zeer wisselend van inhoud. Nu het eindelijk mag, blijkt het niet zo eenvoudig.

Graag wil ik iedereen bedanken die, bewust of onbewust, direct of indirect, heeft bijgedragen aan de totstandkoming van dit proefschrift.

Allereerst de belangrijkste en motiverende inspiratoren.

Liefste Guus. Vanaf het allereerste begin heb je me bijgestaan tijdens deze wetenschappelijke exercitie. Je hebt me geholpen de juiste keuzes te maken en me bijgestaan tijdens alle hoogte- en dieptepunten die deze onderzoeksperiode heeft gekend. Hoewel ik weet dat je je bijdrage aan dit boekje onderschat, weet ik ook zeker dat ik het zonder jou niet had gekund. Dank voor je vertrouwen, je geduld en je adviezen. Laten we de liefde vieren! Ik hou van je!Allerliefste en mooiste Hugo en Liselot! Wat is het toch ontzettend leuk met jullie en ben ik toch blij dat jullie er zijn! Dank voor al jullie gezelligheid, jullie grappen, jullie energie, jullie allerdikste knuffels en voor alle relativering. Mama’s boek is nu eindelijk echt af! Hopelijk net op tijd om te zorgen dat jullie jeugdherinneringen geen typende mopperende mama bevatten. Nu is het tijd voor het feestje en voor leuke boeken! Ik hou van jullie tot aan het hele heelal en weer terug!

Veel dank verschuldigd aan alle vrouwen die belangeloos hebben meegewerkt aan de verschillende studies. De afgelopen jaren heb ik me steeds meer gerealiseerd hoe bijzonder het is dat deze net bevallen vrouwen hebben geparticipeerd in het onderzoek. Heel hartelijk dank voor uw deelname en tijd in zo’n precaire periode als nieuwe moeder.

Mijn promotoren en co-promotor: prof. dr. J.P.W.R. Roovers, prof. dr. J.A.M. van der Post en dr. R.A. Hakvoort. Hoewel het lange tijd een utopie leek, is het dankzij jullie hulp, begeleiding en geduld uiteindelijk toch gelukt dit proefschrift succesvol af te ronden.

Geachte professor Roovers, beste Jan-Paul. De afgelopen jaren ben ik je inzet, visie, ambitie, eerlijkheid en wilskracht steeds meer gaan waarderen. Hoewel onze samenwerking de nodige pieken en dalen heeft gekend, ben ik erg blij met alle mogelijkheden die je me hebt geboden. Je hebt me geleerd kritisch te zijn, niet alleen over de wetenschap maar ook over mijzelf. Veel dank hiervoor. Ik vind het ontzettend knap hoe je zoveel verschillende zaken weet te combineren, zowel wetenschappelijk, klinisch als zakelijk. Ik hoop in de toekomst nog veel van je te mogen leren.

159

Dankwoord

Geachte professor van der Post, beste Joris. De combinatie opleider en promotor moet soms moeilijk zijn geweest, maar je wist me telkens te motiveren om door te gaan en prioriteiten te stellen. Dankzij jouw talent om het grote geheel te blijven zien, lukte het je feilloos om de feiten van de emotie scheiden wanneer dit nodig was. Dank voor je vertrouwen en je begeleiding.

Geachte dr. Hakvoort, beste Robert. Als vervolg op jouw proefschrift, was je vanaf het begin af aan gemotiveerd om de onderzoeken tot een succes te brengen. Ondanks de drukte van de kliniek en al je nevenfuncties bleef je tijd maken om patiënten te includeren, verpleegkundigen mee te krijgen en een soms hopeloze onderzoeker te motiveren en begeleiden. Je directheid en primaire reacties kan ik inmiddels zeer waarderen. Hoewel we het elkaar de afgelopen jaren soms wat moeilijk hebben gemaakt, ben jij echt de drijvende motor geweest achter dit proefschrift. De progressie van het laatste jaar was niet gelukt zonder jouw inbreng. Dankzij jouw hulp, enthousiasme, doorzettingsvermogen en daadkracht is het uiteindelijk gelukt alles af te ronden. Heel veel dank hiervoor!

De promotiecommissie: Prof. dr. M.Y. Bongers, Prof. dr. E. Pajkrt, Prof. dr. S. Geerlings, Prof. dr. M.P. Laguna, Dr. A. Vollebregt, Dr. M.M.J. Withagen. Zes zeer inspirerende vrouwen. Graag wil ik u allen heel hartelijk danken dat u in deze drukke tijden de moeite heeft genomen voor de kritische beoordeling van dit proefschrift en het voeren van de oppositie.

