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Urinary retention during the second trimester of pregnancy: a rare cause
CASE REPORT
URINARY RETENTION DURING THE SECOND TRIMESTER OF PREGNANCY: A RARE CAUSE PAULOS YOHANNES
AND
JOANN SCHAEFER
ABSTRACT Acute urinary retention during pregnancy is rare. Retention secondary to an impacted, gravid uterus is an emergency. Retroversion of the uterus, a history of pelvic inflammatory disease, and large fibroids are predisposing factors. The enlarging gravid uterus and uterine fibroids may trap the uterus inside the pelvic ring, preventing it from ascending into the abdominal cavity; furthermore, a history of inflammatory disease may trap the fundus of the uterus within scar tissue that also may prevent the enlarging, gravid uterus from ascending into the abdominal cavity. The impacted uterus should be manually replaced in the anterior position. Clean intermittent catheterization and placement of a vaginal pessary are temporizing measures. A knowledge of the causes of urinary retention during pregnancy can help prevent spontaneous abortion and other devastating consequences that can arise as a result of a delay in the diagnosis. UROLOGY 59: 946i–946iii, 2002. © 2002, Elsevier Science Inc.
U
rinary retention during pregnancy secondary to an incarcerated uterus is rare, with only 14 cases reported since 1877. Incarceration of the uterus during pregnancy is defined as the inability of the gravid uterus to ascend into the abdominal cavity as a result of scar tissue trapping the fundus of the uterus or a pelvic mass that traps the uterus inside the pelvic ring. This condition has been described in all three trimesters, but is commonly seen between the 10th and 16th week of gestation when the enlarging, retroverted, gravid uterus becomes impacted within the pelvis and causes extrinsic compression of the urethra.1–12 Urinary retention in pregnancy is an emergency, and a failure to make a prompt diagnosis and institute treatment rapidly will result in irreversible uterine ischemia and spontaneous abortion, rupture of the uterus or bladder, rectal gangrene, infection of uterine contents, or death.10 We present a case of urinary retention from an incarcerated gravid uterus during the second trimester.
From the Departments of Surgery (Urology) and Family Medicine, Creighton University, Omaha, Nebraska Address for correspondence: Paulos Yohannes, M.D., Department of Surgery (Urology), Creighton University, 601 North 30th Street, Suite 3822, Omaha, NE 68131 Submitted: October 30, 2001, accepted (with revisions): January 23, 2002 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
CASE REPORT A 15-week G1P1 woman presented with intermittent episodes of abdominal pain, urinary frequency, and urinary retention. The first pregnancy had been uneventful. The patient denied a history of pelvic inflammatory disease. The prenatal care had been uncomplicated up to the point of presentation. The patient had attempted voiding in various positions without success. Bladder catheterization revealed a residual volume of 1500 mL clear urine. Pelvic examination revealed an incarcerated gravid uterus with no evidence of prolapse. It was immediately recognized that the patient had an incarcerated gravid uterus by the history and physical examination. The uterus was manually reduced into the abdominal cavity. This maneuver was performed with the patient in the knee-chest prone position. The index and middle fingers were inserted inside the vagina against the posterior fornix, as the contralateral hand was placed over the lower abdomen to gently reduce the incarceration and replace the uterus in the anterior position. No sedatives were needed, and the patient tolerated the procedure well. No urologic complications were noted for the remainder of the pregnancy. COMMENT Acute urinary retention in women is a rare condition. The etiologic factors responsible for urinary retention in women are multifactorial and include 0090-4295/02/$22.00 PII S0090-4295(02)01551-0 946i
