Voiding Dysfunction or Urinary Retention Following Pelvic Floor Reconstruction

Abstract

Voiding dysfunction is a known complication following pelvic floor reconstruction and can result in a challenging clinical scenario. Meticulous surgical technique and early recognition of voiding problems after surgery are paramount to avoiding long-term sequelae of voiding dysfunction or, in the extreme, urinary retention. While most cases of urinary retention after prolapse repair are transient, some will require surgical intervention. There is no definitive test to distinguish between the two scenarios, but rather the surgeon will use the combination of careful history and physical examination, cystoscopy, and urodynamic studies to guide clinical decision-making. Here, we present a case of urinary retention after prolapse repair (without a concomitant anti-incontinence procedure), which ultimately required transvaginal urethrolysis to resolve.

Commentary by Alexander Gomelsky, LSU Health – Shreveport, Department of Urology, Shreveport, LA, USA

Commentary

• Alexander Gomelsky 

Urinary dysfunction is a diagnostic and therapeutic challenge following any pelvic reconstructive surgery. It may manifest in purely storage symptoms (e.g., urinary frequency, urgency, and urgency urinary incontinence), purely voiding symptoms (e.g., hesitancy, straining to void, elevated postvoid residual (PVR), and urinary retention), or a combination of storage and voiding symptoms. Furthermore, the constellation of symptoms may be similar to the patient’s preoperative status, worsened after surgery, or appear de novo in previously asymptomatic women. These symptoms are frequently bothersome and may cause a significant imposition on a woman’s postoperative quality of life, even in those women with postoperative resolution of their initial stress urinary incontinence (SUI) or pelvic organ prolapse (POP).

Owing to the many constellations of symptoms and postoperative findings, diagnosis and effective treatment is not typically straightforward. The only (relatively) clear scenario is urinary retention after a midurethral sling. If a woman develops impaired emptying and elevated PVR after MUS placement, it is due to excess tension on the sling. While repeating voiding trials after a brief period of indwelling catheterization or beginning clean intermittent catheterization (CIC) is reasonable in the immediate postoperative period (and up to 2–4 weeks), sling incision should be performed if these symptoms persist.

The diagnosis and treatment of postoperative voiding difficulty after POP repair is more challenging. These patients should be separated into two groups: those who underwent a concomitant anti-incontinence procedure and those who did not. In the setting of a sling, retention due to sling obstruction should be first on the differential diagnosis, followed by impaired bladder function due to narcotics, anesthesia, and/or delayed return of bowel function, and pelvic floor spasm/failure of relaxation with voiding. In those without sling placement, the latter factors should be considered as primary causes of urinary retention. The authors of the chapter describe another, less common surgical category: women who underwent POP repair using an augmentation graft with subsequent scarring and urinary retention. As with all women considered for pelvic surgery, a close inspection of preoperative, perioperative, and postoperative factors is imperative in ensuring a successful outcome.

First, prevention and anticipation of postoperative problems is imperative. As the authors correctly point out, the urodynamic definition of obstruction in women is incomplete; however, urodynamics, especially with the use of fluoroscopy, are extremely helpful to define a baseline prior to surgery. Hence, detrusor function, both during filling and emptying, can be documented. I will frequently institute a trial of temporary POP reduction with a pessary in the group of women with both POP and significant storage and emptying symptoms. Being able to re-evaluate preoperative symptoms in this patient population achieves several purposes. First, occult SUI may be more easily demonstrated, which may enhance the patient’s understanding of the concept of occult SUI. Second, an improvement in storage and emptying while the POP is reduced allows for more confidence while counseling the patient regarding postoperative expectations after POP repair. Conversely, if storage and emptying symptoms persist or are unchanged with POP reduction, then there is a strong likelihood that these symptoms may persist after corrective POP surgery and adjunctive treatments may be necessary.

Second, the choice of corrective POP procedure may play a role in the status of postoperative storage and emptying symptoms. The authors correctly point out that repairs of both, the anterior and posterior compartments, may be associated with failure of pelvic floor relaxation and subsequent short-term voiding difficulty. It is also important to note that the use of interposition grafts may, in itself, be associated with additional changes. An acute inflammatory reaction will ensue regardless of adjunct material and eventual incorporation of the interposition material varies. Furthermore, the additional dissection required to reach and expose the attachment points for the graft (e.g. arcus tendineus fascia pelvis and sacrospinous ligament) may ultimately be associated with more scarring.

Third, prompt recognition and management of postoperative complications is imperative. No fault can be found with the authors’ approach in this patient. Conservative measures such as behavioral modification, CIC, nonnarcotic pain control, and enhancing return of bowel function will optimize bladder emptying in the short term. The use of postoperative pelvic floor muscle training may be useful and, although the evidence is sparse in this population, a brief trial of alpha-adrenergic blocker or a percutaneous sacral nerve evaluation is a low-risk, high-reward option. The use of urodynamic evaluation is likewise appropriate, especially when a preoperative study is available for comparison. Cystoscopy should be performed in all of these patients to define postoperative anatomy and eliminate urinary tract injury as a causative factor. Since any de novo voiding symptoms that do not respond to observation and conservative measures ultimately have to be attributed to the original surgery, the decision to pursue additional surgery is a reasonable one. A less-morbid option like a takedown of the previous repair is a good start, proceeding to full urethrolysis if unsuccessful.

The final take-away point is that, even in expert hands, long-term or permanent voiding and storage dysfunction is a distinct possibility despite correct diagnosis and uneventful surgery. This is humbling for the surgeon and further underscores the need for extensive preoperative counseling, even when “routine” procedures are planned. Finally, in the face of postoperative complications, continuing close counseling and maintaining clear lines of communication with the patient and their family cannot be overemphasized.