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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 4  |  Page : 237-239

Postpartum urinary retention mimicking Fowler's syndrome: A case report


1 Urology Division, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Obstetrics and Gynaecology, Barrau Dikko Teaching Hospital, Kaduna State University, Kadunsa, Nigeria

Date of Web Publication8-Dec-2017

Correspondence Address:
Dr. M Ahmed
Division of Urology, Department of Surgery, ABU/ABUTH, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_3_17

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  Abstract 

Urinary retention (UR) is relatively uncommon in women; however, it may occur following childbirth and is termed as postpartum urinary retention (PPUR). PPUR has been variably defined as the abrupt onset of painful or painless inability to completely micturate, requiring urinary catheterization, over 12 hours after giving birth or unable to void spontaneously within 6 hours of vaginal delivery. This is a case of a 22-year-old woman presenting with 12 days history of intractable UR following spontaneous vaginal delivery and repair of episiotomy. The UR persisted despite repeated trial without catheter (TWOC) and bladder training. The absence of an identifiable cause and the failure of the bladder neck to open on micturating cystourethrogram (MCUG) lead to the suspicion of Fowler's syndrome thus the patient was referred to our urology unit. She was seen with an indwelling urethral catheter and there was no significant finding on evaluation except the presence of hard, impacted feces in the rectum. She had rectal enema with evacuation of feces and was able to void spontaneously without catheter. Normal voiding was maintained at 2 months of follow-up.

Keywords: Constipation, Fowler's syndrome, postpartum urinary retention


How to cite this article:
Awaisu M, Ahmed M, Taingson C M, Lawal A T, Sudi. Postpartum urinary retention mimicking Fowler's syndrome: A case report. Arch Int Surg 2016;6:237-9

How to cite this URL:
Awaisu M, Ahmed M, Taingson C M, Lawal A T, Sudi. Postpartum urinary retention mimicking Fowler's syndrome: A case report. Arch Int Surg [serial online] 2016 [cited 2020 Jul 10];6:237-9. Available from: http://www.archintsurg.org/text.asp?2016/6/4/237/220325


  Introduction Top


Urinary retention (UR) is not common in women, it accounts for only less than 1% of the incidence of UR in all sexes. Because of the rarity of UR, the sudden nature and absence of any obvious cause it is often attributed to hysteria and termed psychogenic. However, UR is not uncommon after childbirth and is termed postpartum urinary retention (PPUR). It has been variably defined as the abrupt onset of painful or painless inability to completely micturate, requiring urinary catheterization, over 12 hours after giving birth or unable to void spontaneously within 6 hours of vaginal delivery.[1] In the literature, the estimated incidence of PPUR varies between 0.05% and 37%.[2]

PPUR has been classified into overt and covert retention by Yip et al.[3] Women who are unable to micturate spontaneously within 6 hours after vaginal delivery are categorized as having overt (symptomatic) UR. Those having a postvoid residual bladder volume (PVRBV) of more than 150 mL, detected by ultrasound or by catheterization, with no symptoms of UR are categorized as having covert (asymptomatic) UR. The diagnosis of overt PPUR is easy to make; however, for covert PPUR clinical suspicion should be raised in patients with small voided volumes, urinary frequency, slow or intermittent stream, urgency, bladder pain or discomfort, urinary incontinence and those who strain to void, or describe no sensation to void.[2] The exact etiology of PPUR is unclear, but it is likely to be multifactorial, involving physiological, neurological, and mechanical processes. Significant risk factors associated with PPUR include, epidural and regional anesthesia, prolonged first and/or second stage of labor, instrumental deliveries, primiparity, birthweight of >3.8 kg, perineal lacerations, and episiotomy.[3],[4],[5],[6],[7]

In the absence of any identifiable cause of UR in women, a diagnosis that is often considered is Fowler's syndrome. Fowler's syndrome is a rare cause of UR in young women, which was first described by Professor Clare J Fowler in 1985. The UR may occur spontaneously or following an operative procedure (gynecological, urological) or following childbirth. There is usually no neurological or anatomical abnormality to explain the urine retention. The presence of an electromyographic (EMG) abnormality of the external urethral sphincter and the detection of polycystic ovaries in up to half of the women confirms the diagnosis.[8] The abnormality is thought to be due to a poorly relaxing external urethral sphincter, which is unresponsive and persist despite bladder drainage. Prompt diagnosis, prompt, and appropriate management is the key to ensuring a rapid return to normal bladder function following PPUR.[9]


  Case Report Top


A 22-year-old primiparous woman referred to our urology clinic with persistent inability to pass urine following spontaneous vaginal delivery and repair of episiotomy 12 days earlier in a peripheral hospital. She was unable to pass urine despite the urge to do so with associated suprapubic swelling and discomfort. She was catheterized and about a liter of urine was drained. The UR persisted despite repeated trial without catheter (TWOC) and bladder training over a period of 12 days. The absence of an identifiable cause and the failure of the bladder neck to open on micturating cystourethrogram (MCUG) lead to the suspicion of external sphincter dysfunction consistent with the diagnosis of Fowler's syndrome, thus the patient was referred to our unit with an indwelling urethral catheter for further management. On evaluation of the patient, there was no prior history of lower urinary tract symptoms (LUTS); however, she reported being constipated shortly after birth and only occasionally passed small quantity of feces. There was no abdominal distension or vomiting. There was no history of diabetes or neurologic disease.

Physical examination revealed a young woman with no obvious neurologic abnormality, she had a normal perineum and vulva and a size 16Fr Foley's urethral catheter was situ. Rectal examination revealed copious hard impacted feces. The investigations include a MCUG, which revealed unilateral right ureteric reflux with failure of opening of the bladder neck. abdominopelvic ultrasound scan, electrolyte, urea, and creatinine were normal and no organism was isolated in urine.