neurologic, psychogenic, medical, and inflammatory changes. A pelvic mass due to gynecologic malignancies, fecal impaction, and incarcerated leiomyomas or large fibroids have also been described as a rare, albeit significant, cause of urinary retention.2,3,8,12 In addition, uterine prolapse associated with pelvic mass (ie, gravid uterus) can cause urinary retention by kinking the urethrovesical junction.8 Retention during pregnancy can also occur secondary to lumbar disc herniation, paraurethral abscess, breech presentation, ectopic pregnancy, and conversion psychologic disorder. 2– 6,8 A history of retroversion or retroflexion of the uterus is another predisposing factor to urinary retention during pregnancy. The incidence of retroversion of the uterus during pregnancy is 10% to 15%, and the incidence of urinary retention owing to a retroverted, gravid uterus is 1.4%.3,13 Retroversion is often transient; however, the gravid, retroverted uterus can become impacted, requiring prompt repositioning of the uterus. Incarceration of the retroverted uterus can clinically present as urinary frequency, urgency, agonizing abdominal pain, and intermittent or complete urinary retention. Tenesmus and rectal pressure can also be present. The incidence of an incarcerated uterus is 1:3000.14 During the latter portion of the first trimester, the uterus begins to enlarge out of the pelvis to become an abdominal organ. However, in the presence of a retroverted uterus, the body of the uterus can become entrapped within the pelvis, causing the cervix to wedge against the pubic symphysis, impinging on the urethra. The risk factors that predispose to an incarcerated uterus are as follows: prior gynecologic surgery, pelvic adhesions secondary to pelvic inflammatory disease and/or endometriosis, and posterior wall leiomyoma.3,5 No simple diagnostic tests are available to help identify the cause of urinary retention during pregnancy. A lack of proper knowledge will result in a delay in the diagnosis; therefore, a suspicion of impaction and a proper physical examination by a physician trained in obstetrics is essential. Cystoscopy has been advocated as an additional diagnostic tool by a few investigators. However, insertion of the cystoscope is difficult because of the retrotrigonal mass. Endoscopy helps identify obstructing tumors and allows observation of the elevated trigone, bladder neck, and posterior bladder wall, giving clues to the underlying diagnosis—an incarcerated uterus.3,8,9 When the diagnosis of urinary retention secondary to an incarcerated, gravid, retroverted uterus is made, two treatment options should be considered: catheterization and manual decompression. Permanent Foley catheter placement should be 946ii
avoided because of the high incidence of bacteriuria and subsequent pyelonephritis—without antibiotic prophylaxis; intermittent catheterization may be a viable option until the incarceration is manually reduced.3 A suspension operation to lift the uterus out of the pelvis has been described.15 Although this maneuver may be helpful to prevent future complications, it is seldom necessary during pregnancy. Manual decompression is the most effective and definitive treatment in reducing the incarceration and restoring the blood supply to the gravid uterus. After the bladder is decompressed, the patient is placed in the dorsal lithotomy or knee-chest prone position. Manual reduction of the incarcerated uterus is undertaken by inserting two fingers into the vagina along the posterior wall, while simultaneously pushing on the lower abdominal wall. In most cases, one is able to feel a sudden loss of resistance as the uterus is repositioned into its anterior location; it is important to apply gentle and slow pressure to prevent separation of the placenta or rupture of the uterus. If attempts to reduce the incarceration are not successful in the office, the maneuver can be performed in the operating room under intravenous sedation.7 The position of the gravid uterus can be verified with a pelvic sonogram. In addition, patients should be monitored for postobstructive diuresis after reduction. Finally, although some have advocated the use of a pessary for temporary treatment of urinary retention during pregnancy, pessaries should not be used when impaction of the uterus is present because it will not help restore the blood flow to the uterus. The use of a pessary may be cumbersome and uncomfortable. Pessaries are best suited for patients with a gravid uterus associated with vaginal prolapse. Pessaries help elevate the cervix and uterus, thereby restoring the proper vesicourethral angle. Once ascent of the gravid uterus is documented by physical examination after the first trimester, the pessary can be removed. CONCLUSIONS Urinary retention during pregnancy due to an impacted, gravid uterus may constitute an emergency situation. Prompt diagnosis and manual repositioning of the incarcerated, gravid uterus will prevent spontaneous abortion and devastating consequences to the mother. REFERENCES 1. Van-Winter JT, Ogburn PL, Ney JA, et al: Uterine incarceration during the third trimester: a rare complication of pregnancy. Mayo Clin Proc 66: 608 – 613, 1991. 2. David PR, Gianotti AJ, and Garmel G: Acute urinary retention due to ectopic pregnancy. Am J Emerg Med 17: 44 – 45, 1999. 3. Kondo A, Otani T, Takita T, et al: Urinary retention UROLOGY 59 (6), 2002