Alle gynaecologen en research medewerkers die betrokken zijn geweest bij de organisatie van en inclusies voor de diverse studies in de verschillende centra: Jan-Peter de Bruin, Viviane Dietz, Jules Schagen van Leeuwen, Erica Janszen en Henk Bremer : dank voor jullie geduld en vasthoudendheid. Dankzij jullie hulp is het gelukt de studies succesvol af te ronden. Sieta Kleiterp, Birgit van der Goes, Marieke Linders, Ada van der Ster, Sabine Logtenberg en Corinne van de Griendt, heel hartelijk dank voor jullie hulp met inclusies en het invullen van de CRF’s. Marianne Sanders en Renate de Vries: dank voor het uitbreiden van de thuismonitoring en het thuis bladderscannen van de geincludeerde patiënten. Zonder jullie was het niet gelukt!

Alle overige mede-auteurs wil ik graag hartelijk danken voor hun bijdragen aan de manuscripten die in dit proefschrift staan.

Graag wil ik alle verpleegkundigen in de deelnemende centra hartelijk danken voor jullie hulp bij de inclusies van de patiënten. Hoewel we veel scepsis hebben moeten overwinnen, is het dankzij jullie medewerking uiteindelijk toch gelukt voldoende patiënten te includeren. Bravo!

A

160

Addendum

Alle collega’s in het Spaarne Gasthuis en in het AMC: alle AIOS, ANIOS, onderzoekers, gynaecologen en verpleegkundigen. Teveel om afzonderlijk op te noemen, maar dank voor de fijne samenwerking, de hulp, de adviezen, de lol, de grappen en de prettige sfeer. Bijzondere dank ben ik verschuldigd aan Guus Fons, plaatsvervangend opleider. Dankzij jouw advies en tussenkomst kwam er weer licht aan de horizon, waardoor ik dit proefschrift heb kunnen afronden. Veel dank voor de inzichten en inspiratie.

Mijn geweldige intervisiegroep: Noor, Mel, Gert , Loes, Soof, Jet en Jelle. Wat is het fijn om zo’n vertrouwde groep collega’s te hebben die precies weten of aanvoelen wat er speelt, niet bang zijn voor een kritische noot en met wie ik zo hard kan lachen. Ik hoop dat we nog lang door zullen gaan met onze intervisie (met en zonder M) en kijk uit naar andere uitstapjes.

Mijn paranimfen. Lieve Margot, bijna 10 (!) jaar geleden begonnen we beiden als onervaren jonge agnio’s in het SLAZ. Wat was het fijn een maatje te hebben in deze drukke kliniek, en wat hebben we gelachen tijdens de vrijdagmiddagborrels. Uiteindelijk gingen we beiden een onderzoekstraject in, waarin we gelukkig veel konden sparren over alle hobbels en bobbels. Ik vind het waanzinnig hoe jij alles zo ogenschijnlijk moeiteloos weet te combineren en ook nog zo relaxed blijft. Ik ben dol op je droge humor en je scherpe analyses en bewonder je doorzettingsvermogen. Dank dat ik altijd bij je terecht kan en dat je vandaag naast me wil staan! Lieve Marjet, 8 (!) jaar geleden begonnen we beiden als onderzoeker in het grote onbekende AMC. Wat heb ik met je gelachen tijdens alle (verplichte en soms bizarre) cursussen en wat was het fijn een luisterend oor te hebben als het weer eens niet zo soepel liep. Inmiddels zijn we samen in opleiding en zit onze AMC tijd er weer bijna op. Ik bewonder je ambities, nuchterheid en doortastendheid. Dank voor alle gezelligheid, je bent een geweldige collega en ik hoop dat we nog vaak roomies zullen zijn! Fijn dat je naast me staat vandaag!

Lieve vrienden en vriendinnen, het project is eindelijk af! Ik kan weer overal bij zijn! Lieve Frederiek, Emma, Karin, Vanessa, Karen en Myrthe. Dankzij onze langdurige vriendschap weet ik dat ik altijd bij jullie terecht kan, ook al zien we elkaar minder vaak dan we zouden willen. Jullie zijn me heel erg dierbaar.

Familie Bakker, mijn schoonouders Emma en Harrie. Dank hoe jullie mij in jullie familie hebben opgenomen en dank voor jullie betrokkenheid en interesse. Het boek is dus eindelijk klaar. Ook veel dank voor jullie liefde voor onze kinderen en alle hulp en opvang. Noortje en Frank, wat is het fijn zo’n gezellig schoonzus en - broer te hebben. Laten we snel afspreken voor dat langdurig geplande etentje!