Constipation and fecal impaction was relieved by rectal evacuation with repeated enema over a day, thereafter, urethral catheter was removed and a trial of voiding without catheter was successful as patient was able to void spontaneously. She was subsequently seen at the outpatient unit at 2 months with normal voiding.


  Discussion Top


UR is an uncommon phenomenon in women and accounts for less than 1% of UR in adults. The peculiarities of the female lower urinary tract anatomy compared to that of the males make it less prone to bladder outlet obstruction (BOO) and in the same vein UR is rare. When it does occur it often possess a diagnostic dilemma, the cause of which requires thorough evaluation and a high index of suspicion.

UR may occur at any age; however, there are documented trigger factors, which vary from patient to patient. The UR is generally rare in females; it is not uncommon after childbirth. PPUR is a clinical condition which may be seen in up to 37% of patients after vaginal delivery.[9] It is believed that changes during pregnancy, such as detrusor muscle hypertrophy, perineal or pudendal nerve damage during delivery, and mucosal edema after vaginal delivery, may result in voiding dysfunction.[10] Other risk factors are epidural and regional anesthesia, prolonged first and/or second stage of labor, instrumental deliveries, primiparity, birthweight of >3.8 kg, perineal lacerations, and episiotomy.[3],[4],[5],[6],[7] Our patient developed overt PPUR within 6 hours of postdelivery and the identifiable risk factors were being a young woman, primiparity, and episiotomy. Most PPUR respond to immediate bladder drainage with catheter and usually followed by spontaneous voiding subsequently. In this patient, the persistence of failure to spontaneously void despite repeated TWOCs and bladder training with the additional risk factors of being a young primipara who had episiotomy at childbirth raised the suspicion of Fowler's syndrome. The diagnosis of Fowler's syndrome was further fuelled by the absence of any other identifiable risk factors for UR.

In the classic description of the criteria for diagnosis of Fowler's syndrome, the UR is often in young women (20s) and occurs either spontaneously or provoked by a minor gynecological or urological operative procedure or after childbirth; there is usually no neurological or anatomical abnormality to explain the UR and the presence of a consistent EMG abnormality of the external urethral sphincter and the detection of polycystic ovaries in up to half of the women usually confirm the diagnosis.[8] The clinical presentation of our patient mimicked Fowler's syndrome because of her age (22 years), UR following vaginal delivery and episiotomy repair, the persistence of UR despite repeated catheter drainage and the absence of any other predisposing condition. Though this patient did not have polycystic ovary on sonography, it is only seen in half of the patients with Fowler's syndrome. Though we could not conduct EMG assessment of the external urethral sphincter, the failure of the bladder neck to open on MCUG suggested the possibility of sphincteric dysfunction.

When she presented to our facility, further evaluation with detailed history and examination revealed a preceding history of infrequent, scanty defecation, which, persisted after childbirth was given further consideration and a rectal examination was done with the findings of copious hard impacted feces. It was a pleasant relief when the patient could subsequently void spontaneously after repeated enema and fecal evacuation. The mechanical effect of the impacted feces was most likely the culprit for the persistent UR and the delay in diagnosis could have been avoided with an initial thorough evaluation, high index of suspicion and prompt management of the constipation.


  Conclusion Top


PPUR in this patient, which mimicked Fowler's Syndrome, could have been managed effectively and promptly if greater diligence and attention was paid to the patient's history and physical examination. Mechanical and anatomic factors should always be ruled out in patients with intractable PPUR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cavkaytar S, Kokanali MK, Baylas A, Topcu HO, Laleli B, Tasci Y. Postpartum urinary retention after vaginal delivery: Assessment of risk factors in a case-control study. J Turk Ger Gynecol Assoc 2014;15:140-3.  Back to cited text no. 1
    
2.
Lim JL. Post-partum voiding dysfunction and urinary retention. Aust N Z J Obstet Gynaecol 2010;50:502-5.  Back to cited text no. 2
[PUBMED]    
3.
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;76:667-72.  Back to cited text no. 3
[PUBMED]    
4.
Teo R, Punter J, Abrams K, Mayne C, Tincello D. Clinically overt postpurrum urinary retention after vaginal delivery: A retrospective case-control study. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:521-4.  Back to cited text no. 4
[PUBMED]    
5.
Groutz A, Hadi E, Wolf Y, Gold R, Lessing JB, Maslovitz S, et al. Early postpartum voiding dysfunction: Incidence and correlation with obstetric parameters. J Reprod Med 2004;49:960-4.  Back to cited text no. 5
[PUBMED]    
6.
Carley ME, Carley JM, Vasdev G, Lesnick TG, Webb MJ, Ramin KD, et al. Factors that are associated with clinically overt postpartum urinary retention after vaginal delivery. Am J Obstet Gynecol 2002;187:430-3.  Back to cited text no. 6
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7.
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;46:44-8.  Back to cited text no. 7
[PUBMED]    
8.
Osman NI, Chapple CR. Fowler's syndrome [mdash] a cause of unexplained urinary retention in young women?. Nat Rev Urol 2014;11:87-98.  Back to cited text no. 8
[PUBMED]    
9.
Ismail SIMF, Emery SJ. The prevalence of silent postpartum retention of urine in a heterogeneous cohort. J Obstet Gynaecol 2008;28:504-7.  Back to cited text no. 9
    
10.
Gursoy AY, Kiseli M, Tangal S, Caglar GS, Haliloglu AH, Cengiz SD. Prolonged postpartum urinary retention: A case report and review of the literature: case report. S Afr J Obstet Gynaecol 2015;21:48-9.  Back to cited text no. 10
    




 

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Abstract
Introduction
Case Report
Discussion
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