caused by impaction of a large uterus. Urol Int 37: 87–90, 1982. 4. Schwartz Z, Dgani R, Katz Z, et al: Urinary retention caused by impaction of leiomyoma in pregnancy. Acta Obstet Gynecol Scand 65: 525–526, 1986. 5. Garmel SH, Guzelian GA, D’Alton JG, et al: Lumbar disk disease in pregnancy. Obstet Gynecol 89: 821– 822, 1997. 6. Saultz JW, Toffler WL, and Shackles JY: Postpartum urinary retention. J Am Board Fam Pract 4: 341–344, 1991. 7. Silva PD, and Berberich W: Retroverted impacted gravid uterus with acute urinary retention: report of two cases and a review of the literature. Obstet Gynecol 68: 121–123, 1986. 8. Goldberg KA, and Kwart AM: Intermittent urinary retention in first trimester of pregnancy. Urology 17: 270 –271, 1981. 9. Hansen JH, and Asmussen M: Acute urinary retention
UROLOGY 59 (6), 2002
in the first trimester of pregnancy. Acta Obstet Gynecol Scand 64: 279 –280, 1985. 10. Nelson MS: Acute urinary retention secondary to an incarcerated gravid uterus. Am J Emerg Med 4: 231, 1986. 11. Myers DL, and Scotti RJ: Acute urinary retention and the incarcerated, gravid uterus: a case report. J Reprod Med 40: 487– 490, 1995. 12. Monga AK, Woodhouse CRJ, and Stanton SL: Pregnancy and fibroids causing simultaneous urinary retention and ureteric obstruction. Br J Urol 77: 606 – 607, 1996. 13. Weekes ARL, Atlay RD, Brown VA, et al: The retroverted gravid uterus and its effect on the outcome of pregnancy. BMJ 1: 622– 624, 1976. 14. Gibbons JM, and Paley WB: The incarcerated gravid uterus. Obstet Gyencol 33: 845– 848, 1968. 15. Schussling G, and Beissert M: Uber die retroflexio uteri der schwangerschaft. Z Arztl Fortbil 62: 701–702, 1968.
946iii
URINARY RETENTION DURING THE SECOND TRIMESTER OF PREGNANCY: A RARE CAUSE PAULOS YOHANNES
AND
JOANN SCHAEFER
ABSTRACT Acute urinary retention during pregnancy is rare. Retention secondary to an impacted, gravid uterus is an emergency. Retroversion of the uterus, a history of pelvic inflammatory disease, and large fibroids are predisposing factors. The enlarging gravid uterus and uterine fibroids may trap the uterus inside the pelvic ring, preventing it from ascending into the abdominal cavity; furthermore, a history of inflammatory disease may trap the fundus of the uterus within scar tissue that also may prevent the enlarging, gravid uterus from ascending into the abdominal cavity. The impacted uterus should be manually replaced in the anterior position. Clean intermittent catheterization and placement of a vaginal pessary are temporizing measures. A knowledge of the causes of urinary retention during pregnancy can help prevent spontaneous abortion and other devastating consequences that can arise as a result of a delay in the diagnosis. UROLOGY 59: 946i–946iii, 2002. © 2002, Elsevier Science Inc.
U
rinary retention during pregnancy secondary to an incarcerated uterus is rare, with only 14 cases reported since 1877. Incarceration of the uterus during pregnancy is defined as the inability of the gravid uterus to ascend into the abdominal cavity as a result of scar tissue trapping the fundus of the uterus or a pelvic mass that traps the uterus inside the pelvic ring. This condition has been described in all three trimesters, but is commonly seen between the 10th and 16th week of gestation when the enlarging, retroverted, gravid uterus becomes impacted within the pelvis and causes extrinsic compression of the urethra.1–12 Urinary retention in pregnancy is an emergency, and a failure to make a prompt diagnosis and institute treatment rapidly will result in irreversible uterine ischemia and spontaneous abortion, rupture of the uterus or bladder, rectal gangrene, infection of uterine contents, or death.10 We present a case of urinary retention from an incarcerated gravid uterus during the second trimester.