161

Dankwoord

Lieve Maaike, mijn lieve zusje. Hoewel je het niet altijd leuk hebt gevonden, zal je altijd mijn kleine zusje blijven. We voelen elkaar heel goed aan en hoewel we het soms heftig oneens kunnen zijn, weet ik dat het ook altijd weer goed komt en dat we er altijd voor elkaar zullen zijn. Aan een half woord hebben we vaak genoeg. Dank dat ik altijd bij je terecht kan als er iets is. Dank ook voor je mooie en creatieve cover ontwerp, het is echt prachtig geworden! Hoewel ik je erg mis nu je al een aantal jaar zo ver weg woont, moet je weten dat ik ook ontzettend trots op je ben. Ik bewonder je optimisme, je positiviteit, je flexibiliteit en je doorzettingsvermogen. Ik hou van je! Thomas, dank voor alle liefde die je aan Maaike geeft. Ik ben trots op hoe jullie het samen doen!

Lieve papa en lieve mama, dank voor jullie onvoorwaardelijke liefde, steun en eindeloos vertrouwen. Dankzij jullie sta ik hier vandaag en ben ik geworden wie ik ben. Jullie liefdevolle basis en betrokkenheid hebben ervoor gezorgd dat ik me heb kunnen en durven te ontwikkelen. Dank voor alle mogelijkheden die jullie me hebben geboden en dat jullie me hebben geleerd om door te zetten. Zonder jullie was dit boek er niet geweest. Dank ook voor al jullie liefde en zorgen voor onze kinderen. Ik weet dat jullie vandaag ontzettend trots zijn maar weet ook dat ik trots ben om jullie dochter te zijn. Ik hou van jullie!

A

AADDENDUM



PhD Portfolio

Dankwoord

Curriculum Vitae

164

Addendum

165

Curriculum Vitae

CURRICULUM VITAE

Femke Elisabeth Maria Mulder werd op 6 mei 1982 geboren in het toenmalige Sint Elisabeth Ziekenhuis te Leiderdorp, in volkomen stuitligging met een moeizame forceps op een nakomend hoofd.

Zij groeide samen met haar zusje Maaike op in Voorschoten. Na het behalen van haar Gymnasium diploma aan het Stedelijk Gymnasium te Leiden begon zij in september 2000 met de Geneeskunde opleiding aan de Vrije Universiteit van Amsterdam.

Na het afronden van haar doctoraal deed zij een extra curriculaire klinische stage in het Huruma Hospital in Mkuu, Tanzania. In december 2005 begon zij met haar co-schappen, waarvoor zij voor haar co-schap huisartsgeneeskunde in Oranjestad, Aruba, verbleef. Tijdens haar co-schap Verloskunde en Gynaecologie in het Spaarne Ziekenhuis te Hoofddorp werd de interesse voor het vak gewekt.

Na het behalen van haar artsexamen in december 2007 werkte zij als ANIOS op de afdeling Gynaecologie en Verloskunde in het Sint Lucas Andreas Ziekenhuis te Amsterdam.

In januari 2010 kreeg zij de mogelijkheid in het AMC te starten met een promotie traject bij prof. J.P.W.R. Roovers en prof. J.A.M van der Post naar postpartum urine retentie, waarmee een samenwerking tussen de urogynaecologie en verloskunde tot stand kwam. Dit onderzoek heeft geresulteerd in dit proefschrift. Tijdens het onderzoek is Femke blijven werken als ANIOS in het AMC. Zij participeerde in meerdere projecten tijdens haar onderzoeksperiode. Voor de TRUDIL studie deed zij een scholarship in het Nepean Medical Centre, University of Sydney in Penrith, Australië waar zij van Prof. H.P. Dietz de techniek voor 3D bekkenbodem echo’s leerde. Ook heeft zij meegewerkt aan de ontwikkeling van een device voor een gestandaardiseerde episiotomie.

In juni 2013 begon Femke met de opleiding tot gynaecoloog in het Spaarne Ziekenhuis te Hoofddorp (opleider Dr. A. Vollebregt). Sinds oktober 2015 is zij terug als AIOS in het AMC te Amsterdam (opleider Prof.dr. J.A.M. van der Post).

Femke woont samen met Guus Bakker en hun kinderen Hugo en Liselot in het pittoreske Weesp.

A

uva-dare (digital academic repository) postpartum urinary ... · postpartum urinary retention (pur)...

Documents