Journal of Obstetrics and Gynaecology

ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: https://www.tandfonline.com/loi/ijog20

Postpartum urinary retention: a survey of

obstetrics and gynaecology residents in the United
States

Gnankang Sarah Napoe, Naomi N. Adjei, Anne C. Cooper, Christine A. Raker

& Nicole B. Korbly

To cite this article: Gnankang Sarah Napoe, Naomi N. Adjei, Anne C. Cooper, Christine A.
Raker & Nicole B. Korbly (2020): Postpartum urinary retention: a survey of obstetrics and
gynaecology residents in the United States, Journal of Obstetrics and Gynaecology, DOI:
10.1080/01443615.2019.1706159

To link to this article: https://doi.org/10.1080/01443615.2019.1706159

Published online: 18 Feb 2020.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
https://doi.org/10.1080/01443615.2019.1706159

ORIGINAL ARTICLE

Postpartum urinary retention: a survey of obstetrics and gynaecology residents

in the United States
Gnankang Sarah Napoea, Naomi N. Adjeib, Anne C. Coopera, Christine A. Rakerc and Nicole B. Korblya
a
Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Women and Infants Hospital,
Warren Alpert Medical School of Brown University, Providence, RI, USA; bDepartment of Obstetrics, Gynecology and Reproductive Sciences,
Yale New Haven Hospital, New Haven, CT, USA; cDepartment of Obstetrics and Gynecology, Division of Research, Women and Infants
Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA

ABSTRACT KEYWORDS
Postpartum urinary retention (PUR) is a common and potentially morbid condition if not recognised Postpartum urinary
and managed promptly. We surveyed obstetrics and gynaecology (OBGYN) residents to determine resi- retention; PUR; bladder
dents’ knowledge of the management of PUR. A total of 168 OBGYN residents in ACGME accredited distension; protocol;
OBGYN residents
programmes in the United States completed the survey. A percentage of 30.3 reported having a PUR
prevention protocol at their institution, 43.3% reported not having a protocol and 26.7% did not know
whether a protocol existed. About 89.3% of participants reported having previously taken care of a
patient with PUR and 17.1% reported prior formal teaching on the management of PUR. Those who
reported having a protocol were more likely to report feeling comfortable managing PUR. Overall,
knowledge was low for management of PUR. Given the potential morbidity associated with inadequate
management of PUR, formal education and standardisation through national guidelines may help
improve care of patients with PUR.

IMPACT STATEMENT

What is already known on this subject? PUR is a common condition and if left untreated may
lead to long-term impacts on patients’ health. Early recognition of the condition and appropriate
management can prevent these complications. Protocols have been shown to improve patient out-
comes. Thus, it has been postulated that the implementation of protocols could improve recogni-
tion of the condition.

What do the results of this study add? No previous studies have looked at the impact of PUR
management protocols on physicians in training. Because physicians in training are often the first-
in-line to manage patients at academic institutions, we sought to determine the proportion of
obstetrics and gynaecology residents in the United States who report having a PUR management
protocol at their institution and how this impacts their reported comfort at caring for patients with
PUR, knowledge on PUR risk factors and recognition of scenarios concerning for PUR. While aware-
ness of a PUR protocol did not lead to increased knowledge of risk factors or increased recognition
of scenarios concerning for PUR, it did increase resident comfort with managing PUR patients. We
also found that overall PUR knowledge was low.

What are the implications of these findings for clinical practice and/or further research?
Based on our findings, OBGYN residents would benefit from having protocols at their institutions
since it increased their comfort at managing patients with PUR. Further, formal education on PUR
is likely needed to improve knowledge of risk factors and recognition of scenarios concerning
for PUR.

