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10/1/2019

Evaluation and Management of Urinary Retention Caused by Pelvic Organ Prolapse (POP)

Author: Amanda Owens, DO, FACOG

Mentor: D. Scott Wiersma, MD
Editor: Abimbola Famuyide, MD, MBBS

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Pelvic organ prolapse (POP) is a common gynecologic condition causing symptoms in 4-8% of women. Women with prolapse beyond the hymen are more likely to present with obstructive voiding symptoms such as hesitancy, weak or intermittent flow, sensation of incomplete emptying or require splinting to facilitate voiding. When these symptoms are present further evaluation should begin.

A pelvic organ prolapse quantification system (POP-Q) exam is recommended as an objective and reproducible tool to describe the severity of descent in the anterior, posterior and apical compartments.  Advanced anterior wall prolapse can lead to urethral kinking while advanced posterior wall prolapse can directly compress the urethra leading to bladder outflow obstruction.  As many as 30% of patients with stage III-IV POP will have obstructive voiding leading to urinary retention.

Retention can be demonstrated by measuring post void residual (PVR) within 10 minutes of a patient voiding to empty their bladder.  Assessment can be accomplished by bladder scan or catheterization.  Bladder scan is easy to use and is less invasive for patients but can yield unreliable results in obese patients.  Catheterization may be more readily available in some clinical settings and PVR value >100mL is generally considered abnormal.  Urinalysis with culture should also be performed to rule out infection. Upper urinary tract evaluation may be indicated in patients with a PVR >300mL that persisted 6 months or longer using renal ultrasound and serum creatinine to assess for hydronephrosis and renal impairment respectively.

Patients with urinary retention due to prolapse are much more likely to have chronic, partial obstruction, and if left untreated can progress to complete obstruction.  Management is aimed at improving symptoms and reducing potential complications such as urinary tract infection, hydronephrosis and renal impairment.  In addition, defecatory dysfunction including constipation can be a contributing cause of retention and should be addressed. Non-surgical therapies involve stopping constipation inducing medications, dietary changes, use of bulking agents, correction of prolapse with manual replacement, timed voids and pessary use. Patients with significant symptoms or those who have failed initial conservative therapies may benefit from reconstructive surgery or obliterative procedure to correct prolapse and relieve voiding dysfunction.

Most patients with advanced POP and elevated PVRs show normalization of PVR after surgical correction. In the immediate post-operative period, hematoma formation and tissue inflammation related to healing can lead to urinary retention in up to 8% of cases. Independent risk factors for post-operative urinary retention include blood loss >100mL, high-grade cystocele and concomitant Levator muscle or Kelly plication.  Most are successfully managed with an indwelling catheter for up to 72 hours although 1% of patients may require intermittent catheterization for 1-2 weeks post-surgery.

Further Reading:

Stoffel JT, Peterson AC, Sandhu JS, Suskind, et al. AUA White Paper on Nonneurogenic Chronic Urinary Retention: Consensus Definition, Treatment Algorithm, and Outcome End Points.   J Urol. 2017 Jul;198(1):153-160. doi: 10.1016/j.juro.2017.01.075. Epub 2017 Feb 3.

Committee on Practice Bulletins-Gynecology, American Urogynecologic Society. Practice Bulletin No. 185: Pelvic Organ Prolapse. Obstet Gynecol. 2017 Nov;130(5):e234-e250. doi: 10.1097/AOG.0000000000002399.

Barber, MD.  Symptoms and outcome measures of pelvic organ prolapse.  Clin Obstet Gynecol. 2005 Sep;48(3):648-61.

Initial Approval May 2019. Published 10/1/19.

 

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