From the Departments of Surgery (Urology) and Family Medicine, Creighton University, Omaha, Nebraska Address for correspondence: Paulos Yohannes, M.D., Department of Surgery (Urology), Creighton University, 601 North 30th Street, Suite 3822, Omaha, NE 68131 Submitted: October 30, 2001, accepted (with revisions): January 23, 2002 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
CASE REPORT A 15-week G1P1 woman presented with intermittent episodes of abdominal pain, urinary frequency, and urinary retention. The first pregnancy had been uneventful. The patient denied a history of pelvic inflammatory disease. The prenatal care had been uncomplicated up to the point of presentation. The patient had attempted voiding in various positions without success. Bladder catheterization revealed a residual volume of 1500 mL clear urine. Pelvic examination revealed an incarcerated gravid uterus with no evidence of prolapse. It was immediately recognized that the patient had an incarcerated gravid uterus by the history and physical examination. The uterus was manually reduced into the abdominal cavity. This maneuver was performed with the patient in the knee-chest prone position. The index and middle fingers were inserted inside the vagina against the posterior fornix, as the contralateral hand was placed over the lower abdomen to gently reduce the incarceration and replace the uterus in the anterior position. No sedatives were needed, and the patient tolerated the procedure well. No urologic complications were noted for the remainder of the pregnancy. COMMENT Acute urinary retention in women is a rare condition. The etiologic factors responsible for urinary retention in women are multifactorial and include 0090-4295/02/$22.00 PII S0090-4295(02)01551-0 946i
neurologic, psychogenic, medical, and inflammatory changes. A pelvic mass due to gynecologic malignancies, fecal impaction, and incarcerated leiomyomas or large fibroids have also been described as a rare, albeit significant, cause of urinary retention.2,3,8,12 In addition, uterine prolapse associated with pelvic mass (ie, gravid uterus) can cause urinary retention by kinking the urethrovesical junction.8 Retention during pregnancy can also occur secondary to lumbar disc herniation, paraurethral abscess, breech presentation, ectopic pregnancy, and conversion psychologic disorder. 2– 6,8 A history of retroversion or retroflexion of the uterus is another predisposing factor to urinary retention during pregnancy. The incidence of retroversion of the uterus during pregnancy is 10% to 15%, and the incidence of urinary retention owing to a retroverted, gravid uterus is 1.4%.3,13 Retroversion is often transient; however, the gravid, retroverted uterus can become impacted, requiring prompt repositioning of the uterus. Incarceration of the retroverted uterus can clinically present as urinary frequency, urgency, agonizing abdominal pain, and intermittent or complete urinary retention. Tenesmus and rectal pressure can also be present. The incidence of an incarcerated uterus is 1:3000.14 During the latter portion of the first trimester, the uterus begins to enlarge out of the pelvis to become an abdominal organ. However, in the presence of a retroverted uterus, the body of the uterus can become entrapped within the pelvis, causing the cervix to wedge against the pubic symphysis, impinging on the urethra. The risk factors that predispose to an incarcerated uterus are as follows: prior gynecologic surgery, pelvic adhesions secondary to pelvic inflammatory disease and/or endometriosis, and posterior wall leiomyoma.3,5 No simple diagnostic tests are available to help identify the cause of urinary retention during pregnancy. A lack of proper knowledge will result in a delay in the diagnosis; therefore, a suspicion of impaction and a proper physical examination by a physician trained in obstetrics is essential. Cystoscopy has been advocated as an additional diagnostic tool by a few investigators. However, insertion of the cystoscope is difficult because of the retrotrigonal mass. Endoscopy helps identify obstructing tumors and allows observation of the elevated trigone, bladder neck, and posterior bladder wall, giving clues to the underlying diagnosis—an incarcerated uterus.3,8,9 When the diagnosis of urinary retention secondary to an incarcerated, gravid, retroverted uterus is made, two treatment options should be considered: catheterization and manual decompression. Permanent Foley catheter placement should be 946ii