Introduction
Postpartum urinary retention (PUR) is a condition with inci-
dence between 0.45% and 17.9% (Saultz et al. 1991; Yip et al.
1997; Carley et al. 2002; Kekre et al. 2011). PUR can be either
overt or covert. Overt PUR is defined as the inability to void
within 6 h of delivery or removal of indwelling catheter and
covert PUR is defined as the partial ability to void, but with
an elevated amount of urine remaining in the bladder known
as the post-void residual (Yip et al. 1997; Carley et al. 2002).
PUR has a spectrum of severity, with a large proportion of
patients resuming normal voiding within a few days, though
others may have prolonged bladder dysfunction requiring
catheterisation for several days to months (Kekre et al. 2011;
Buchanan and Beckmann 2014).
PUR can be distressing to postpartum women. It has been
shown to decrease quality of life, and, although rare, serious
long-term sequalae have been reported (Mustonen et al.
2001; Doumouchtsis et al. 2008; Joelsson-Alm et al. 2009).

CONTACT Gnankang Sarah Napoe sarahnapoe@gmail.com Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive
Pelvic Surgery, Women & Infants Hospital/Warren Alpert Medical School of Brown, University, 101 Plain Street, 5th Floor, Providence, RI 02903, USA
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 G. S. NAPOE ET AL.

Prompt recognition of PUR and management with catheter- Results

isation may prevent additional bladder injury due to overdis-
We collected a total of 168 surveys from OBGYN residents. A
tension and sequelae.
response rate could not be tabulated since the survey was
Because of this, the Royal College of Obstetricians and
sent out through third parties and we are unable to report
Gynaecologists (RCOG) in the United Kingdom recommended
on the number of residents who received the survey. Of the
a protocol for postpartum bladder management. Although
168 residents who started the survey, 148 completed the
no nationwide recommendations exist in the United States
entire survey, indicating a completion rate of 88%.
(US), some hospitals have implemented protocols for PUR.
OBGYN residents from all years of training and throughout
After implementation of a guideline for PUR, busy high-risk
the United States were respondents (Table 1). Fifty (30.3%)
obstetrics labour and delivery unit were able to decrease
respondents reported being aware of the presence of a PUR
rates of PUR, decrease rates of catheterisation and increase
protocol at their institution, 71 (43.0%) reported not having a
medical providers’ awareness of PUR (Stanley and
protocol and 44 (26.7%) did not know whether they had a
Conner 2015).
protocol and 133 (89.3%) respondents reported having previ-
We aim to survey US obstetrics and gynaecology (OBGYN)
ously taken care of a patient with PUR.
residents, who are first-line physicians in managing postpar-
Recognition of risk factors for PUR was low with 22.1%
tum patients, on their current practices. The primary object-
(n ¼ 151) of respondents correctly identifying all risk factors
ive of the study was to determine awareness of PUR
(summary presented in Table 2).
protocols by OBGYN residents. The secondary objectives
A total of 149 participants responded to questions on
were to determine resident knowledge of risk factors, recog-
scenarios concerning for PUR. Answers are summarised in
nition of scenarios concerning for PUR and reported comfort
Table 3. Only 25.5% of residents correctly identified
at managing PUR. We hypothesise that OBGYN residents
all scenarios.
aware of a protocol at their institutions will report more com-
Respondents who reported being aware of a PUR manage-
fort at managing PUR, have higher knowledge of PUR risk
ment protocol were more likely to report comfort with man-
factors and higher recognition of scenarios concerning for
aging patients with PUR. Impact of protocol awareness on
PUR when compared to those unaware of a protocol.
PUR management comfort, recognition of PUR scenarios and
knowledge of PUR risk factors is summarised in Table 4.
Materials and methods The majority of residents (82.9%, n ¼ 152) reported never
having received formal teaching on the management of PUR.
This study was submitted for ethics review to the Women
Residents who had received formal teaching were more likely
and Infants Hospital institutional Review Board and was
to recognise scenarios concerning for PUR when compared
determined to be exempt. This is a cross-sectional survey of
to those without formal teaching (42.3% versus 22.0%,
OBGYN residents in Accreditation Council for Graduate
p ¼ .03). Formal teaching on PUR made no difference on
Medical Education (ACGME)-accredited programmes in the
familiarity with risk factors (p ¼ .49).
US that was administered electronically through Survey
Residents who reported having previously taken care of
MonkeyV (www.surveymonkey.com) during the month of
R

patients with PUR were more likely to correctly identify all

March 2018. The residents were contacted through an email
message sent to their programme director or programme
coordinator who was then asked to forward the email to the Table 1. Demographics.
programme’s residents. A reminder email was sent out once Geographic location n ¼ 147
and the survey remained open for a total of 2 weeks. We Northeast 85 (57.8%)
contacted residents at ten separate institutions to determine Midwest 19 (12.9%)
South 21 (14.3%)
if they had received the survey. Fifty percent of those resi- West 22 (15.0%)
dents reported having received the survey. All OBGYN resi- Residency setting n ¼ 148
dents in the US were eligible to participate. All persons not Academic hospital 100 (67.6%)
Community hospital 46 (31.1%)
currently in OBGYN residency were excluded. Other 2 (1.3%)
A 24-item questionnaire was used to assess awareness of Post Residency plans n ¼ 149
a protocol for PUR at residents’ primary institution, as well as General OBGYN practice 59 (39.6%)
FPMRS fellowship 11 (7.4%)
knowledge regarding PUR risk factors, recognition of scen- Maternal Female Medicine fellowship 17 (11.4%)
arios concerning for PUR and comfort with management of Other fellowship 56 (37.6%)
Undecided 19 (12.8%)
PUR. Level of training of respondents and post-residency
aspirations were also assessed. The questionnaire was
reviewed by a small group of urogynaecologists for readabil- Table 2. Risk factors for PUR (n ¼ 151).
ity and to ensure that there was agreement on knowledge Known risk factor Correct answer (%)
questions prior to use. Multiparity No 36.4
Descriptive statistics were used to report demographics Instrumental delivery Yes 93.4
Anal sphincter lacerations Yes 47.7
and knowledge data. Associations between knowledge of Epidural analgesia Yes 95.4
PUR management and having a protocol were assessed with Fast labour No 62.9
chi-square or Fisher’s exact test. All risk factors correctly identified by same respondent 22.1
 JOURNAL OF OBSTETRICS AND GYNAECOLOGY 3

Table 3. Scenarios concerning for PUR (n ¼ 149).

Scenarios Concern for PUR Correct answer (%)
25 yo G1P1 8 h s/p spontaneous vaginal delivery Yes 51
(SVD) with previously firm fundus who now has
a boggy uterus and passing blood clots. About
30 min ago, she voided 100 mL of urine.
28 yo G2P2 postoperative day 2 from repeat C- Yes 35.6
section with new urinary frequency and
incontinence.
32 yo postpartum day one from SVD with three No 97.9
separate voids of 300 mL of urine with firm
fundus and benign abdominal exam who leaked
a small amount of urine after coughing.
30 yo postoperative day one from C-section for Yes 93.3
arrest of descent after pushing for 3 h now 8 h
status post catheter removal who has not
yet voided.
All scenarios correctly identified by same respondent. 25.5

Table 4. Impact of protocol awareness on PUR management comfort and recognition.

Aware of presence of a protocol Unknown or no protocol p Value
No. of respondents (%) 50 (30.30) 115 (69.70)
Comfort managing PUR (n ¼ 43) (n ¼ 106)
Yes 35 (81.40) 68 (64.15) .04
No 8 (18.60) 38 (35.85)
Risk factors for PUR
Correct 9 (20.9%) 24 (22.6%) .82
Incorrect 34 (79.1%) 82 (77.4%)
Recognition of PUR scenarios
Correct 13 (31.0%) 25 (23.8%) .37
Incorrect 29 (69.0%) 80 (76.2%)
Bold value represents a statistically significant.