avoided because of the high incidence of bacteriuria and subsequent pyelonephritis—without antibiotic prophylaxis; intermittent catheterization may be a viable option until the incarceration is manually reduced.3 A suspension operation to lift the uterus out of the pelvis has been described.15 Although this maneuver may be helpful to prevent future complications, it is seldom necessary during pregnancy. Manual decompression is the most effective and definitive treatment in reducing the incarceration and restoring the blood supply to the gravid uterus. After the bladder is decompressed, the patient is placed in the dorsal lithotomy or knee-chest prone position. Manual reduction of the incarcerated uterus is undertaken by inserting two fingers into the vagina along the posterior wall, while simultaneously pushing on the lower abdominal wall. In most cases, one is able to feel a sudden loss of resistance as the uterus is repositioned into its anterior location; it is important to apply gentle and slow pressure to prevent separation of the placenta or rupture of the uterus. If attempts to reduce the incarceration are not successful in the office, the maneuver can be performed in the operating room under intravenous sedation.7 The position of the gravid uterus can be verified with a pelvic sonogram. In addition, patients should be monitored for postobstructive diuresis after reduction. Finally, although some have advocated the use of a pessary for temporary treatment of urinary retention during pregnancy, pessaries should not be used when impaction of the uterus is present because it will not help restore the blood flow to the uterus. The use of a pessary may be cumbersome and uncomfortable. Pessaries are best suited for patients with a gravid uterus associated with vaginal prolapse. Pessaries help elevate the cervix and uterus, thereby restoring the proper vesicourethral angle. Once ascent of the gravid uterus is documented by physical examination after the first trimester, the pessary can be removed. CONCLUSIONS Urinary retention during pregnancy due to an impacted, gravid uterus may constitute an emergency situation. Prompt diagnosis and manual repositioning of the incarcerated, gravid uterus will prevent spontaneous abortion and devastating consequences to the mother. REFERENCES 1. Van-Winter JT, Ogburn PL, Ney JA, et al: Uterine incarceration during the third trimester: a rare complication of pregnancy. Mayo Clin Proc 66: 608 – 613, 1991. 2. David PR, Gianotti AJ, and Garmel G: Acute urinary retention due to ectopic pregnancy. Am J Emerg Med 17: 44 – 45, 1999. 3. Kondo A, Otani T, Takita T, et al: Urinary retention UROLOGY 59 (6), 2002
caused by impaction of a large uterus. Urol Int 37: 87–90, 1982. 4. Schwartz Z, Dgani R, Katz Z, et al: Urinary retention caused by impaction of leiomyoma in pregnancy. Acta Obstet Gynecol Scand 65: 525–526, 1986. 5. Garmel SH, Guzelian GA, D’Alton JG, et al: Lumbar disk disease in pregnancy. Obstet Gynecol 89: 821– 822, 1997. 6. Saultz JW, Toffler WL, and Shackles JY: Postpartum urinary retention. J Am Board Fam Pract 4: 341–344, 1991. 7. Silva PD, and Berberich W: Retroverted impacted gravid uterus with acute urinary retention: report of two cases and a review of the literature. Obstet Gynecol 68: 121–123, 1986. 8. Goldberg KA, and Kwart AM: Intermittent urinary retention in first trimester of pregnancy. Urology 17: 270 –271, 1981. 9. Hansen JH, and Asmussen M: Acute urinary retention
UROLOGY 59 (6), 2002
in the first trimester of pregnancy. Acta Obstet Gynecol Scand 64: 279 –280, 1985. 10. Nelson MS: Acute urinary retention secondary to an incarcerated gravid uterus. Am J Emerg Med 4: 231, 1986. 11. Myers DL, and Scotti RJ: Acute urinary retention and the incarcerated, gravid uterus: a case report. J Reprod Med 40: 487– 490, 1995. 12. Monga AK, Woodhouse CRJ, and Stanton SL: Pregnancy and fibroids causing simultaneous urinary retention and ureteric obstruction. Br J Urol 77: 606 – 607, 1996. 13. Weekes ARL, Atlay RD, Brown VA, et al: The retroverted gravid uterus and its effect on the outcome of pregnancy. BMJ 1: 622– 624, 1976. 14. Gibbons JM, and Paley WB: The incarcerated gravid uterus. Obstet Gyencol 33: 845– 848, 1968. 15. Schussling G, and Beissert M: Uber die retroflexio uteri der schwangerschaft. Z Arztl Fortbil 62: 701–702, 1968.
946iii