scenarios concerning for PUR when compared to residents
with no such experience (28.6% versus 0% p ¼ .012). When
we looked at the ability to identify two out of three scenarios
concerning for PUR, experience was even more significant
(58.7% versus18.8%, p ¼ .002).
Discussion
In this survey of OBGYN residents in the US, the vast majority
(89.3%) of residents have cared for patients with PUR. Only
about one-third of participants were aware of a PUR manage-
ment protocol at their institution. We found that knowledge
of a PUR protocol was associated with comfort managing PUR.
These findings are similar to reports from Stanley and Conner
who instituted a PUR management protocol and reported an
increase in awareness of the condition after its implementa-
tion. They also reported that the protocol led to decreased
variation in patient management and decreased rate of PUR
and catheterisation (Stanley and Conner 2015). In our study,
we did not confirm the presence of a protocol. We speculated
that a lack of awareness would be comparable to not having
a protocol, as those unaware of a protocol could not use it.
Awareness of a PUR protocol did not lead to increased
knowledge of risk factors or increased recognition of scen-
arios concerning for PUR. Despite this, it did increase resident
comfort with managing PUR patients. Clear guidelines for
clinical decision making, increases provider comfort with
managing this problem and may also decrease variation in
the management of these patients. Protocols in general have
been shown to improve patient care (Grimshaw and
Russell 1993).
Experience with taking care of patients with PUR was
associated with recognition of scenarios concerning for PUR.
This is not surprising as clinical experience in residency is
meant to increase trainee recognition of common scenarios.
While residency intentionally includes an increase in the level
of responsibility with advancing years of training, we know
anecdotally that junior residents tend to care more often for
routine postpartum patients and, therefore, may miss an
opportunity to diagnose PUR.
The implementation of protocols, along with formal teach-
ing, could improve recognition of PUR. Formal teaching was
associated with recognition of scenarios which should
prompt evaluation of patients.
A limitation of this study is that we were able to sample
only a fraction of U.S. residents and residency programmes
as a result of our online survey distribution in a population
with known e-mail fatigue. The fact that the respondents
were mostly from the Northeast and affiliated with academic
hospitals suggests we have accurately sampled a subset of
the population.
Conclusion
Most US OBGYN residents care for patients with PUR.
Residents aware of a PUR management protocol report more
comfort with PUR management. Reported formal teaching on
PUR was associated with recognition of scenarios for PUR.
Measures that could improve management of
PUR include:
First, incorporate formal teaching on PUR to narrow the
gap in knowledge.
4 G. S. NAPOE ET AL.
Second, because experience is what is most associated
with recognition of scenarios concerning for PUR, senior resi-
dents leading postpartum teams should pay close attention
to the care provided by their junior team members.
Finally, regardless of knowledge, the presence of a proto-
col was associated with more comfort at PUR management.
Therefore, we recommend implementation of PUR manage-
ment protocols.
Disclosure statement
The authors report no conflict of interest.
References
Buchanan J, Beckmann M. 2014. Postpartum voiding dysfunction: identi-
fying the risk factors. Australian and New Zealand Journal of
Obstetrics and Gynaecology 54:41–45.
Carley ME, Carley JM, Vasdev G, Lesnick TG, Webb MJ, Ramin KD, Lee RA.
2002. Factors that are associated with clinically overt postpartum urin-
ary retention after vaginal delivery. American Journal of Obstetrics
and Gynecology 187:430–433.
Doumouchtsis SK, Jeffery S, Fynes M. 2008. Female voiding dysfunction.
Obstetrical & Gynecological Survey 63:519–526.
Grimshaw JM, Russell IT. 1993. Effect of clinical guidelines on medical
practice: a systematic review of rigorous evaluations. The Lancet 342:
1317–1322.
Joelsson-Alm E, Nyman CR, Lindholm C, Ulfvarson J, Svensen C. 2009.
Perioperative bladder distension: a prospective study. Scandinavian
Journal of Urology and Nephrology 43:58–62.
Kekre AN, Vijayanand S, Dasgupta R, Kekre N. 2011. Postpartum urinary
retention after vaginal delivery. International Journal of Gynecology &
Obstetrics 112:112–115.
Mustonen S, Ala-Houhala IO, Tammela TL. 2001. Long-term renal dys-
function in patients with acute urinary retention. Scandinavian Journal
of Urology and Nephrology 35:44–48.
Saultz JW, Toffler WL, Shackles JY. 1991. Postpartum urinary
retention. The Journal of the American Board of Family Practice 4:
341–344.
Stanley AY, Conner BT. 2015. Implementing a clinical practice guideline
to manage postpartum urinary retention. Journal of Nursing Care
Quality 30:175–180.
Yip SK, Brieger G, Hin LY, Chung T. 1997. Urinary retention in the post-
partum period. The relationship between obstetric factors and the
post-partum post-void residual bladder volume. Acta Obstetricia et
Gynecologica Scandinavica 76:667–672.